zi..:£w§.~)_éfil .» uh. I: {Ll 3'2... 1 it . 1! I ‘cv .9?wa ti... 3.9 w. .r a trunnigguz 3" . mm. . m5.n...u (1.53.1.9... .3: .9 "his a .123..a...r..wu?fi. :‘gw. , . .l i . . Qqunfirr a. 1...... . :5 hr! .: . .11.. 4.»: i...» . wash-u. 2.15....» sagas. rt . 5.93.5. 21k...1.v il .55 1!).1). :1 f. u»: . .52.... 1 "1.. 11 54.3.3.1}: in. . |!.. I...) 1.5... 1143 at: x 5.52:5!» rug... «6. It I . {inf - ’wvnaa ‘05. 0.. 55...... ,5 .1 l. I... . i ‘1...’.....P! ..v .2221... s» . "5‘ ‘I Yul. . .f V‘l I \ 'r“ _."_a . O A 'u‘ UP?” " T‘W Michigaé': State University This is to certify that the dissertation entitled HIV ANTIBODY TESTING AMONG LATINAS: A TEST OF THE THEORY OF PLANNED BEHAVIOR presented by Diana Morrobel has been accepted towards fulfillment of the requirements for Ph . D 0 degree in PSYChO logy MM Map! professor Date l/Z50/0/ MSU is an Affirmative Action/Equal Opportunity Institution 0-12771 PLACE IN RETURN Box to remove this checkout from your record. TO AVOID FINES return on or before date due. MAY BE RECALLED with earlier due date if requested. DATE DUE DATE DUE DATE DUE MIXER? 10:? 29mg “WEE ll zoos 6/01 CJCIRCIDOtODUOpGS-p. 15 HIV ANTIBODY TESTING AMONG LATINAS: A TEST OF THE THEORY OF PLANNED BEHAVIOR By Diana Morrobel A DISSERTATION Submitted to Michigan State University in partial fulfillment of the requirements for the degree of DOCTOR OF PHILOSOPHY Department of Psychology 2001 X53: infections 3“ and COmmUK amt-0d,V ‘65 fumed 0“ U empirical ln‘ cultural fact ‘ behax'ior amt theory ofpl'dl factors such a hypothesized undersmdihg the theory of t The pm research Stud}; Demographic toward HIV . inst-menu 1 ABSTRACT HIV ANTIBODY TESTING AMONG LATINAS: A TEST OF THE THEORY OF PLANNED BEHAVIOR By Diana Morrobel Nearly two decades afier the advent of HIV antibody testing, the number of HIV infections among Latinas residing in the United States has reached epidemic proportions and continues to rise (CDC, 2000). HIV/AIDS prevention strategies such as HIV antibody testing programs have not been effective with Latinas (CDC, 1997b). Research focused on understanding HIV antibody testing behavior is characterized by a lack of empirical investigations that are grounded in psychological theory and which consider cultural factors. The present study examined the factors that impact HIV antibody testing behavior among Latinas by empirically testing the constructs and pathways found in the theory of planned behavior (Ajzen, 1991) and extending the theoretical model to include factors such as acculturation, perceived HIV risk, and current health status. It was hypothesized that the extended model would provide a more comprehensive understanding of the factors that influence Latinas’ HIV antibody testing behavior than the theory of planned behavior model. The present investigation involved two studies: elicitation and prospective research study. During the elicitation research study, 18 Latinas were administered the Demographic Questionnaire and were asked to identify their salient beliefs and attitudes toward HIV antibody testing. The prospective research study involved administering instruments that were developed with the information obtained in the elicitation study as prescribed b} included 13C HIV antibod status. im oh and HIV ant. Struc reiationships ' eon of pie testing behax HIV antihoc'; W5 excellen behavior mo. RVSEA= 0,: behax‘ior a: a among Latin; Thee lmeni‘ntion < resemhers tt der dimEd at mm prescribed by the theory of planned behavior. Participants for the prospective study included 139 Latinas who completed measures on: perceived HIV risk, attitudes toward HIV antibody testing, subjective norms, perceived behavioral control, current health status, involvement with Latino culture, involvement with American culture, intention, and HIV antibody testing behavior. Structural equation modeling (SEM) was used to test the hypothesized relationships in both models (the theory of planned behavior model and the extended theory of planned behavior model). The present findings revealed that HIV antibody testing behavior among a sample of Latinas is best predicted by their attitudes toward HIV antibody testing and intention to be tested. The overall fit of the extended model was excellent (CFI=O.97, TLI= 0.95, IF I= 0.97, RMSEA=.O7). The theory of planned behavior model provided an ideal fit for the data (CF I= 1.00, TLI= 1.02, IF I= 1.00, RMSEA= 0.00). The present findings strongly support the use of the theory of planned behavior as a conceptual approach to understanding and promoting HIV antibody testing among Latinas. The current research has important implications for AIDS prevention and intervention efforts and policies. The findings highlight the need for counselors and researchers to focus greater attention on Latinas’ attitudes and salient beliefs in order to develop more effective and culturally appropriate prevention and intervention programs aimed at increasing the number of Latinas being tested for HIV antibodies. T 0 those who will not rest until a cure is found iv motix'a' SClé‘l'IIi paste in I113 ACKNOWLEDGMENTS I want to extend my sincerest gratitude to Dr. Anne Bogat for her guidance, motivation, and support throughout my academic career. She taught me how to become a scientist that is driven not only by sound research techniques and design, but also by my passion to make a difference. Dr. Francisco Villarruel has been a wonderful mentor and an inspiration. I am thankful for the conversations over coffee and the heartfelt advice. I am grateful to Dr. Rick DeShon for his invaluable expertise and patience during the statistical analyses. He is a brilliant teacher. I am also grateful to Dr. Gersh Kaufman for his support and thoughtful comments. Furthermore, I owe a special thank you to Dr. Jon A. Lacey and Debbie Kolk of the AIDS Education and Training Center. I am proud to have been a part of their commitment to helping those affected by HIV/AIDS. I would like to take this opportunity to thank my family for inspiring my love of culture and the belief in the power of family. They taught me that success requires love, humility, kindness, sacrifice, but most importantly collaboration. No hubiera llegado tan lejos sin su amor y apoyo. I am also thankfiJl to the Karamsingh family for their love and support. Finally, I would like to thank my fiance Rav for his unending love, generosity, and amazing editorial skills. His unselfishness, companionship, and humor allowed me to pursue this goal without giving up. LIST 0? IABI LIST OF FIGI' KEY FOR TIiI IRIRODL' CII HIV AIDS ...... HIV A HIV at The t‘. RCVIEW of E I‘CIIEVIOI ..... HI\' EXp Rationale “math C” "J I 7: .P‘ (Sip m TABLE OF CONTENTS LIST OF TABLES .............................................................................................................. ix LIST OF FIGURES .............................................................................................................. x KEY FOR THE MEASUREMENT MODELS .................................................................. xi INTRODUCTION ................................................................................................................ l HIV/AIDS ............................................................................................................................ 1 HIV/AIDS among ethnic minorities ........................................................................ 2 HIV/AIDS and Latinas ................................................................................. 3 HIV antibody testing ............................................................................................... 5 The HIV antibody test .................................................................................. 6 Importance of HIV antibody testing ............................................................ 7 HIV antibody testing among women ........................................................... 8 The theory of planned behavior ............................................................................. 12 Behavior ..................................................................................................... 12 Intention ..................................................................................................... 13 Perceived behavioral control .......................................................... 13 Attitude toward a behavior ............................................................. 13 Subjective norm ............................................................................. 14 Review of the literature of studies investigating HIV antibody testing behavior ............... 15 HIV antibody testing and the theory of planned behavior ..................................... 15 Expanding the theory of planned behavior ............................................................ 20 Factors associated with HIV antibody testing behavior ............................ 20 Factors associated with intention to be tested for HIV antibodies ............ 21 Current health status ...................................................................... 21 Perceived HIV risk ......................................................................... 23 Acculturation: A moderating factor associated with HIV antibody testing behavior .......................................................................................... 25 Involvement with Latino culture .................................................... 27 Involvement with American culture .............................................. 29 Rationale for Present study ................................................................................................ 31 Hypotheses ......................................................................................................................... 34 1. Hypotheses Regarding how Attitudes toward HIV Antibody Testing, Subjective Norms toward HIV Antibody Testing, Perceived Behavioral Control, and Current Health Status influence Intention to be tested ....................................................... 34 2. Hypothesis regarding Perceived HIV risk .......................................................... 35 3. Hypothesis regarding the relationship between intention to be tested and HIV antibody testing behavior ...................................................................................... 36 vi 4. Hy Amer 5.. H}. behax METHOD... Elicitation R: Partic Mate: Procc Prospective I Partit Mate Proc RESLITS _ Rem 4. Hypotheses Regarding Involvement with Latino culture and Involvement with American culture .................................................................................................... 36 5. Hypothesis Regarding a test of the expanded model of the theory of planned behavior .................................................................................................................. 36 METHOD .......................................................................................................................... 37 Elicitation Research ........................................................................................................... 37 Participants ............................................................................................................. 37 Materials ................................................................................................................ 37 Demographic Questionnaire ...................................................................... 37 Elicitation Research Questionnaire ............................................................ 38 Procedure ............................................................................................................... 38 Prospective Research ......................................................................................................... 40 Participants ............................................................................................................. 40 Materials ................................................................................................................ 41 Demographic Questionnaire ...................................................................... 41 Current Health Status Questionnaire ......................................................... 42 The Cortes, Rogler, & Malgady Biculturalism Scale ................................. 43 Perceived I-HV risk ..................................................................................... 44 Attitude toward HIV antibody testing ........................................................ 44 Behavioral Beliefs .......................................................................... 45 Outcome Evaluations ..................................................................... 45 Subjective norm toward HIV antibody testing ........................................... 45 Normative Beliefs .......................................................................... 45 Motivation to Comply .................................................................... 46 Perceived behavioral control over HIV antibody testing ........................... 46 Intention to be tested .................................................................................. 47 HIV antibody testing behavior ................................................................... 47 Procedure ............................................................................................................... 47 Interviewer training .................................................................................... 51 RESULTS ......................................................................................................................... 52 Review of Measurement Model ............................................................................. 54 Current Health Status (CHEALTH) ........................................................... 54 The Cortes, Rogler, and Malgady Biculturalism Scale .............................. 54 Involvement with Latino Culture Subscale (CLATIN) .............................. 54 Involvement with American Culture Subscale (CAMERICA) .................. 55 Perceived I-IIV Risk (REVRISK) ............................................................... 56 Attitude Toward HIV Antibody Testing .................................................... 57 Attitude Toward HIV Antibody Testing (MATT) ......................... 57 Behavioral Beliefs and Outcome Evaluations (GH) ...................... 57 Subjective Norms ....................................................................................... 58 Perceived Behavioral Control (PCONTROL) ........................................... 60 vii Result Result DISCL‘SSIO‘ The E Major Intention to be Tested for HIV Antibodies (CEl) ...................................... 60 HIV Antibody Testing Behavior (BEHAVIOR) ........................................ 60 Results of the Hypotheses ...................................................................................... 61 Hypothesis 1 ............................................................................................... 62 Hypothesis 2 ............................................................................................... 62 Hypothesis 3 ............................................................................................... 63 Hypothesis 4 ............................................................................................... 63 Results of the Extended Model of the Theory of Planned Behavior ...................... 63 Model l-Hypothesized Model ................................................................... 64 Hypothesis 5 ............................................................................................... 64 DISCUSSION .................................................................................................................... 66 The Extended Model of the Theory of Planned Behavior ..................................... 67 Major Findings ....................................................................................................... 67 Pathway from attitude toward HIV antibody testing to intention .............. 67 Pathway from subjective norms to intention .............................................. 70 Pathway from perceived behavioral control to intention ........................... 76 Pathway from current health status to intention ......................................... 79 Pathway from perceived HIV risk to attitude toward HIV antibody testing .......................................................................................... 79 Pathway from intention to behavior ........................................................... 84 Involvement with Latino culture as a moderator of the relationship between intention and behavior ................................................................ 86 Involvement with American culture as a moderator of the relationship between intention and behavior ................................................................ 89 Overall fit of the extended model .............................................................. 92 Limitations ............................................................................................................. 93 Conclusion ............................................................................................................. 95 APPENDICES ................................................................................................................... 99 Appendix A: Elicitation Research Questionnaire ................................................ 100 Appendix B: Informed Consent Form for Elicitation Research .......................... 106 Appendix C: Prospective Research Questionnaire .............................................. 110 Appendix D: F lyer ............................................................................................... 164 Appendix E: Informed Consent Form for Prospective Research ........................ 166 Appendix F: Participant Contact Form ............................................................... 170 Appendix G: Figures ............................................................................................ 172 Appendix H: Tables ............................................................................................ 178 REFERENCES ................................................................................................................ 201 viii Table I. Table 2. Table 3. Table-1. Ia'rle fa. Table 5b. Table 6_ Table 7, Table 8, Table 9. Table 10_ Table 13. Table 13. Table 14 Table 1. Table 2. Table 3. Table 4. Table 5a. Table 5b. Table 6. Table 7. Table 8. Table 9. Table 10. Table 11. Table 12. Table 13. Table 14. LIST OF TABLES Demographic Information for Elicitation Research Study Participants ............................................................................................... 178 Demographic Information for Prospective Research Study Participants ............................................................................................... 180 Psychometric Properties of Measures: Means, Standard Deviations, and Range ................................................................................................. 183 Psychometric Properties of Current Health Status ................................... 184 Psychometric Properties of Involvement with Latino Culture Subscale ................................................................................................... 188 Psychometric Properties of Involvement with American Culture Subscale ................................................................................................... 1 89 Psychometric PrOperties of Perceived HIV Risk ..................................... 190 Psychometric Properties of Attitudes toward HIV Antibody Testing ...................................................................................................... 191 Psychometric Pr0perties of Behavioral Beliefs X Outcome Evaluations Scale ......................................................................................................... 192 Subjective Norms (Normative Beliefs X Motivation to Comply)- Items and factor loadings ......................................................................... 194 Psychometric Properties for Immediate Family Norms Subscale ............ 195 Psychometric Properties of Community Norms Subscale ....................... 196 Psychometric Properties of Perceived Behavioral Control Scale ........... 197 Psychometric Properties of the HIV Antibody Testing Behavior Scale ......................................................................................................... 198 Correlation Matrix for Measures ............................................................. 200 ix Figure 1. Figure 2. Figure 3. Figure 4. Figure 5. Figure 6. LIST OF FIGURES Theory of Planned Behavior Theoretical Model ...................................... 172 Extended Model of the Theory of Planned Behavior .............................. 173 Extended Theory of Planned Behavior Measurement Model .................. 174 Revised Extended Model of the Theory of Planned Behavior ................ 175 Hypothesized Extended Model of the Theory of Planned Behavior Results ...................................................................................................... 176 Theory of Planned Behavior Results ........................................................ 177 REVRISK TUTTI AIFXORV ACOXTNORX PCONTROL CHEALTH C El CLATTN CLATXCEI CAMERICA COLXCE] BEHAVIQ R REVRISK MATT AIFNORM ACOMNORM PCONTROL CHEALTH CE 1 CLATIN CLATXCE 1 CAMERICA CAMXCEI BEHAVIOR KEY FOR THE MEASUREMENT MODELS Perceived HIV risk Attitude toward HIV antibody testing Immediate family subjective norms Community subjective norms Perceived Behavioral Control Current health status Intention to be tested for HIV antibodies Involvement with Latino culture Interaction term--Involvement with Latino culture X Intention to be tested for HIV antibodies Involvement with American culture Interaction term-~Involvement with American culture X Intention to be tested for HIV antibodies HIV antibody testing behavior xi Acquirer reached epidcm serious current ' mom Mime lrrununodeticie American “on. scientists hat e become an inte With HIV antit c‘h’iic minoriti Catanja‘ I9961 antibody testir- recenlll‘ been i INTRODUCTION Acquired Immune Deficiency Syndrome, most commonly known as AIDS, has reached epidemic proportions in the United States and is considered one of the most serious current public health crises. It appears that the face of AIDS is changing. Ethnic minority women are becoming infected with the virus that causes AIDS, the Human Immunodeficiency Virus (HIV), at an alarming rate, currently surpassing that of Anglo- American women (CDC, 2000). To date there is no cure for AIDS, hence, social scientists have focused their efforts on prevention. Testing for HIV antibodies has become an integral component in the prevention of AIDS. The factors that are associated with I-HV antibody testing behavior, however, are poorly understood, particularly among ethnic minorities (Godin, Myers, Lambert, Calzavara, & Locker, 1997; Sabogal & Catania, 1996). The present study attempted to elucidate which factors predict HIV antibody testing behavior among Latinas--an ethnic minority subgroup which has recently been hardest hit by the AIDS epidemic. HIV/AIDS Worldwide, the rate of HIV infection has been steadily increasing (CDC, 2000). AIDS has affected thousands of Americans at an unprecedented rate. As of December, 1999, there have been more than 750,000 (774,647) HIV positive cases reported to the Centers for Disease Control and Prevention (CDC, 2000). This figure is considered an estimate that underreports the actual number of individuals that are infected with HIV. AIDS is system by bindi 'heir number th normally contrt leaves the persc parasites. and tr HIV is transmi‘E secretions. and membranes or t that Im'OlVe dir successful at pr AIDS. Ethnic 1 infecred with I‘: transmission CC States The Al the United Stat 57°”: of an Alt AIDS is a devastating viral disease caused by HIV. HIV attacks the immune system by binding to T helper lymphocytes through their CD4 receptors and depletes their number through various mechanisms (Harrison & McArthur, 1995). T cells normally control and coordinate the body’s immune responses. The loss of these cells leaves the person susceptible to opportunistic infections by viruses, fungi, bacteria and parasites, and to an increased incidence of lymphomas (Harrison & McArthur, 1995). HIV is transmitted through contact with certain fluids (i.e., blood, semen, vaginal secretions, and breast milk) that can be introduced to the body through mucous membranes or the bloodstream. HIV is transmitted when one participates in behaviors that involve direct contact with HIV-infected fluids. While medical advances have been successful at prolonging the onset of AIDS, there is currently no cure for HIV infection or AIDS. HIV/AIDS among ethnic minorities Ethnic minorities presently constitute the largest growing population of those infected with HIV in the United States (CDC, 2000). Despite prevention efforts, HIV transmission continues at alarming rates, particularly for certain subgroups in the United States. The AIDS epidemic has affected racial and ethnic minority groups differently. In the United States, ethnic minorities comprise approximately 20% of the population and 57% of all AIDS cases (CDC, 2000; US. Bureau of Census, 1990). In 2000, there were a total of 3935-: AsianPaci T: I: reported to hat times larger th; the year 2005 t of Writes (Ma W; Warner ““0 Fears t.\'>' among “'Omer infected With I so, " "° OfLhe L's C9585 is SCVen I996) Fuflhfi total of 292,522 (38%) African-Americans, 141,694 (18%) Latinos', 5,728 (1%) Asian/Pacific Islanders, and 2,337 (003%) American Indians/Alaskan Natives who were reported to have AIDS (CDC, 2000). The AIDS cases among Latinos is two and a half times larger than that among non-Latino Whites (Fernandez, 1995). It is projected that by the year 2005 the number of newly reported AIDS cases among Latinos will surpass that of Whites (Maldonado, 1998). HIV/AIDS and Latinas Women comprise one of the largest HIV risk groups in this country (Amaro, 1995; CDC, 2000; Cochran & Mays, 1989; Nyamathi, Bennett, Leake, Lewis, & Flaskerud, 1993; Nyamathi, Stein, & Brecht, 1995; Wilson, Jaccard, Levinson, Minkoff, & Endias; 1996). The number of women diagnosed with AIDS is doubling every one to two years (Nyamathi et al., 1995). In particular, Latinas comprise 20% of AIDS cases among women residing in the United States (CDC, 2000). The percentage of Latinas infected with HIV/AIDS is particularly alarming when one considers that they represent 5% of the US. population (U .8. Bureau of the Census, 1997). The proportion of AIDS cases is seven times higher among Latinas than for non-Latinas (Sabogal & Catania, 1996). Furthermore, the rapid rate of HIV infection has greatly impacted women in their childbearing years-- ages 25 to 44 (CDC, 2000). HIV/AIDS is now the third leading cause of death among women in the United States (CDC, 1995). ' For the purposes of this paper, Latino(s) refers to Latino men and women. Latina(s) refers to women. Specit. minority “”037 heterosexual c actit'ity) (Am; Tullilox‘e. 199 Sincer. 8; GIT! transmission i: Latinas. intrax Puerto Rican \ 15ers is cited a Ford. Cheng. 6 transmission is Resean Specific behaviors are the predominant routes of HIV infection for ethnic minority women--sharing intravenous drug use paraphernalia and unprotected heterosexual contact with at-risk partners (i.e., failure to use condoms during sexual activity) (Amaro, 1995; Catania, Coates, Golden, Dolcini, Peterson, Kregeles, Siegel, & Fullilove, 1994; CDC, 1997; Jemmott & Jemmott, 1991; Weeks, Schensul, Williams, Singer, & Grier, 1995). Intravenous drug use has been identified as the mode of HIV transmission in 43% of AIDS cases among Latinos (CDC, 2000). Among US. born Latinas, intravenous drug use was the predominant form of exposure, in particular among Puerto Rican women (Fernandez, 1995). Heterosexual contact with intravenous drug users is cited as an increasing cause for HIV infection among Latinas (Simon, Weber, Ford, Cheng, & Kerndt, 1996). The number of AIDS cases due to heterosexual transmission is greater among Latinas than Anglo-American women, and is continuously increasing (CDC, 2000; Cochran & Mays; 1989; Ferraro, 1998; Simon et al., 1996). The cumulative incidence of AIDS attributable to heterosexual contact among women is eleven times greater for Latinas than Anglo-Americans (Weeks et al., 1995). Latinas continue to be at high risk for HIV infection. Researchers must address the needs of Latinas who are already infected by investigating HIV antibody testing behavior. Understanding such patterns will aid in providing Latinas with timely medical care and treatment to prolong the onset of AIDS for those who are ser0positive, and educating them on how to prevent HIV infection among their partners and family (i.e. children). To date, investigators have failed to pay attention to n understand uh ntunber of AI HIV 3 comprehensit became at all; ll'ortley. C hu. Moltotofi Le. PleVention eft SUIVIVaI of HI attention to the importance of HIV antibody testing among Latinas. It is crucial to understand the factors that lead to HIV antibody testing behavior in order to reduce the number of AIDS cases among Latinas. HIV antibody testing HIV antibody counseling and testing has become the foundation for comprehensive HIV prevention and treatment efforts in the United States since it first became available in 1985 (Irwin, Valdiserri, & Holmberg, 1996; Phillips & Coates, 1995; Wortley, Chu, Diaz, Ward, Doyle, Davidson, Checko, Herr, Conti, Farm, Sorvillo, Mokotoff, Levy, Hermann, & Norris-Walczak; 1995 ; Valdiserri, 1997). Secondary prevention efforts to decrease disease-related morbidity and deaths and to prolong survival of HIV infected individuals have focused on early detection of HIV through testing and counseling seropositive individuals about treatment options and the importance of prophylactic and antiviral treatment (Siegel, Karus, Raveis, 1997). Counseling and testing provide individuals with knowledge about HIV serostatus which enables them to make informed decisions to change the behaviors that may put themselves or others at risk for HIV infection. It also provides them with access to early medical care, treatments, and prophylaxis that may delay the progression of HIV disease, prolong the onset of AIDS, and increase their survival time if they are seropositive (Beardsell, 1994; Kalichman, Somlai, Adair, & Weir, 1996; Phillips & Coates, 1995; Wilson, Jaccard, Levinson, Minkoff, & Endias, 1996; Wortely etal., 1995). Individuals who fail to be tested soon afier engaging in high-risk behavior face worse treatment outcomes IS” despite PIC)“ irjected “till among resear homosexual a gender ditierc re factors th: The HIV an! HIV a (CDC. 1997). organism has bOdy When it from disease, they do not pr The E. antibodl' tesr urine. nga}, home HIV te. reacute Or a, 5 outcomes (Siegel, Raveis, & Gorey, 1998). Recent national statistics have shown that despite prevention efforts, Latinas continue to engage in high-risk behaviors and become infected with HIV (CDC, 2000). The circumstances, beliefs, and attitudes of Latinas that inform their decision to be tested for HIV antibodies have received minimal attention among researchers. Prevention programs have been predominantly focused on homosexual and bisexual men, and have neglected issues of racial, cultural, class, and gender differences (Weeks et al., 1995). Hence, the present study exclusively examined the factors that influence HIV antibody testing behavior among Latinas. The HIV antibody test HIV antibody testing is the only accurate method to ascertain HIV infection (CDC, 1997). The HIV antibody test detects HIV antibodies that are produced when an organism has been infected by HIV. Unlike other antibodies produced by the human body when it comes into contact with a virus, HIV antibodies do not protect the body from disease. They do not protect a person or make a person immune from AIDS, and they do not prevent a person from transmitting HIV to anyone else (CDC, 1998b; Kalichman, 1996). The Enzyme-Linked Immunosorbent Assay (ELISA) is the most widely used HIV antibody test (CDC, 1998). This screening test can be performed on blood, saliva, and urine. Today individuals also have the option of taking the blood test at home using a home HIV test kit. If the result is negative, there is no further testing. If the test is reactive or “positive,” screening tests are repeated using the same specimen. If an ELISA test yields two nsay test. else for HIV antibt' Kalichman. 19 tires longer 1( tCDC,1998bi SEVEra testing in the t deVlduals “I been tested; by infected in div; tints 10 1h Eir s and lesrjng tar infected Perso- interVention ti at‘ailab]e as a deSigned TO I]; lifts b€en ShO‘k; m3} reduce I,- ofknou-iedgil test yields two or more reactive results, a different test such as the Immunofluorescence assay test, also known as the Western blot test, is used to confirm these results as positive for HIV antibodies (CDC, 1998b; Farnham, Gorsky, Holtgrave, Jones, & Guinan, 1996; Kalichman, 1996; Spielberger & Kassler, 1996). The Western blot is more specific and takes longer to perform than the ELISA. Together, the two tests are 99.9% accurate (CDC, 1998b). Importance of HIV antibody testing Several reasons have been posited to relate the importance of HIV antibody testing in the efforts to control the AIDS epidemic in the US: a) a significant number of individuals who are HIV infected or who have engaged in HIV risk behaviors have never been tested; b) the often long asymptomatic or latency phase of HIV infection means that infected individuals may not be aware of their infection or their potential to transmit the virus to their sexual partners, needle-sharing partners, or their offspring; c) counseling and testing targeted only to persons reporting HIV risk behaviors will not identify infected persons who may deny or be unaware of risk behaviors; (1) early medical intervention that may delay the onset of AIDS symptoms and death is more widely available as a result of the introduction of new medications and drug assistance programs designed to help individuals finance their medical costs; e) zidovidine (AZT) treatment has been shown to reduce the rate of perinatal HIV transmission; f) counseling and testing may reduce high-risk behaviors, especially among those testing HIV-positive; and g) lack of knowledge regarding HIV serostatus may result in the misdiagnosis of HIV-related Il ‘ :,~ ‘ v‘th - . -.. Q orsonmwr . I (:1! F' J“; . 4.15.:r' & k ‘ In The - I ._.~.Y.l ITS-13‘ Ila-4;“: «A- H ‘. L‘. .~‘ - , n Lt Lun‘elnlg ‘ » seek these 5: “omen who HIV antihoc In 1‘. Latinos. but tCDC. 199T continue to it al., 1996; 6; Coates. l medical problems and missed Opportunities to receive medical treatment that may prevent opportunistic infections and prolong the onset of AIDS (Irwin et al., 1996; Norton, Miller, & Johnson, 1997; Siegel et al., 1998). In the last decade, in an effort to access underserved populations, several US. organizations (i.e., US. Public Health Service and the National AIDS Commission) and many health care providers have recommended expanding voluntary HIV antibody counseling and testing in several clinical settings where individuals may not specifically seek these services (American Medical Association, 1994; CDC, 1993; CDC, 1998; Irwin et al., 1996). Yet, despite efforts to expand the availability of HIV antibody testing, the number of Latinas who seek voluntary testing is markedly less than the estimate of women who are HIV infected (CDC, 1997). HIV antibody testing among women In 1995, fewer than half of all HIV tests were performed on African-Americans or Latinos, but these groups accounted for more than 70% of all HIV-positive test results (CDC, 1997). It is estimated that between 30% and 70% of Americans who have or continue to engage in HIV risk behaviors have never been tested, including Latinas (Irwin et al., 1996; Kalichman et al., 1996; Kalichman & Hunter, 1993; Phillips, 1993; Phillips & Coates, 1995). Previous research on HIV antibody testing behavior has focused primarily on understanding the relationship between HIV counseling and testing, and behavior change among drug rehabilitation clients, gay and bisexual men, sex industry workers, and STD or prenatal . Gielen. Fad 8; Schoenb. clients of pi who are at—r providers (1 those wome not necessai behaviors ti Phillips. 19' Rese infection frc influence er} AmO-HE Stud American \V AngIO‘Am’c; The use Ofg subgroup an. neCesgar}. to order to imp; QXCIUSit-eh. f or prenatal clinic clients (Battle, Cummings,Yamada, & Kransnovsky, 1996; Carlson Gielen, Faden, O'Campo, Kass, & Anderson, 1994; Miller, Hennessy, Wendell, Webber, & Schoenbaum, 1996). Studies use samples drawn from particular populations, such as clients of public clinics, and therefore do not include individuals in the general population who are at-risk but have not sought voluntary testing or who were tested by private providers (Kalichman & Hunter, 1993). A limited number of studies have examined those women who are not members of traditional high risk groups such as women who do not necessarily have a history of drug abuse, prostitution, or STDs, yet may participate in behaviors that place them at risk for HIV infection (Battle et al., 1996; Carovano, 1991; Phillips, 1993). Researchers have identified barriers that prevent women who are at risk for HIV infection from learning their HIV status; however, few have examined the factors that influence ethnic minority women subgroups’, such as Latinas’ decision to be tested. Among studies that address gender differences, Latinas are often grouped with African- American women into a single category, “minority women,” and are often compared to Anglo-American women. But differences among ethnic minority women are significant. The use of global terms, such as “minority women,” ignores the heterogeneity of each subgroup and minimizes the importance of individual subgroup differences. Since it is necessary to understand AIDS preventive behavior, such as HIV antibody testing, in order to impact the rate of infection among ethnic minority women, future studies must exclusively focus on individual ethnic minority women subgroups such as Latinas. Rese being at higl those diagnc factors that 2 National All not plan to t research etfc HIV and ma originally do “ithout Cons Cultural Valu Social unit ar Seeking beha Peragfllo, 19 high risk gro the limitatlor In ad- COHCSPIUaliZ hat-e attemp. Research that focuses on select populations that have been traditionally viewed as being at high risk for HIV infection (i.e., gay White males, intravenous drug users, and those diagnosed with a sexually transmitted disease (STD)) is unable to elucidate the factors that affect the testing patterns and behavior of other groups. Results from the National AIDS Survey found that 60% of Latinos and African-Americans who reported engaging in at least one high-risk behavior for HIV infection have never been tested or do not plan to be tested (Phillips, 1993). Phillips’ (1993) findings suggest that current research efforts have excluded a significant proportion of individuals who are at risk for HIV and may account for the lack of effectiveness of prevention efforts that were originally developed for White, gay men and have been applied to women of color without considering gender and cultural factors [e.g., religion, communication style, and cultural values such as familismo (familism)- the emphasis on the family as the primary social unit and source of support and guidance] that affect sexual practices and health seeking behavior (Amaro, 1988; Amaro, 1995; Marin, 1991; Mays & Cochran, 1988; Peragallo, 1996). The present study focused on Latinas who are members of traditional high risk groups as well as Latinas who are not characterized as such in order to address the limitations in previous research. In addition, previous studies are characterized by a lack of theory-driven models, conceptualizations, and methodology. Since the onset of the AIDS epidemic, researchers have attempted to understand HIV risk and HIV/AIDS- preventive behavior without much success (Fisher, Fisher, & Rye, 1995; Godin et al., 1997; Kalichman, 1998). The 10 Ii nature is chi: "informal and z. I approach to 8’. resulted in inc. elucidate the t. al. 1995; God been tested to al., I997; Phil the theory of ; leg- condon. Carusodc M. lien. & Ajz; llamett'ork ti I AIDS-pret-e:~ adearth of r. theory as II I. The Present ; 1993) to in... latinas.-a g Pret'ention .. literature is characterized by research that fails to be theory driven and instead relies on “informal and ad hoc conceptualizations” (Fisher et al., 1995, p.255). This “unsystematic approach” to studying AIDS preventive behaviors, such as HIV antibody testing, has resulted in inconclusive and contradictory findings that further impede the efforts to elucidate the factors that influence the behavior to seek HIV antibody testing (Fisher et al., 1995; Godin et al., 1995; Phillips & Coates, 1995). Few theory-based models have been tested to assess the psychosocial predictors of AIDS preventive behaviors (Godin et al., 1997; Phillips & Coates, 1995; Fisher et al., 1995; Nyamathi et al., 1995); however, the theory of planned behavior has predicted a variety of AIDS- preventive behaviors (e.g., condom use) (Abraham & Sheeran, 1994; Ajzen, 1991; Cochran, Mays, Ciarletta, Caruso, & Mallon, 1992; F ishbein, Middlestadt, & Hitchcock, 1994; Madden, Scholder Ellen, & Ajzen, 1992). Although the theory of planned behavior provides a theoretical framework for identifying and analyzing the factors that can predict the performance of AIDS-preventive behavior, a review of the psychological and medical literature revealed a dearth of research studies that have comprehensively tested the propositions of this theory as it relates to HIV antibody testing behavior (Godin et al., 1997; Phillips, 1993). The present study utilized the theory of planned behavior (Ajzen, 1991; Madden et al., 1992) to investigate the factors that can predict HIV antibody testing behavior among Latinas--a group whose rate of HIV infection is continuously increasing and with whom prevention efforts have failed to produce long-lasting changes in participation in AIDS preventive behaviors. 11 The tl attitudes. inte designed to r l991). The t originally pn behatior by control t A}, z Aizen (”1991 aSSPmI‘tion (Madden et C0ml‘lere xt- IO PTEdict 3 adding the - Acc action Peri] intention 1C AIZen‘ 199 intention IC control ("1hr The theormfplfled behyior The theory of planned behavior addresses the relationships between beliefs, attitudes, intentions, and behavior (see Figure l) (Ajzen, 1991; Madden et al., 1992). It is designed to predict and explain specific human behavior in specific contexts (Ajzen, 1991). The theory of planned behavior is an extension of the theory of reasoned aetion originally proposed by Fishbein and Aj zen (1975) which seeks to explain and predict behavior by identifying the causal antecedents of behavior that are under volitional control (Ajzen, 1988; Ajzen & Fishbein, 1980). With the theory of planned behavior, Aj zen (1 991) expands the original theory’s model to address its limitation-- the assumption that most behaviors are under the individual’s “fiill volitional control” (Madden et al., 1992, p. 3). Ajzen argues that many social behaviors are not under complete volitional control of the individual, hence, the theory is limited in its usefulness to predict a number of social behaviors. The modification of the original model entails adding the variable “perceived behavioral control” as one of the determinants of behavior. Behavior According to the theory of planned behavior, behavior is defined as a specific action performed by an individual (Aj zen, 1991). Behavior is a function of the behavioral intention to perform a particular behavior and perceived behavioral control (Ajzen, 1988; Ajzen, 1991). An individual’s behavior is determined by motivational factors such as the intention to perform or not perform a behavior and the individual’s actual behavioral control (the availability of requiSite opportunities and resources such as time, money, 12 knowledge. sk leaflet Intentir memnnnin. Godin et al.. 1 irftuence a be much of an et' stronger the i According tc behavioral c indiyidual' (Ajzen. 19 required in 0\'ercomi I’Madden p055633. knowledge, skills, and cooperation of others) (Madden et al.,1992). Totem—011 Intention precedes and predicts behavior (Abraham & Sheeran, 1994). Behavioral intention is interpreted as the determination to try to perform a behavior (Ajzen, 1988; Godin et al., 1997). Intentions are assumed to capture the motivational factors that influence a behavior. They are indications of how hard people are willing to try, of how much of an effort they are planning to exert, in order to perform the behavior. The stronger the intention to engage in a behavior, the more likely should be its performance. According to the theory, there are three determinants of behavioral intention: perceived behavioral control, attitude toward the behavior, and subjective norms. Perceived behavioral control. Perceived behavioral control refers to the individual’s perception of the ease or difficulty of performing the behavior in question (Ajzen, 1991). It consists of the individual’s beliefs regarding his/her possession of required resources, opportunities, and skill for performing a specific behavior and overcoming the obstacles or barriers that prevent him/her from performing the behavior (Madden et al., 1992). The more resources and opportunities individuals think they possess, the greater their perceived behavioral control. Attitude towafl behflor. Attitude toward the behavior is the individual’s - positive or negative evaluation of performing the behavior in question (Ajzen, 1988; Fishbein & Ajzen, 1975). Individuals are said to have salient beliefs about the behavior and that the specific behavior will lead to certain consequences. These beliefs are 13 coupled with toward the he‘s etaluation oft associations ( subjectite nor groups think i to comply \Vi‘. fisher et al., ' whom the inc friends. and l approval or t 35 Sheeran_ Alt‘n influenCE be depending ( “994) State attimde 10V Ac coupled with the evaluation of such consequences to form a positive or negative attitude toward the behavior. The attitude toward the behavior is determined by the individual’s evaluation of the outcomes associated with the behavior and by the strength of the associations (Ajzen, 1991). Subjective norm. Behavioral intentions are also a function of an individual’s subjective norm, which is defined as the individual’s belief that specific individuals or groups think he/she should or should not perform the behavior as well as the motivation to comply with the specific referents (F ishbein & Ajzen, 1975; Fishbein et al., 1994; Fisher et al., 1995). It is believed to be the social pressure placed by the people or groups whom the individual considers important in his/her life (e.g., parents, spouse, close friends, and co-workers). It is the salient belief regarding the perception of other people’s approval or disapproval of his/her performing the specific behavior in question (Abraham & Sheeran, 1994). Although attitudes toward the behavior and subjective norms are believed to influence behavioral intention, the importance of these two factors is expected to vary depending on the behavior and the individual (Fishbein et al., 1994). F ishbein et al. (1994) states that individuals will intend to perform a behavior when they have a positive attitude toward performing it and/or when they believe that the pe0ple important to the individual think they should perform it (F ishbein et al., 1994). According to the theory of planned behavior, research involves a three-step process. First, investigators must conduct elicitation research to empirically, rather than 14 i .taiu'tely . ides . sources oi reict pertorming the Ajzen & Fish'r as the basis ic suhiectit'e not ‘0 predict a behaxiots intuitively, identify salient beliefs about the consequences of the specific behavior, sources of referent influence on the behavior, and the ease or difficulty level related to performing the behavior that are relevant to the population of interest (Ajzen, 1991; Ajzen & Fishbein, 1980). Second, elicitation research data is content analyzed and used as the basis for constructing measures of the theorized underpinnings of attitudes, subjective norms, and perceived behavioral control. Third, measures are administered to a larger sample for further investigation and understanding of the specific behavior. Review of the literature of studies investigating HIV antibody testing The theory of reasoned action and the theory of planned behavior have been used to predict and explain why individuals have or have not engaged in a wide variety of behaviors, including HIV/AIDS-related behaviors (e. g., condom use and HIV antibody testing), among individuals in traditional high risk groups (Abraham & Sheeran, 1994; Chan & Fishbein, 1993; Cochran et al., 1992; Fishbein, 1990; F ishbein, Chan, O’Reilly, Schnell, Wood, Becker, & Cohn, 1992; Fisher et al., 1995; Jemmott & Jemmott, 1991; Jemmott, Jemmott, & Hacker, 1992; Ross & McLaws, 1992). Studies provide evidence that behavioral intentions are predictors of specific AIDS preventive behavior (i.e., condom use). However, these studies have predominantly failed to test other propositions of the model (i.e., subjective norms, personal attitudes, or perceived behavioral control). HIV antibody testing and the theory of planned behavior Studies which utilize the theory of planned behavior to understand the factors that 15 aziect HIV test conduct elicit. prediction of Godin et al. t 1 gay men‘s inz: taking the test who had a pc to take the tes test before an have greater I997). Panic ltat’e intentic lGodin et al likely to hat 343.70. regpeL assessed in Tisi 33rd itrgmeI SUCICCII‘.‘e “flame ll affect HIV testing behavior have been characterized by failures to assess behavior and conduct elicitation research as posited by the theory. Instead, focus has been on the prediction of behavioral intention (Godin et al., 1997; Phillips, 1993). For example, Godin et a1. (1997) found that among a group of highly educated Whites, bisexual and gay men’s intention to be tested for HIV antibodies was predicted by attitudes toward taking the test and perceived behavioral control regarding taking the test. Individuals who had a positive attitude toward taking the test were more likely to have the intention to take the test compared to those with negative attitudes. Men who had never taken the test before and had a positive attitude toward taking the test were 40 times more likely to - have greater intentions to take the test than those with negative attitudes (Godin et al., 1997). Participants who perceived taking the test as “easy” were 4 times more likely to have intentions to take the test than those who perceived the behavior as “difficult” (Godin et al., 1997)., In another example, Phillips (1993) found that Latinos were less likely to have intentions to be tested when compared to African-Americans (28% and 34%, respectively). Other components of the theory of planned behavior were not assessed in such studies. Fisher et a1. (1995) found that among gay men and heterosexual university men and women HIV antibody testing behavior was predicted by intentions. Attitudes and subjective norms toward HIV antibody testing accounted for a significant portion of the variance in intentions as predicted by the theory of planned behavior (Fisher et al., 1995). 16 Gener' SCVCIEI reason populations ti: highly educat 1995'. Godin these researcl differences (I the third leac paid minima Seco Planned belt Conducted t the theory . and intentit been IESted I993). TI]: distinct CO] in Pal'ticipanI hence ma} Edemlfi th Generalizations from these studies, however, should be evaluated with caution for several reasons. First, participants in these studies are not representative of a number of populations that are at risk for HIV infection. Participants were "primarily White," highly educated, bisexual and gay men, and heterosexual undergraduates (Fisher et al., 1995; Godin et al., 1997). Furthermore, women are not prOportionally represented among these research studies. Studies that include women in their sample fail to examine gender differences (Phillips, 1993; Fisher et al., 1995). Despite the fact that HIV/AIDS is now the third leading cause of death among all women in the United States, investigators have paid minimal attention to women (CDC, 1998). Second, these studies failed to assess all of the variables included in the theory of planned behavior. Godin etal.(1997) focused exclusively on intentions. Phillips (1993) conducted the only study on ethnic minorities, yet failed to assess critical components of the theory, such as attitudes and subjective norms toward testing. In addition, behavior and intentions were assumed to be one in the same. Individuals who reported to have been tested or intended to be tested within the next year were grouped together (Phillips, 1993). The theory of planned behavior clearly states that intentions and behavior are two distinct concepts. Third, elicitation research was not performed. Therefore, it is likely that participants were asked to respond to questions that were not appropriate or salient and hence may not have provided accurate results. It is important for researchers to initially identify the factors that influence HIV antibody testing among particular subgroups l7 though elicita Founh The instrumen anong Latinc formally Iran: paricipants (l the lllSlr‘dmCIl instruments t is one of the and techniqu 0an 8; .\I detelopment '"He- timolation OI Rl‘ddetez. ‘ each ofthe t through elicitation. Fourth, there is a lack of culturally and linguistically appropriate instruments. The instrument used in the single study that examined HIV antibody testing behavior among Latinos was written in English (Phillips, 1993). The instrument was never formally translated into Spanish. Interviews with monolingual Spanish speaking participants (25%) were conducted without a standardized or validated Spanish version of the instrument (Phillips, 1993). Research with culturally diverse populations requires instruments that are culturally appropriate. The translation of data collection instruments is one of the most important components in a research project with culturally diverse pOpulations (Marin & Marin, 19991). There are well-established translation guidelines and techniques to ensure accurate and culturally appropriate translation of instruments (Marin & Marin, 1991). Improper translations result in invalid findings. The development of culturally appropriate instruments, however, goes beyond the mere translation of an instrument (Marin & Marin, 1991; Rogler, 1989; Rogler, Malgady, & Rodriguez, 1989). It requires conducting a “subjective cultural study of a group” to identify the values, norms, beliefs, attitudes, and expectancies that are associated with each of the constructs to be studied for a particular group (Marin & Marin, 1991). The responses from this inquiry are then used to develop the instruments (Marin & Marin, 1991). Instruments that are culturally and linguistically appropriate contain language and constructs that are specific and relevant to the group being studied. Instruments that have been used to assess HIV antibody testing behavior among Spanish speaking participants 18 ’1 have not beer. culturally apt inherited by indit'idual su To 6... behat ior and HIV antibod: it requires c; addressed th rousing ex( utilizing cult Pfil‘lfiVlor 02’: that affect L “Ole that in ; [H636 facto; have not been developed exclusively for Spanish speaking individuals, which makes culturally appropriate and valid interpretations difficult. Cultural subgroups may be influenced by different norms and beliefs. Measures that are not developed for use with individual subgroups may fail to assess such idiosyncracies (Phillips, 1993). To date, investigators have failed to comprehensively assess the theory of planned behavior and the factors that predict the behavior of HIV antibody testing. Getting an HIV antibody test is a crucial AIDS-preventive act, but it remains poorly understood and it requires culturally and methodologically appropriate investigation. The present study addressed the lack of theory based-research and attention to ethnic minority women by focusing exclusively on Latinas and examining their HIV antibody testing behavior utilizing culturally appropriate constructs and conceptualizations. The theory of planned behavior offers a conceptual framework to begin to explore and understand the factors that affect Latinas and their decision to seek HIV antibody testing. Ajzen and F ishbein note that in addition to variables proposed by the theory, other variables (environmental or personal) may enhance prediction of a specific behavior; hence, they too should be included in the theoretical model (Ajzen, 1991; Ajzen & F ishbein, 1980). Several factors have been associated with HIV antibody testing behavior and may enhance researchers’ ability to predict HIV antibody testing behavior. The following discussion will elaborate these factors and their possible role in the theoretical model that was utilized to examine Latinas’ HIV antibody testing behavior. 19 ---1 . M‘, t 4\\r ISLIOIS u..\ ‘ ___.,—-—-— studies exars. - hate t‘ocuse; behatiors. d. current healt Most testing behal Sabogal 8; C testing beha' l; Catania ‘ Slgtilticaml' tested than ma? Yttlec indit ldua': related 10 . impomc into ~§ral pg Expanding the theog of planned behavior Factors associated with HIV antibody testing behavior Investigators’ attempts to elucidate the factors that predict testing patterns have been plagued by inconsistent and inconclusive findings (Wilson, et al., 1996). Few studies examining the factors that predict an individual’s decision to be tested for HIV have focused on Latinas. The factors that have been studied are participation in high risk behaviors, demographic factors (i.e. age, marital status, and socio-economic status), current health status, perceived HIV risk, and acculturation. Most studies report no significant relationship between age and HIV antibody testing behavior (Kalichman et al., 1996; Meadows & Catalan, 1994; Phillips, 1993; Sabogal & Catania, 1996). In addition, marital status does not significantly predict testing behavior among women (Battle et al., 1996; Meadows & Catalan, 1994; Sabogal & Catania, 1996). Income among a heterosexual sample of Latinos, however, was significantly related to HIV testing behavior. Middle class Latinos were more likely to be tested than those of lower income (Sabogal & Catania, 1996). These findings, however, may reflect the accessibility of testing services and health care among wealthier individuals. Research studies have failed to assess if level of education is significantly related to testing behavior among Latinas. Ajzen and F ishbein (1980) acknowledge the importance of sociodemographic variables but warn that they “do not constitute an integral part of [the] theory but are instead considered to be external variables” (p. 9). “There is no necessary relationship between any external variable and a given behavior” 20 by Ajzen and theoretical n‘, Pant . antibody test their Africar. participatior Studies that participatiort Women atter tested for H1 al.. l996). I category Pi 01“I.atin& a , Factors assti Cur Latina HIV and HIV an A xxx-la“) U" related 5‘” GOre. & B r (Ajzen & Fishbein, 1980, p. 85). The present study followed the recommendations made by Ajzen and Fishbein (1980) and did not include sociodemographic variables in the theoretical model. Participation in high risk behaviors has not been significantly related to HIV antibody testing among a general Latino population. Phillips (1993) found that unlike their African-American counterparts, there was no significant relationship between participation in high risk behaviors and rate of HIV antibody testing among Latinos. Studies that report significant correlations between HIV antibody testing and participation in high risk behaviors among ethnic minority women exclusively focus on women attending prenatal and family planning clinics, who did not voluntarily seek to be tested for HIV antibodies (Sorin, Tesoriero, & LaChance-McCullough, 1996; Miller et al., 1996). In addition, investigators grouped Latinas and African-American into a single category. Hence, it is not clear how representative the findings from these two studies are of Latinas and may therefore explain some of the inconsistency in findings. Factors associated with intention to be tested for HIV antibodies Current health status. Failing health is one of the most powerful motivators for Latina HIV-infected women to seek testing. Women most often seek medical attention and HIV antibody testing later in the course of the disease, have a higher number of sexually transmitted diseases and serious infections, and have a greater duration of HIV- related symptoms than do men (Kalichman et al., 1996; McAdam, Richardson, Lewis, Gore, & Brettle, 1997; Siegel et al., 1997; Siegel et al., 1998; Wortley et al., 1995). As 21 many as 40% related sympn medications I 1997). Siege six months at Fifty-sit pert they first sus African-Ami Decii afllibOdl leg: ft 21].. 1995 ). factor that it antibody {CS due to illne, We“ heai their d€terit STDS \Vew medical p“ repOn53d le< Ag many as 40% of peOple with HIV infection do not get tested until after they develop HIV- related symptoms, causing substantial delays in initiating antiretroviral and prophylactic medications (Kalichman et al., 1996; Rees Davis, Deren, Beardsley, Wenston, & Tortu, 1997). Siegel et a]. (1997) found that 23% of women in their study waited approximately six months after learning of their seropositive status before seeking medical treatment. Fifty-six percent of Puerto Rican women sampled waited over a year (M= 490 days) after they first suspected that they were HIV infected before seeking testing. In contrast, African-American and Anglo-American women delayed testing for less than a year. Decline in health status has been positively correlated with increased rates of HIV antibody testing among women (McAdam et al., 1997; Rees Davis et al., 1997; Wortley et al., 1995). Rees Davis et a]. (1997) found that a woman’s poor health was the only factor that increased the probability of being tested. In a study that assessed HIV antibody testing patterns, Wortley et a1. (1995) found that 62% of women sought testing due to illness. It appears that women’s intentions to be tested were influenced by their current health status; they wanted to discover whether HIV infection was the reason for their deteriorating health. McAdam et al.(l 997) found that women who had a history of STDs were more likely to express intention to be tested than those with no significant medical problems. Women who were asymptomatic and viewed themselves as “healthy” reported less intent to be tested for HIV antibodies than women who were HIV symptomatic or had a history of STDs (Siegel et al., 1998). As a result of seeking testing services at a later point in the progression of the 22 disease. the ti dramatically "r diagnosed n: diagnosed \Vi assess the in: can impact '.-. case of Latir. be tested. A heharior mg. :reater the d HIV antion int'estigator: Per. afillbod't- tee direction of“ 91132111. 8; t \ T‘r. into: his } a! disease, the time between HIV testing and the diagnosis of AIDS for Latinos is dramatically brief. Wortley et al. (1995) found that 39% of Latinos in their sample were diagnosed with AIDS within two months of taking the HIV antibody test; 56% were diagnosed within a year. Statistics for Latinas were not reported. Future research should assess the influence of current health status (illness and HIV symptoms) on Latinas’ decision to be tested for HIV antibodies utilizing the theory of planned behavior. The theory of planned behavior states that environment and/or situational factors can impact an individual’s intention to perform a specific behavior (Ajzen, 1991). In the case of Latinas, it appears that current health status may affect an individual’s intention to be tested. Accordingly, the effect of current health status on HIV antibody testing behavior may be mediated by intention to be tested. In other words, it is believed that the greater the decline in health the more likely that she will express intent to be tested for HIV antibodies, thereby increasing the rate of HIV antibody testing. To date, investigators have failed to explore this relationship. Perceived HIV risk’. Perceived risk for HIV infection is a predictor of HIV antibody testing. Studies, however, have produced contradictory findings regarding the direction of this relationship (McQuiston, Doerfer, Parra, & Gordon, 1998; Meadows, Catalan, & Gazzard, 1993; Phillips, 1993; Siegel_et al., 1998; Valdeserri, Moore, Gerber, 2 The terms perceived HIV-risk and perceived susceptibility are often used interchangeably in the literature to refer to an individuals’ subjective perception of his/her risk of HIV infection (Kowalewski, Henson, Longshore, 1997). The present study will use the term perceived HIV risk. 23 Campbell. Dil themselves to l993; Myers. reported that great risk for olPuerto le alach of test information 321ml‘les that “Omen at a WICEiVed H themselves risk {Meade Imet-VIEWS t 1‘th litem “-0an “hi l “altered It I fEmil leg. a “MF- Tl Campbell, Dillon, & West, 1993). Some researchers found that those who felt themselves to be at greater risk had stronger intentions to take the test (Meadows et al., 1993; Myers, Orr, Locker, & Jackson, 1993; Valdeserri et al., 1993). Phillips (1993) reported that 45% of Puerto Ricans and 13% of Mexican-Americans who perceived a great risk for HIV infection planned to test or had been tested for HIV. Among a sample of Puerto Rican women, however, perception of high risk for HIV infection was linked to a lack of testing (Siegel et al., 1998). Siegel et al. and Meadows et al. provide information related to the perceived consequences of testing among women in their samples that shed light on these contradictory findings. Meadows et al. (1993) surveyed women at a prenatal clinic and found that most women who intended to be tested perceived HIV antibody testing as having great benefits to their unborn child, partner, and themselves. Eighty-three percent of the women in this sample had low perceived HIV risk (Meadows et al., 1993). Siegel et a1 (1998), on the other hand, conducted in-depth interviews with women who had already received a diagnosis of HIV seropositive and asked them to discuss why and when they were tested for HIV antibodies. In this study, women who perceived themselves to be at risk for HIV infection and delayed testing evaluated the consequences of HIV antibody testing negatively. For example, some women expressed feeling frightened of knowing that they were HIV seropositive and, worried that if they were HIV seropositive they would be abandoned and shame their families, and did not want to have to disclose their HIV serostatus to their children and family. These findings suggest that individuals’ perceptions and salient beliefs 24 specifically r: through their contradiction relationship mediated b} risk were mt therefore hat intentions u WTCElVed } mOIE neg-fl IESIed' SI] Named be serOPOSIIIt betwem F Iouard}{. \l ami‘DQdE. meagra: ace U1 1;” Specifically related to their risk of HIV infection can affect their intention to get tested through their evaluations of the consequences of HIV antibody testing. Hence, contradictions among studies can be explained by the theory of planned behavior. The relationship between perceived HIV risk and intention to be tested for HIV antibodies is mediated by attitudes toward HIV antibody testing. Women who had low perceived HIV risk were most likely to evaluate the consequences of HIV testing as being positive, therefore having positive attitudes toward HIV testing, which then influenced their intentions to be tested (Meadows et al., 1993). On the other hand, women who had high perceived HIV risk evaluated the consequences of HIV testing as negative, thus having more negative attitudes toward HIV testing, which then influenced their intentions to be tested. Since previous studies have not tested all of the components of the theory of planned behavior utilizing a general population of Latinas (i.e., those who are not HIV seropositive or attendees at a prenatal clinic), the present study assessed if the relationship between perceived HIV risk and HIV antibody testing behavior is mediated by attitudes toward HIV antibody testing and intention. Acculturation: A moderating factor associated with HIV antibody testing behavior While the literature suggests there is a link between intention to be tested and HIV antibody testing behavior (e.g., Godin et al., 1997; Fisher et al., 1995), acculturation may moderate this relationship. Previous studies have commonly ignored the effects of acculturation on HIV antibody testing behavior. To date, only one research study has examined the relationship between acculturation and HIV antibody testing behavior 25 I l among Latin acculturated endorsed lov C atariia' s cc 0996) meas on languagcl acculturated ‘preferred a equal fluer measure 1: Language PIOCESS j IHIEracti Maidor‘ ‘1 file among Latinos (Sabogal & Catania, 1996). Sabogal & Catania (1996) found that highly acculturated Latinos were seven times more likely to have been tested than those who endorsed low levels of acculturation. Several flaws, however, plague Sabogal and Catania’s conceptualization and measurement of acculturation. Sabogal & Catania (1996) measured acculturation using a four-item questionnaire that focused exclusively on language use and, preference. Respondents were characterized as “highly acculturated” if they preferred and primarily spoke English and “low acculturated” if they preferred and primarily spoke Spanish. Individuals who spoke Spanish and English with equal fluency were characterized as highly acculturated. Sole reliance on items which measure language use and mastery, while ignoring values and beliefs, is problematic. Language use and mastery is only one of four major components of the acculturation process for Latinos. Accurate assessment of acculturation also involves measuring ethnic interaction, ethnic identity, and cultural traditions and values (Cuellar, Arnold, & Maldonado, 1995; Padilla, 1995). Therefore, it can be argued that acculturation was not accurately captured by Sabogal and Catania. Acculturation is a dynamic process of change and adaptation that results from continuous first-hand contact between individuals or groups of different cultures (Berry, 1995). Acculturation has traditionally been viewed as a unidirectional process (Berry, 1995; Cortes, Rogler, & Malgady, 1994; Szapocznik, Kurtines, & Fernandez, 1981); immigrants are engaged in adopting the host culture’s values and norms, while rejecting the values of their culture of origin. More recent views define the acculturation process 26 among Lati: simultaneoi origin and t acculturatit independe: American u incep ende culture. 5 Americar llllel’actig among L 35 a he: Hit a, Spams among Latinos as one of biculturality (Cortes et al., 1994). Biculturalism is defined as 3 simultaneously occurring acculturative process along both the individual’s culture of origin and the host culture (Szapocznik, et al., 1981). Cortes et al. (1994) propose that acculturation should be measured using a “two dimensional representation with independent scales measuring the level of Hispanic [Latino] involvement and the level of American involvement” (p. 711). The present study assessed acculturation utilizing two independent scales; involvement with Latino culture and involvement with American culture. Since acculturation (i.e., involvement with Latino culture and involvement with American culture) greatly impacts behavior, further investigation of these potential interactions is critical in understanding what contributes to HIV antibody testing behavior among Latinas. Involvement with Latino culture. High involvement with Latino culture can act as a barrier to HIV antibody testing. Latinas who are highly involved with Latino culture are more likely to speak or prefer to speak only in Spanish (Soriano, 1991). Many of the HIV antibody testing facilities lack Spanish-speaking staff (Soriano, 1991). Monolingual Spanish speaking Latinas will find it difficult to seek information regarding HIV antibody testing and communicate with staff to request to be tested. In addition to language, cultural values such as familismo (familism) may serve as a barrier to testing. Familismo has been used to describe the feelings of loyalty, reciprocity, and closeness shared among members of Latino families (Cortes, 1995; Sabogal, Marin, & Otero-Sabogal, 1987). It highlights the interdependence among Latinos and their extended family. Familismo is 27 guided by m polite. 3111le dictate that -. antithdV IC guided by notions of respeto (respect), confianza (trust), and personalismo (emphasis on polite, amicable, and personal communication) (Cortes, 1995). It is associated with the dictate that one’s nuclear and extended family, network of compadres and comadres (godfathers and godmothers, as well as close family friends that are considered kinship), and the clergy are the preferred emotional support and support systems. The obligation and loyalty toward family members and the need for the family to present a good image to the outside world proscribe that problems (e.g., drug use) and sexuality be kept private and hidden from others outside of the family (Amaro, 1988; Soriano, 1991). HIV antibody testing involves the possible disclosure of behaviors that may be viewed as “shameful” or disloyal to the family and may discourage a woman from seeking to be tested for HIV antibodies. Hence, Latinas who have the intention to be tested may not get tested due to the influence of familismo and cultural values that require confidentiality within the family. Involvement with Latino culture does not directly impact intention to be tested. However, high involvement with Latino culture may moderate the relationship between intention to be tested and HIV antibody testing behavior. Latinas can express intention to be tested for HIV antibodies regardless of their level of involvement with Latino culture. For example, women who are highly involved with Latino culture can still express great intent to be tested for HIV antibodies because of their deteriorating health, but may not actually get tested because of their inability to speak English and cultural values such as familismo or confiarzza. The degree to which intention to be tested is able to predict HIV 28 antibody testing behavior among Latinas may vary as a function of their involvement with Latino culture. While a Latina with the intention to be tested for HIV antibodies might be expected to be tested, this may not be the case if she is highly involved with Latino culture. This moderating effect may occur because involvement with Latino culture affects Latinas’ ability to access health care and discourages disclosure of one’s sexuality and high HIV-risk behaviors to those outside of her immediate family. Involvement with American culture. High involvement with American culture may help to strengthen the relationship between intention to be tested and HIV antibody testing behavior by acting as a facilitator. Latinas who are highly involved with American culture are more likely to speak English fluently and have more extensive contact with Anglo-Americans and other ethnic groups (Cuellar etal., 1995; Marin, Sabogal, Marin, Otero-Sabogal, & Perez-Stable, 1987; Soriano, 1991). Contact with other groups leads to the modification and/or adoption of new values, attitudes, language, and beliefs that may alter traditional help-seeking pathways to include traditional Western medicine, increase the level of knowledge related to HIV antibody testing, and facilitate getting tested at sites that are primarily staffed by English-speaking health professionals (Garza & Gallegos, 1995; Olmedo& Padilla, 1978; Williams & Berry, 1991). This interaction may explain the low rates of HIV antibody testing among Latinas who have limited involvement with American culture. Organista (1998) found that 50% of a sample of Mexican-American farrnworkers with limited involvement with American culture had erroneous beliefs regarding HIV antibody testing (e. g., the belief that one 29 couldconu:1 in addition '1 re} tionshi? latinos. All noted. the I institutions institutions help from i such as Hl‘ latinos hi: culture ma testing he." indit‘iduai HIV antit- and straig'. Latinas n) such disc. intentions \‘u' intention milderare could contract AIDS from taking the HIV antibody test) and were less likely to be teSted. In addition to language and beliefs, Anglo-American help-seeking patterns can impact the relationship between intention to be tested and HIV antibody testing behavior. Unlike Latinos, Anglo-Americans tend to solve problems with the aid of a professional. As noted, the Latino culture is founded on a tradition of reliance on the family and religious institutions for problem solving, and soliciting help from those outside of these institutions may be considered a form of “disrespect” (Rosado & Elias, 1993). Seeking help from professional health care providers (i.e., medical doctors or nurses) for services such as HIV antibody testing is not viewed as a violation of values or traditions among Latinos highly involved with American culture, hence involvement with American culture may moderate the relationship between intention to be tested and HIV antibody testing behavior. Finally, Anglo-American values emphasize self-dependency, and individual competition, and accentuate candid and direct communication (Torres, 1983). HIV antibody testing requires that the individual feel comfortable engaging in an open and straightforward discussion regarding behaviors such as drug use and sexuality. Latinas who are highly involved in American culture may feel more comfortable having such discussions with an HIV counselor and therefore follow through with their intentions to be tested and actually do get tested for HIV antibodies. While involvement with American culture does not directly impact Latinas’ intention to be tested for HIV antibodies, involvement with American culture may moderate the relationship between intention to be tested and HIV antibody testing 30 behavior. Ir antibody tes; with Amerit intolyemer; tested and i Sine been seekir for HIV Al I0 understa | one of the . Researche] SiOWQd an. factors afi‘ part ‘0 the SubgrOUp on Latin: explore 1 among 1 behavior. In other words, the degree to which intention to be tested is able to predict HIV antibody testing behavior among Latinas may vary as a function of their involvement - with American culture. To date, researchers have failed to assess the potential role that involvement with American culture may have on the relationship between intention to be tested and HIV antibody testing among Latinas. Rationale for the present study Since the onset of the AIDS epidemic in the United States, social scientistshave been seeking to understand AIDS preventive behaviors across populations that are at risk for HIV/AIDS. Latinas, however, are strikingly underrepresented in studies that attempt to understand and predict HIV antibody testing behavior, even though Latinas possess one of the fastest-growing rates of new HIV infection in the United States (CDC, 2000). Researchers have generally studied gay men, even though the incidence of new cases has slowed among this population (CDC, 1997). Studies have failed to demonstrate which factors affect HIV antibody testing behavior among different populations. This is due in part to the current literature’s failure to examine within group differences of cultural subgroups. The present study addressed this deficit in the field by focusing exclusively on Latinas. This exclusive focus provided the current investigation with the ability to explore thoroughly the factors of Latino culture that affect HIV antibody testing behavior among Latinas. Most research studies that attempt to identify predictors of HIV antibody testing is correlational and without any theoretical underpinnings. Even when theory has been 31 ‘7 nth. appredtc i planned beh. preventive t Jemmott & to compreh; the measure study the. a all of them Tne presc: IF: CUiIL‘LIa“: Willi 1h 6 dem'ed ISSUQS C 3‘an g dpp Cgf. applied to this topic area, the efforts have been insufficient. For example, the theory of planned behavior has been utilized by researchers attempting to understand AIDS preventive behaviors (Cochran et al., 1992; Fisher et al., 1995; Godin et al., 1997; Jemmott & Jemmott, 1991). The literature, however, is characterized by studies that fail to comprehensively assess all elements of the theory. The majority of studies emphasize the measurement of intention, but neglect to explore and assess behavior. To date, no study that attempts to explore HIV antibody testing behavior among Latinas has assessed all of theoretical underpinnings of the theory of planned behavior, specifically behavior. The present study is the first to address this deficit in current literature. In addition, current published studies ignore the importance of conducting culturally appropriate and valid investigations by failing to perform elicitation research with the population under study. Instead, researchers have relied on conceptualizations derived from other p0pulations and applied them to new groups without considering issues of validity. Studies that attempt to understand HIV antibody testing behavior among cultural subgroups must rely on concepts and methodology that are culturally appropriate and valid. The present study utilized the information provided by Latinas to develop appropriate conceptualizations of HIV antibody testing and methodology that is grounded in psychological theory. In order to better understand HIV antibody testing behavior among Latinas, a theoretical model of predictors was developed for the proposed study based on the theory of planned behavior, the literature on HIV/AIDS, and Latino culture (see Figure 2). This 32 research stu factors that Latinas. L‘r present stUc guidelines {LL it two med: moderating Annette an infl tuence a1" 1995 l bfihavior model } hi‘POIhes lie.. in“ included facmr in 1995 l. ( antibgd: ths r93: research study proposed to evaluate a theoretically-derived model aimed at identifying factors that will adequately predict HIV antibody testing behavior among a sample of Latinas. Unlike previous research that utilized the theory of planned behavior, the present study assessed all variables and conducted research in accordance with theoretical guidelines (Ajzen, 1991). The present study also extended Ajzen’s theory of planned behavior by adding to it two mediating variables (i.e., current health status and perceived HIV risk) and two moderating variables (i.e., involvement with Latino culture and involvement with American culture). Perceived HIV risk and current health status have been found to influence HIV antibody testing behavior (Meadows et al., 1993; Phillips, 1993; Rees Davis et al., 1997; Siegel, 1997; Siegel et al., 1998; Valdesserri et al., 1993; Wortley et al., 1995). However, the relationship between these factors and HIV antibody testing behavior among Latinas has never been empirically tested utilizing a theoretically based model. Hence, the present study sheds light on this relationship by empirically testing the hypothesized mediating relationship using the theory of planned behavior. Acculturation (i.e., involvement with Latino culture and involvement with American culture) was also included in the expanded model. Acculturation has been implicated as an influential factor in understanding the behavior of Latinos that reside in the United States (Padilla, 1995). Only one study has examined the relationship between acculturation and HIV antibody testing behavior (Sabogal & Catania, 1996). However, several problems plague this research study, namely the manner in which acculturation was defined, the 33 A..— instrurnent , pertorrned associate. dCVCIOPQ V acmitnst g instruments used to assess this phenomenon, and the lack of theory. The present study addressed such problems by defining and assessing acculturation among Latinas using a biculturalism model and instrument. The present study was conducted in two phases. First, elicitation research was performed to identify the salient beliefs, important referents, and difficulty level directly associated with HIV antibody testing among a group of Latinas. Second, instruments developed from the data produced in the elicitation phase of this research were administered to a larger sample of Latinas. Hypotheses Based on the review of the literature and implied pathways of the theory of planned behavior, the following hypotheses were posited: (Please refer to Figure 2) 1. Hypotheses Regarding how Attitudes toward HIV Antibody Testing, Subjective Norms toward HIV Antibody Testing. Perceived Behavioral Control and Current Health Status Influence Intention to be Tested 1a. A direct, significant positive relationship was predicted between attitudes toward HIV antibody testing and intention to be tested. Latinas with positive attitudes toward HIV antibody testing (ie., have positive salient beliefs about HIV testing and evaluate the consequences of testing as positive) will be more likely to intend to be tested than those with negative attitudes. See path A. 1b. A direct, significant positive relationship was predicted between subjective 34 norms and intention to be tested for HIV antibodies. Latinas who have positive subjective norms toward HIV antibody testing (i.e., believe that the important people in her life would approve of her getting the HIV antibody test and want to comply with referent’s wishes) will have greater intention to be tested than those who have negative subjective norms. See path B. 1c. Perceived behavioral control over HIV antibody testing is predicted to have a direct positive effect on intention to be tested for HIV antibodies. Individuals who have a low perceived level of control over HIV antibody testing behavior (i.e., view the behavior as difficult) will be less likely to intend to be tested. See path C. 1d. Current health status is hypothesized to have a negative direct effect on intention to be tested for HIV antibodies. Latinas with poor current health are more likely to have greater intentions to be tested than those who report no current health concerns. See path E. 2- WWW—m A direct, positive relationship is predicted between perceived HIV risk and attitudes toward HIV antibody testing. Latinas who perceive their risk for HIV as high will be less likely to have positive attitudes toward HIV antibody testing than those who perceived their risk for HIV as low. See path D. 35 '1. Hi-Fti‘ii‘. .tnerican O‘- hm\ ___ 3. Hypothesis Regarding the Relationship Between Intention to be Tested and HIV Antibody Testing Behavior A direct, positive relationship is predicted between intention to be tested for HIV antibodies and HIV antibody testing behavior. Latinas who express high intent to get tested will be more likely to get tested for HIV antibodies than those who express no intent. See path F. 4. Hypotheses Regarding Involvement with Latino culture and Involvement with American culture A woman’s involvement with Latino and American cultures will moderate the relationship between intentions to be tested and HIV antibody testing behavior. 4a. Women who score high on intention to be tested are less likely to be tested, when they are highly involved with Latino culture. See path G. 4b. Women who score high on intention to be tested are more likely to be tested when they are highly involved with American culture. See path H. 5. Hypothesis Regarding a Test of The Expanded Model of the Theog of Planned Behavior The expanded model of the theory of planned behavior is the better fitting model when compared to the original model proposed by Ajzen. 36 Participar; Pa: (M= 34. S- themselve- percent \c full time. participar SOmEOHe diagnosis SerOposit nature Of AIDS is l T inclUdeql METHOD Elicitation Research Participants Participants consisted of eighteen females between the ages of 20 and 60 years (M= 34, SD= 12.94) of Latin American descent. Sixty-seven percent identified themselves as Mexican-American, 22% Puerto Rican, and 11% Dominican. Sixty-seven percent were Catholic. Fifty percent had never been married and 44% were employed full time. Most participants completed high school (89%). Sixty-seven percent of participants reported never to have been tested for HIV antibodies, however, 83% knew someone who had been tested. None of the participants who were tested reported a diagnosis of HIV ser0positive but 72% reported knowing someone who was HIV seropositive. Half reported knowing someone who was diagnosed with AIDS. The nature of the relationship or contact the participant had with individual diagnosed with AIDS is unclear as it was not directly assessed by questionnaire. The participants were recruited in various community agencies (e.g., colleges, universities, HIV prevention community meetings, and Latino social clubs). All of the participants were recruited in Lansing, Michigan. Most participants (72%) chose to be interviewed in English. For further demographics see Table 1. Materials Demographic Questionnaire. Demographic information that was collected included: (a) age of the participant, (b) marital status, (c) religion, ((1) educational 37 attainment. . individuals instrument tell verse; E; hv the prin procedures six standart uuestionne referents 1' tested, 53 disadvan attainment, (e) ethnicity, (f) history of HIV antibody testing, and (g) knowledge of individuals who were tested for HIV antibodies or diagnosed with HIV or AIDS. The instrument was translated and backtranslated by bilingual bicultural Latina translators well versed in Mexican and Caribbean idioms of the Spanish language. See Appendix A. Elicitation research questionnaire. An open-ended questionnaire was developed by the principal investigator of the present study in accordance with the standard procedures outlined by Ajzen and F ishbein (1980). Ajzen and F ishbein (1980) provide six standard questions to be adapted to the specific behavior under study. The present questionnaire consists of six open-ended questions designed to elicit salient beliefs and referents for being tested for HIV antibodies, and the perceived ease or difficulty of being tested. Sample questions include “What do you believe are the advantages and disadvantages of you getting tested for HIV antibodies?” and “Are there people or groups who would approve of your being tested for HIV antibodies?” See Appendix A for a copy of the questionnaire. Procedure A structured interview was used as the method of data collection. All of the instruments and materials used in the study are English-Spanish bilingual instruments. Face-to-face structured interviews were conducted in English or Spanish, depending on the preference of the study participant, by the principal investigator who is a bilingual bicultural Latina. Participants were informed that the experiment was anonymous and that their responses will be kept confidential. Participants were advised that their 38 participation requir Participants vvere rt annime. They we: describing the pan. provided informed the Demographic 1" Participants were p lnformatior the responses for e. participation required answering a series of questions relating to HIV antibody testing. Participants were reminded that they might refuse participation or end the interview at anytime. They were then presented with an Informed Consent Agreement form describing the parameters of participation (See Appendix B). Once the participant provided informed consent the interview commenced. Participants were presented with the Demographic Questionnaire followed by the Elicitation Research Questionnaire. Participants were paid $10 for their participation at the end of the interview. Information obtained from the elicitation research was content analyzed. All of the responses for each of the six questions were transcribed. Duplicate items were removed. The principal investigator reviewed the remaining items and generated a list of categories that reflected themes in the data (Miles & Huberman, 1994). In order to ensure reliable categorization of responses, four raters (the principal investigator and three individuals who were blind to the study’s hypothesis) sorted all of the responses using the list of the categories. Raters were asked to group similar items into one category. Raters were also given the option to create additional categories if he/she felt none of the existing categories were an adequate representation of the response in question. Categories that included more than one response and had a 50% or more inter-rater reliability were selected and utilized to construct the measures of the theorized underpinnings of attitudes, subjective norms, and perceived behavioral control which were used during the prospective phase of this study (Ajzen & F ishbein, 1980). Raters consisted of one male (a graduate student in psychology) and three females 39 _ fist,“ _ (an admlIIISI for clients \\ and the prin raters had It working wi‘ Particip ants Part Mexican-A seven perce age (CDC. years Of ag Forty-two had childre number of Years (M: In regards (an administrator in an agency that provides educational services to health care providers for clients who are diagnosed with HIV/AIDS, an undergraduate student in psychology, and the principal investigator). Raters were not paid for their participation. Three of four raters had multiple years of experience in working in the field of HIV/AIDS including working with Latinos residing in Michigan. Prospective Research Participants - Participants consisted of 139 adult females of Latin American descent (e.g., Mexican-American, Puerto Rican, and Dominican) residing in Michigan. Since ninety- seven percent of all AIDS cases among Latinas have been among those under 65 years of age (CDC, 1998), the present study only recruited women who were between 18 and 64 years of age . Participants’ age ranged from 18 to 64 years (M= 31.42, SD= 10.23). F orty-two percent were married while 37% had never been married. Sixty-three percent had children. The majority of women (69%) were born in the United States and the number of years participants resided in the United States ranged from 4 months to 56 years (M= 24.15, SD= 14.17). Seventy-six percent chose to be interviewed in English. In regards to employment, 49% were employed. The mean number of years of education was 13.27 (SD= 3.43). All of the participants reported a negative or unknown HIV serostatus. Women who had a diagnosis of HIV seropositive were not eligible for participation in the current study, because there would be reason for them to be tested again in the firture. F orty-five percent of the women knew someone who was HIV 4o positive and 42°. 0 contact or relatior HIVAIDS is unl L'nlike p in SID or pren: in order to inter are also at risk local ESL clag (Ommmiity 3. Jackson. Kat interview at Clemggmp.n Al that qua , ‘9}? biting Parrjcip ”134m: (\\afi incl positive and 42% knew someone who had been diagnosed with AIDS. The extent of contact or relationship participants had with individuals who were diagnosed with HIV/AIDS is unknown as it was not directly assessed. Unlike previous research, the participants for the present study were not recruited in STD or prenatal clinics. Participants were recruited primarily in non-medical settings in order to interview women who have not been represented in the existing literature but are also at risk for HIV. Latinas were recruited in schools (i.e., colleges, universities, local ESL classes), social groups, churches, community based organizations, and community agencies located throughout Michigan (i.e., Ann Arbor, Grand Rapids, Jackson, Kalamazoo, and Lansing). Participants were paid $10 for completing the initial interview and $5 for the follow-up interview. Table 2 contains more detailed demographic information pertaining to the Latinas in the present sample. Materials All of the instruments used in this study are in Spanish and English. Instruments that did not exist in Spanish were translated into Spanish and back translated into English by bilingual and bicultural Latinos to assure proper translation and meaning. Since participants represented several Latino subgroups, the Spanish vocabulary used in the instruments contains all appropriate variations of the word and avoids colloquialisms (Marin & Marin, 1991). See Appendix C for a copy of the instrument. Demographic Information Questionnaire. Demographic information collected includes: (1) age of the participant, (2) marital status, (3) level of education, (4) religion, 41 (5) birthplace. tor household inc orr HIV antibody re diagnosed With Current a Bil-item instr related symptt questionnaire iniotmation and a I4-ite Participant questionn; lDeMarcc questlom Sl’mtbttsr “ems I] “11086 indh\‘\ \Y'efiyx' 34- (5) birthplace, (6) immigration history, (7) generational status, (8) occupation, (9) household income, (10) number of children, (11) contact with anyone who has sought HIV antibody testing, and (12) contact with anyone who is HIV positive or has been diagnosed with AIDS. Current Health Status Questionnaire. The Current Health Status Questionnaire is a 30-item instrument that assessed participants’ overall health status and HIV/AIDS- related symptoms. This instrument consists of two questionnaires: a 16-item questionnaire developed by Folkman, Chesney, Pollack, & Coates (1993) to elicit information regarding the presence of symptoms related to HIV/AIDS within the last year and a l4-item questionnaire that was designed by the present author to assess participants’ overall current health status during the last year. The F olkman et al. questionnaire has been frequently used and found to be a reliable and valid measure (DeMarco, 1998; Folkman, Chesney, Pollack, & Coates, 1993). The Folkman et al. questionnaire required participants to indicate whether they had experienced each of the symptoms during the last year by checking all of the items that applied. Questionnaire items that assessed overall health status were derived from consultations with physicians whose patients include individuals with HIV/AIDS, personal experience working with individuals who are HIV positive and health care providers, and HIV/AIDS certification training seminars for case managers in the state of Michigan. Overall health was rated on a 4-point Likert scale (l= excellent, 4: very poor) and the remaining items required that the participants respond with a Yes (scored as 1) or No (scored as 0) answer. Sample 42 items include the last year?" The Cor appropriate ins Cortes et al. (I dalelol’ed Ilm rim-hour gym the Creation ( mmughout 1 Preferences. 33‘ of nine 1 nine 318mg : mUch are ‘1 Part of E’Q\ De this Scale PUenO RI Scale QQU IElaIed 1C items include the following: “Have you sought treatment for any health problem in the last year?” The CortesLRogler, and Malgady Biculturalism scale. In response to the lack of appropriate instruments to measure acculturation among Latinos (i.e. Puerto Ricans), Cortes et al. (1994) developed a scale to measure biculturalism. The scale items were developed through the use of cultural consultants or focus groups. Members met for six, two-hour group meetings to discuss their experiences. Discussions focused on p_ue_str_a manerJaLde ser (our way of being). Group discussions were content analyzed, resulting in the creation of eighteen items representing various themes. The major themes that arose throughout the discussions were language preference and usage, values, ethnic pride, food preferences, child rearing practices, and interpersonal relations (Cortes et al., 1994). One set of nine items assess the degree of involvement in Latino culture, and a parallel set of nine items reflected degree of involvement in “American” culture. For example, “How much are American values a part of your life?” versus “How much are Latino values a part of your life?” Despite its previous exclusive use with Puerto Ricans, the present study utilized this scale for all Latinas in the sample. The word Latino was inserted in the place of Puerto Rican. D. E. Cortes (personal communication, September 1, 1998) states that this scale could be used for assessing biculturalism among other Latino subgroups. Items related to food were recorded on a scale of 1 to 7. Items regarding language, pride, and enjoyment of Spanish or American television programs required individuals to respond 43 on a 5 point ratir enjoy speaking i Spanish. All of subscale. highe designed to eli questions hav- perception an and by the m STOUpS inclu Hulley, 199 I9931Nyan 1993.“), par from (I) \‘ Chances m At \ Sfimaniic on a 5 point rating scale. For example, responses to the question, “How much do you enjoy speaking Spanish?,” range from (1) tremendous enjoyment to (5) do not speak Spanish. All of the remaining items were recorded on a 4-point rating scale. For each subscale, higher scores indicate greater involvement in the culture. Perceived HIV risk. Perceived HIV risk scale consisted of three questions designed to elicit participants’ subjective perceptions of risk for HIV infection. These questions have been used by researchers at the Centers for Disease Control to assess risk perception among women across the United States and Puerto Rico (Miller et al., 1996) and by the majority of investigators focusing on HIV/AIDS research among different groups including Latinas (Catania, Coates, Kegeles, Fullilove, Peterson, Marin, Siegel, & Hulley, 1992; DiClemente, 1991; Kalichman, Hunter, & Kelly, 1992; Meadows et al., 1993; Nyamathi et al., 1993; Phillips, 1993; Simon, Morse, Balson, Osofsky, Guamer, 1993). Participants were asked to respond to questions on a 4-point Likert scale ranging from (1) Very good chance to (4) No chance at all. Sample question is “What are the chances that you will get the AIDS virus (HIV) sometime in your lifetime?” All items were reverse coded. Attitudes toward HIV antibody testing. The present instrument was created by the present author following the established guidelines and format by Ajzen and F ishbein (1980). General attitudes toward HIV antibody testing were measured using five 7-point semantic differential scales (-3= bad to +3= good; ~3= foolish to +3= wise; -3= unpleasant to +3= pleasant; -3= useless to +3= useful; -3= harmful to +3= beneficial). 44 ICSIt 331C 6X r1 3 Items were summed and a mean was calculated and used as indicator of attitudes toward HIV antibody testing. Beh_avioral beliefs Twenty-two salient behavioral beliefs about the outcomes/consequences of getting tested for HIV antibodies within the next month were identified in the elicitation research and were used to assess behavioral beliefs in the prospective research. Respondents rated each of the 22 behavioral beliefs on a 7-point Likert scale (1= extremely unlikely to 7= extremely likely) (range= 22 to 154). Outcome Evaluations In order to measure the individual's evaluation of the outcomes, participants were asked to judge each of the 22 beliefs regarding the outcomes of getting testing for HIV antibodies using 7-point Likert scale (-3 extremely bad to +3 extremely good) (range: - 66 to =66). Subjective norm toward HIV antibody testing. One item was used to assess overall subjective norm. Participants were asked to respond on a 7-point Likert scale (-3 extremely disapprove to +3 extremely approve) to the question “If you got tested for HIV antibodies within the next month, most people who are important to you would _ ” Norm_ative beliefs This scale assessed respondents’ subjective norms toward HIV antibody testing-- their perception of whether specific referents would approve or disapprove of the participant getting tested for HIV antibodies. Elicitation research findings revealed 45 dance behavi ponu' lfyot uho rnont appr infl thirteen referents identified by Latinas as influential in their HIV antibody testing behavior. Participants were asked to rate each of the thirteen normative beliefs on a 7- point Likert scale (-3 strongly disapprove to +3 strongly approve). Sample items include: If you got tested for HIV antibodies within the next month, your mother (or the person who is a mother figure in your life) would . If you got tested within the next month, most of your friends would . Higher scores indicate greater perceived approval by referents. Motivation to comply In addition to normative beliefs, the individual’s subjective norm is also influenced by her motivation to comply with each referent (Chan & Fishbein, 1993; F ishbein & Ajzen, 1975). Hence, respondents were asked to indicate the likelihood that they would comply with each of the 13 referents by answering questions such as, “Generally speaking, you do what your mother (or the mother figure in your life) wants you to do,” on a 7-point scale from (1) Not at all to (7) Very much (Ajzen & Fishbein, 1980). Perceived behavioral control. Perceived behavioral control over HIV antibody testing was assessed by using four items taken from scales used by Ajzen and his colleagues (Ajzen & Madden, 1986; Ajzen, Timko, & White, 1982; Madden et al., 1992; Schifier & Ajzen, 1985). Respondents were asked to respond to the questions using a 7-point Likert scale. Sample questions include, “For me to be tested for HIV antibodies in the next month would be [(1) very difficult to (7) very easy] and “How much 46 H: -—._ control do you it absolutely no cc lntentior month was asse antibodies with Il=extrerne\g interview. I “Emitting time 3&3?“ involves appoinrr Page“? 633.1 gr HOme 3 lick hQY ‘lit, control do you have over getting tested for HIV antibodies in the next month? (I) absolutely no control to (7) complete control. Intention to be tested. Intention to be tested for HIV antibodies within the next month was assessed by one item (Ajzen & Fishbein, 1980): “I intend to be tested for HIV antibodies within the next month.” Respondents were asked to respond on a 7-point scale (1=extremely unlikely to 7: extremely likely). HIV antibody testing behavior. Behavior was assessed one month after the initial interview. HIV antibody testing requires planning by individuals, therefore researchers examining HIV antibody testing behavior have utilized “one month” as the amount of time appropriate for assessing testing behavior (Fisher et al., 1995). HIV antibody testing involves several steps (e.g., getting information about available testing sites, making an appointment, getting tested, and returning for the results). Questionnaire consists of twenty items that were developed by the principal investigator of this study and are designed to elicit information related to HIV antibody testing at a testing site or using a Home HIV test kit. Questions were based on information obtained from experts at the Michigan Department of Community Health, HIV counselors, representatives of the only home HIV test kit (i.e., Home Access Health), and current HIV antibody testing literature. Bragging Recruitment efforts included approaching all Latina women at the various recruitment sites (i.e., social clubs, churches, community based organizations, colleges, 47 and universities l the various sites met specific eh; American desc addition to on- agencies, chu COPY 0f the i one her in INKS QWduct tl Participa- IreEmmet SQthES Dani ci Panic QfinQ mitt in la and universities) to participate in this study. Staff, counselors, pastors, and instructors at the various sites were asked to help in the recruitment process by identifying Latinas who met specific eligibility criteria for participation in the study (i.e. must be of Latin- American descent, reside in the United States, and be between the ages of 18 and 60). In addition to on-site recruitment, flyers were distributed and posted at colleges, community agencies, churches, and stores that service the Latino community (see Appendix D for a copy of the flyer). Once the potential participant was identified, the principal investigator contacted her in person or by phone and requested her voluntary participation and arranged a date to conduct the interview if the present time was inconvenient. In order to ensure that the participant did not suffer any possible negative consequences, such as differential treatment by the referral source, and to prevent breaches of confidentiality, referral sources were not informed if the identified potential participant agreed or did not agree to participate in the study. Interviews were conducted in a setting agreed upon by the participant and interviewer. Participants who responded to the flyer contacted the principal investigator by using an 800- telephone number that was listed. During the initial contact, respondents were informed about the study and were asked to provide consent to participate in the study (see Appendix E for a copy of the consent form). Initial interviews were conducted by one of two trained interviewers (principal investigator or a Latina bilingual bicultural Mexican-American graduate student in social work). Participants were informed that their identity and responses would be kept strictly 48 confidential. P: series of questit living in the L" permission to interview (Se. provide cont: contact the p Participants r€5ponses c COHIICIEnti; “Urnbers, and the li: A instrumE Face-10_ ‘he met $h0\\n and re hue“? bA‘Qai that confidential. Participants were advised that their participation would require answering a series of questions relating to HIV/AIDS, their health, and their experiences as a Latina living in the United States. In addition, they were asked to provide the researcher with permission to contact them in a month for follow up questioning regarding the first interview (See Appendix F for a copy of the Contact Form). Participants were asked to provide contact information for themselves and 3 other people who would be able to contact the participant if she were to move, change address or telephone number. Participants were informed that the Contact Form would not be stored with their responses or in the same locked file cabinet as the interview to ensure participants’ confidentiality. Every survey and contact form had matching subject identification numbers. The primary investigator was the only person with access to the contact forms and the list of matching subject identification numbers. A structured interview was used as the method of data collection. All of the instruments and materials used in the study were English-Spanish bilingual instruments. Face-to-face structured interviews were conducted in English or Spanish depending on the preference of the study participant. Similarities in ethnicity and gender have been shown to enhance the establishment of rapport, willingness to disclose, and the validity and reliability of the data collected (Marin & Marin, 1991). Hence, participants were interviewed by bilingual (English-Spanish) Latinas. This is particularly important because a great number of questions that were asked related to HIV and sexuality- topics that are considered “taboo” and may not be openly discussed unless the individual feels 49 comfortable tvitl Participc. the parameters \ 7 or end the intert were given the t participation lnSIIUmemg v Questionnai‘ Risk. Minn Testing, p the inte” and Were Parnth primar comfortable with the interviewer. Participants were presented with an Informed Consent Agreement form describing the parameters of participation. They were reminded that they might refuse participation or end the interview at anytime. After reading the Informed Consent form, participants were given the opportunity to ask questions or voice any concerns regarding their participation. Once the participant provided her informed consent, the interview began. Instruments were presented in the following order: Demographic Information Questionnaire, Current Health Status Questionnaire, Biculturalism Scale, Perceived HIV Risk, Attitudes toward HIV Antibody Testing, Subjective Norms toward HIV Antibody Testing, Perceived Behavioral Control, and Intention to be tested. Upon completion of the interview, participants were given the opportunity to ask questions of the interviewer, and were asked to review the information on the Contact Form to ensure its accuracy. Participants were paid $10. Participants were also provided with a business card with the primary investigator’s name and phone number if they had any further questions or concerns, or to obtain information regarding results or publications. The principal investigator or the undergraduate female research assistant contacted participants one month after the interview in order to assess HIV antibody testing behavior. Participants were not asked to provide any information regarding their HIV serostatus during their follow up interview. The primary investigator made up to three attempts to contact the participant at the telephone number provided by the participant. If participant did not respond after the third attempt, the primary investigator 50 called the indiv had been asses~ contact forms \ follow-up inter Interviewer tr: The a included dist and instrum Privacy an: Situations t The interx IEChniqUC Conductir called the individuals listed in the Contact Form. Once the HIV antibody testing behavior had been assessed, the primary investigator mailed her a $5 money order and participants’ contact forms were destroyed to ensure anonymity of responses after both the initial and follow-up interviews were completed. Interviewer training The author of the present study trained all interviewers. Training sessions included discussions regarding: (a) the topic of the study, (b) the purpose, (c) the method and instruments, (d) the environment where the data will be collected, (e) issues of privacy and confidentiality, and (f) recommendations about how to handle hypothetical situations that may arise in the interview. Interviewers conducted two mock interviews. The interviews were reviewed for accuracy of recording responses and interviewing technique. The primary investigator provided feedback to interviewers prior to conducting their first interview. Interviewers were kept blind to the study’s hypotheses. 51 the analyses o‘t observed varial made. The arr behavior was j WW. and B‘. the Values f0} 21 scale result (Hoyle, 199:- values Was c AIFNORM, analyseS We skeuneSS “ and SkeWne except fOr I and CAM); these Ihree Are RESULTS Structural equation modeling (SEM) was used to test the hypothesized relationships in the extended model of the theory of planned behavior (Figure 2). Prior to the analyses of the hypotheses, decisions regarding missing data, nonnorrnality of observed variables, and the measurement properties of the scales for this sample were made. The amount of missing data for the extended model of the theory of planned behavior was less than 10% for all variables except for COMNORM (45%), IFNORM (46%), and BEHAVIOR (17%). COMNORM and IFNORM were created by summing the values for items in their respective scales. Therefore, missing values for items within a scale resulted in the exclusion of cases. This decreased sample size can affect results (Hoyle, 1995). In order to address the problem of missing data, the mean of the observed values was calculated and used in all analyses. Two variables (ACOMNORM and AIFNORM) were created to represent these changes. The final sample size for the analyses was 139. The data was also examined to determine if excessive kurtosis and skewness were present, as these characteristics can also affect the results. Kurtosis (KU) and skewness (SU) values for most variables were adequate (range fiom -l .23 to 1.57) except for BEHAVIOR (KU= 37.38, SU= 5.80), CLATXCE] (KU= 9.17, SU= 18.49), and CAMXCEl (KU= -1.87, SU= -3.20) indicating that the distribution of scores for these three variables is nonnorrnal. A review of the measurement properties of the scales used to assess the latent 52 constructs in if determine if tl‘ literature. Fo uneconduct between the To detennir lncrenienra_ were exam explorator Structure Principal deleted : d‘xSCI’Ep, than th reStrl Beh constructs in the extended model of the theory of planned behavior was necessary to determine if the collected data fit the hypothesized factor structure reported in the literature. For scales consisting of 5 or more items, confirmatory factor analyses (CFA) were conducted using AMOS to determine if there was an acceptable degree of fit between the observed data and the hypothesized factor structure for each questionnaire. To determine degree of fit, Comparative Fit Index (CPI ), Tucker- Lewis Index(TLI), Incremental Fit Index (IF I), and Root Mean Square Error of Approximation (RMSEA) were examined3. For those measures that did not have an acceptable degree of fit, exploratory factor analyses (EF A) were conducted using SPSS to improve the factor structure of these measures. All exploratory factor analyses were conducted using a principal components factor analysis with a Promax rotation. Items were generally deleted if : (1) factor loadings were below .40; (2) an item loaded on two factors and the discrepancy between the item factor loadings was less than 0.30; or (3) a factor had less than three items that met the above requirements. These preliminary steps led to the improved measurement model (Figure 3) which was then used to analyze the hypothesized relationships between the constructs. The results of the preliminary steps for the Extended Model of The Theory of Planned Behavior are presented in the following section. 3Guidelines for interpreting CF I, TLI, and IF I: 1.00= ideal fit; 0.90-0.99= excellent fit; 0.85- 0.89= average fit; <0.85 = poor fit. Guidelines for interpreting RMSEA: 0.00-0.05= excellent fit; 0.05-0.08= moderate fit; 0.08-0.10= acceptable fit; >0.10= poor fit (Bollen, 1989; Hoyle, 1995). 53 Please It measures. const and the Key for abbreviations ‘ measure and s This were IQmOV they did nc demograpp lack Q{ \‘2 Stale. T OX’era“ ‘ Perfgm 93? Chi 3% igq}; Review of Measurement Model Please refer to the measurement model (Figure 3) for the factor structures, measures, constructs, and pathways in the Extended Theory of Planned Behavior Model and the Key for the Measurement Model for an outline of the measures, scales, and abbreviations used in the model. The means, standard deviations, and range for each measure and subscale are listed in Table 3. Current Health Status (CHEALTH) This measure was used to assess participants’ current health status. Six items were removed prior to the analysis of the psychometric properties of the scale because they did not provide information regarding current health status. Instead, they provided demographic information regarding the present sample. Descriptive statistics revealed a lack of variance for eighteen items. Those items were, therefore, also removed from the scale. The final version of the scale consisted of four items (a =.44): two items related to overall current health status and two from the F olkman et al. scale. A CFA was not performed. The scale is represented by CHEALTH in Figure 4. See Table 4 for psychometric properties of the scale. Higher scores indicate poorer health status. The Cortes, Rogler, and Malgady Biculturalism Scale This measure was used to assess acculturation. Participants’ level of acculturation is defined as their score on each scale--their level of involvement with Latino culture and American culture, independently. Involvement with Latino Culture subscale1CLATIN). The initial CF A for the 54 _..- a... in... as“ Involvement ' data [7,3 (of: .08]. Items rt do not speak final scale cc acceptable (( Critt literature on I: Second g inmeunne “ith genera mimber of: correlations ObSenred St is repTCSen 12s 1“\'Ol\’emg anexeerie IFI§ with Lati; Involvement with Latino Culture (LATIN) subscale demonstrated an excellent fit for the data [x2 (df 27, N=139) = 49.53, p<.001, CFI= 0.99, TLI= 0.99, IFI= 0.99, RMSEA= .08]. Items related to food preferences and comfort level associating with Americans who do not speak Spanish were deleted from the scale to increase internal consistency. The final scale consisted of seven items. The internal reliability for this sample was acceptable (or: .72). Criterion validity was evaluated through the use of indicators noted in the literature on acculturation (Cortes et al., 1994): generational status (0= first generation, 1: second generation or more), language (1= English, 2= Spanish), and number of years in the United States. Involvement in Latino culture scale was significantly correlated with generational status (5 -.25, p<.05) and language (r= .20, p<.05). Correlation with number of years failed to reach significance (r: -. l 6, p>.05). In order to reduce high correlations between variables in the model, LATIN variable was centered (mean - observed score). The centered score (CLATIN) was used in all SEM analyses. This scale is represented by CLATIN in Figure 4. High scores indicate greater involvement with Latino culture. See Table 5a for additional psychometric properties of the scale. Involvement with American Culture (CAMERICA). The initial CFA for the Involvement with American Culture (AMERICAN) subscale indicated that the data was an excellent fit for the data [,8 (df 45, N=139) = 38.28, p<.001, c1=1= 1.00, TLI= 1.00, IFI= 1.00, RMSEA= .06]. Items related to food preferences and comfort level associating with Latinos who do not speak English were deleted from the scale to increase internal 55 #:- consistency. t,) (a: .7 ). Crit literature on of years in t - a. niticantlj (I) (L) It and number Correlation: I mean - ob: analyses, ' greater inv properties Weak relat Th cOnsisted IIEm_tO 1&1 Was rEmO abOut bfiir consistency. The final scale consisted of seven items. Internal reliability was acceptable (a= .73). Criterion validity was evaluated through the use of indicators noted in the literature on acculturation (Cortes et al., 1994): generational status, language, and number of years in the United States. The scale measuring involvement in American culture was significantly correlated to generational status (r=.23, p<01), language (1;: -.33, p <.01), and number of years living in the United States (_r_= .20, p <.05). In order to reduce high correlations between variables in the model, the AMERICAN variable was centered (mean - observed score). The centered score (CAMERICA) was used in all subsequent analyses. This scale is represented by CAMERICA in Figure 4. High scores indicate greater involvement with American culture. See Table 5b for additional psychometric properties of the scale. The correlation between the two scales of involvement yielded a weak relationship (.03). Perceived HIV risk (REVRISK) This measure was used to assess participants’ perceived risk for HIV. The scale consisted of three items, therefore, a CF A was not performed. Due to a low corrected item-total correlation, the item regarding level of concern about being infected with HIV was removed from this scale. The item appears to have assessed participants’ anxiety about being infected rather than their perception of HIV risk. All items were reverse coded. Scores for the two remaining items were summed to obtain an overall score for perceived HIV risk (REVRISK). This scale is represented by REVRISK in Figures 4 and 56 5. Higher sc reliability (or Attitude to“ m participants differential planned bet indicated a: 0.85, 1H: ( ‘36) This : more positi psychomet 3;} the Sum of COUCSPODC toward HT EValuate u Stud): Th CF]: 088 BEhavl'Ora 5. Higher scores indicate greater perceived HIV risk. This scale demonstrated adequate reliability ((1: .88). Table 6 contains psychometric properties of the scale. Attitude toward HIV antibody testing Attitude toward HIV antibody testing (MATT). This five item scale measured participants’ attitude toward HIV antibody testing. The mean of the five semantic differential items was considered a direct measure of attitude as outlined by the theory of planned behavior (Ajzen, 1988). The initial CFA of this hypothesized one factor scale indicated an adequate fit for the data [)8 (df 5, N=1 39) = 31.40, p_<.OOl, CFI= 0.95, TLI= 0.85, IF I: 0.95, RMSEA= .20]. The internal consistency of the scale was acceptable (a= .86). This scale is represented by MATT in Figures 4, 5, and 6. Higher scores indicate more positive attitudes toward HIV antibody testing. See Table 7 for additional psychometric properties of the scale. Miofleliefs and Outcome Evaluations (GH). According to Ajzen (1991), the sum of the cross-products of the twenty-two behavioral beliefs and their corresponding evaluations can be viewed as an indirect measure of individuals’ attitudes toward HIV antibody testing. This questionnaire required participants to rate and evaluate twenty-two behavioral beliefs identified during the elicitation phase of this study. The initial CF A demonstrated a poor fit [)8 (df 209, N=139) = 772.638, p<.001, CFI= 0.88, TLI= 0.85, IF I= 0.88, RMSEA= .14] for the data. The internal consistency of the scale was acceptable (0: = .76). As predicted by the theory of planned behavior, Behavioral Beliefs scale and Outcome Evaluation scale were significantly correlated with 57 “—— Attitudes tow respectitely). Beliefs (a :9 data an indirt See Table 8 f antibody test Suby consisted of thirteen refc disapprove Scale is a Q mfemur (a: beliefs reg; (Allen, 19 [7.2 Ni 65, A“ EPA t. items 1‘ng conta'm e d subjeqi“ boil] faCtt Attitudes toward HIV Antibody Testing Behavior (MATT) (_r= .32, 9 <01; 1: .23, 2 <0], respectively). Each independent scale had acceptable internal reliability [(Behavioral Beliefs (a =.9l) and Outcome Evaluations Scale (on = .82)]. Due to the poor fit of the data, an indirect measure (GH) of attitudes was not used in the analyses of the model. See Table 8 for psychometric properties of the scale. In summary, attitudes toward HIV antibody testing is represented solely by the semantic differential scale (MATT). Wm Subjective norms were measured by two scales. The Normative Beliefs Scale consisted of 13 items that assessed participants’ perception of whether each of the thirteen referents identified in the elicitation phase of this study would approve or disapprove of their getting tested for HIV antibodies (F96). The Motivation to Comply Scale is a thirteen item scale that measured participants’ motivation to comply with each referent («F .89). Subjective norms is operationalized as the multiplicative product of beliefs regarding referents’ wishes and the participants’ motivation to comply with them (Ajzen, 1991; Ajzen & Fishbein, 1980). The initial CFA indicated a poor fit for the data [x2 (df 65, N=139) = 346.27, p<.001, CF I= 0.80, TLI= 0.73, IFI= 0.81, RMSEA= .18]. An EFA with a Promax Rotation supported a two factor solution; the first factor included items regarding God and nuclear family’s subjective norms, whereas the second factor contained items regarding community and more biologically distant family members’ subjective norms. See Table 9 for factor loadings. Alpha reliabilities were acceptable for both factors [Immediate Family Norms (IFNORM) a: .87; Community Norms 58 (COMNORM: Accord correlated with subscale was s Subjective No correlated (_r= Subscales \Vel additional p5} A signifi COMNORM were absent items blank, ‘he initial su prevent the . 511m Scores paniclIJant. COmpleted 1 [hErefore’ r Scores “as (COMNORM) a =.87]. According to the theory of planned behavior, subscales should be significantly correlated with the overall measure of subjective norms. The Immediate Family Norms subscale was significant correlated (_r= .59, p <.01) with one item that assessed general Subjective Norms(Il). The Community Family Norms subscale was significantly correlated (_r= .39, p<.01) with the item measuring general Subjective Norms scale. Subscales were kept separate in all SEM analyses. See Table 10 and Table 11 for additional psychometric properties of the scales. A significant amount of data (45%) was missing in both variables (IFNORM and COMNORM) due to participants’ lack of response to items that pertained to referents that were absent in their lives. For example, participants who did not have siblings left those items blank. As a result of missing data, only 76 cases were included in the calculation of the initial subjective norms score. In order to address the problem of missing data and to prevent the exclusion of cases, overall scores for the two factors were revised. Separate sum scores for items in the IFNORM and COMNORM factors were calculated for each participant. The sum score for each participant was then divided by the number of items completed by the participant. The final subjective norm values for each participant, therefore, represent the mean score of their observed responses. The mean of observed scores was used to reflect participants’ immediate family norms (AIFNORM) and community norms (ACOMNORM) and used in analyses of the model. These scales are represented by AIFNORM and ACOMNORM in Figures 4, 5, and 6. High scores on 59 both scales ine- tested for HIV Perceived bel‘ This ft getting tested ' total correlatit coefficient of represented t properties of intention to .\ Inter likely is h 1‘ resPOnded . Th and Was a. queSIian QYGEr to E Variance. The final both scales indicate a greater perceived approval by referents for the participant to be tested for HIV antibodies. Perceived behaviorammtrol (PCONTROL) This four item measure assessed how much control participants’ felt they had over getting tested for HIV antibodies. One item was removed due to a low corrected item- total correlation and to increase internal reliability. Reliability analysis yielded an alpha coefficient of .60 for the remaining 3 items. A CF A was not performed. This scale is represented by PCONTROL in Figures 4, 5 , and 6. See Table 12 for psychometric properties of the scale. Intention to be tested for HIV antibodies (CEI) Intention to be tested for HIV antibodies was measured using one item. How likely is it that you will be tested for HIV antibodies within the next month? Participants responded on a l to 7 Likert scale. This item is represent by CE] in Figures 4, 5, and 6. HIV antibody testing behavior (BEHAVIOR) This 20-item questionnaire assessed participants’ HIV Antibody Testing Behavior and was administered one-month after the completion of the initial interview. The questionnaire consisted of items relating to the number of steps needed to be taken in order to be tested for HIV antibodies. Sixteen items were removed due to a lack of item variance. An additional item was removed due to a low corrected item-total correlation. The final scale consisted of three items. Therefore, a CFA was not performed. All items were scored on a scale of 0= No to 1=Yes. The internal consistency was acceptable (a= 60 .79). This sc. psychometric behax'ioral stt each hypothe Equation Mt rePresented [he Objectix (HOSE, \e suc‘n as C, indiCaIOr eTTOr in eSIimE mgde and COVE 199 XX“ e .79). This scale is represented by BEHAVIOR in Figures 4, 5, and 6. See Table 13 for psychometric properties of the scale. Higher scores indicate a greater number of behavioral steps taken toward getting tested for HIV antibodies. Results of the Hypotheses The following section will discuss the results of the hypotheses in the model. For each hypothesis in the Extended Model of the Theory of Planned Behavior Structural Equation Modeling (SEM) analyses were conducted using the scales discussed above and represented in Figure 4. SEM is a confirmatory statistical methodology that allows for the objective evaluation of the adequacy of fit of a theoretical model to the collected data (Hoyle, 1995). The advantages of using SEM over standard approaches of data analysis such as correlation, multiple regression, and ANOVA are: (1) SEM allows for multiple indicators and latent variables to be examined together, (2) SEM allows for measurement error in all variables, and (3) SEM allows for direct and indirect effects between factors (Hoyle, 1995). Maximum likelihood (ML) estimation wasemployed to yield optimal parameter estimates. ML is the standard method of estimating parameters in structural equation models. Research indicates that ML performs reasonably well under less than optimal conditions (e.g., small sample sizes; Byme, 2001; Hoyle & Panter, 1995). The covariance matrix was used in all analyses. The statistical package, AMOS (Arbuckle, 1999) was used to perform the SEM analyses. See Table 14 for the correlation matrix of the indicators in the model. 61 Hrpothesis 1 la: A lll\' antibod one-tailed te positive atti‘ HlV antibot lb: . tested for H -0.01 , g 2 - orlfi-tailed 1 prediCted l: 1c: behaViora‘] testy The; “er e not p Id intemmn 1 Responde % A Hypothesis 1 1a: As predicted, a direct positive relationship was found between attitudes toward HIV antibody testing and intention to be tested (standardized [3 = 0.35, z = 4.55, p_ <.05, one-tailed test; Path A, Figure 5). This finding suggests that respondents who have more positive attitudes toward HIV antibody testing are more likely to intend to get tested for HIV antibodies. 1b: A direct, positive relationship between subjective norms and intention to be tested for HIV antibodies was not supported [Immediate Family Norms (standardized [1 = -0.01, z = -0.06, one-tailed test) Community Norms (standardized B = -0.13, _z_ = -1.21, one-tailed test)]. These results indicate that intention to be tested is not directly predicted by subjective norms. 1c: A direct, positive relationship was not demonstrated between perceived behavioral control and intention to be tested (standardized B = -0. 12, z = -1.44 one-tailed test). These results indicate that individuals who perceived greater behavioral control were not more likely to intend to be tested for HIV antibodies. 1d: A direct, positive relationship was not found between current health status and intention to be tested for HIV antibodies (standardized 13 = 0.13, g = 1.67, one-tailed test). Respondents who had poorer current health status were not more likely to get tested for HIV antibodies. W A direct, positive relationship between perceived HIV risk and attitudes toward 62 “a“ .. ,- , HIV antibod} These results As pr relatit behax Cam HIV antibody testing was not supported (standardized [3 = 0.04 z = 0.41, one-tailed test). These results demonstrate that respondents with greater perceived HIV risk were not more likely to have more positive attitudes toward getting tested for HIV antibodies. Hypothesis 3 As predicted, a direct, positive relationship was demonstrated between intention to be tested for HIV antibodies and HIV antibody testing behavior (standardized B = 0.20 g = 2.27, p <.05 one-tailed test; Figure 5). Hypothesis 4 4a: Involvement with Latino culture was not shown to moderate the relationship between intention to be tested for HIV antibodies and HIV antibody testing behavior (CLATXCEI: standardized [3 = -0.05 z = -0.56, one-tailed test; CLATIN: (standardized [3 =-0.07 ; = -O.75, one-tailed test). Respondents who scored high on intention were not less likely to be tested when they were highly involved with Latino culture. 4b: Involvement with American culture was not shown to moderate the relationship between intention to be tested for HIV antibodies and HIV antibody testing behavior (CAMXCEI: standardized D = 0.16 _z_ = 1.73, p<.05 one-tailed test; CAMERICA: (standardized [3 =0.09 _z_ = 1.01, one-tailed test). Respondents who scored high on intention were not more likely to be tested when they were highly involved with American culture. Results of the Extended Model of the Theory of Planned Behavior This section presents the results of the overall fit of the hypothesized extended 63 model of tl using the « \e\'e\ of I Increme; “ETC 6); yielde indiee relat’t RM: dire. ir‘r’te model of the theory of planned behavior. As stated above, these analyses were conducted using the statistical software, AMOS, and the chi-square statistic, degrees of freedom, level of probability, Comparative Fit Index (CPI), Tucker—Lewis Index (TLI), and Incremental Fit Index (IF I), and Root Mean Square Error of Approximation (RMSEA) were examined to determine the degree of fit of the model. Model l-Hypothesized Model The initial hypothesized extended model of the theory of planned behavior yielded a significant chi-square statistic of 76.05 (44, N= 139, p <.001; Figure 5). The fit indices suggested that the fit of the model (i.e., how well the data fit the hypothesized relationships between constructs) was excellent (CF I= 0.97, TLI= 0.95; IF I= 0.97; RMSEA= .07). Several relationships outlined in the model were not in the predicted direction (i.e., immediate family norms to intention, community family norms to intention, and perceived behavioral control to intention). The only relationships that reached statistical significance were attitudes toward HIV antibody testing to intention and intention to HIV antibody testing behavior. Hyppthesis 5 The extended model of the theory of planned behavior (Figure 5) was not the best fitting model when compared to the model of the theory of planned behavior (Figure 6). The Theory of Planned Behavior model yielded a chi-square statistic of 1.93 (df=4, N=139, p>.05, Figure 6). The fit indices indicated that the fit of the theory of planned behavior model was ideal (CFI= 1.00, TLI= 1.02, IFI= 1.00, RMSEA= 0.00). Analyses 64 comparing tl: comparing the revised model with the original model suggested that the theory of planned behavior was superior [Ax2 (4, N=139)= 74.12]. 65 The cu inten'ention e as a conceptu; Latinas. The sample of La intention to 1 focus greate‘ Effective prt being testec Nee leECtiQn a. the imPOn among La SabOgal a DISCUSSION The current research has important implications for AIDS prevention and intervention efforts. It provides strong support for using the theory of planned behavior as a conceptual approach to understanding and promoting HIV antibody testing among Latinas. The present findings revealed that HIV antibody testing behavior among a sample of Latinas is best predicted by their attitudes toward HIV antibody testing and intention to be tested. These findings highlight the need for counselors and researchers to focus greater attention on Latinas’ attitudes and salient beliefs in order to develop more effective prevention and intervention programs aimed at increasing the number of Latinas being tested for HIV antibodies. Nearly two decades after the advent of HIV antibody testing, the rate of HIV infection among Latinas continues to rise. Although prevention efforts have emphasized the importance of HIV antibody testing, national statistics reflect the lack of testing among Latinas, a group that is considered at great risk for HIV/AIDS (CDC, 1998; Sabogal & Catania, 1996). Little is known about the factors that influence Latinas to get tested. Three reasons for this lack of information are (i) the absence of a theoretical framework, (ii) the absence of a multivariate analysis of the data in several of the previous studies, and (iii) the lack of exclusive focus on Latina populations. The purpose of this research study was to examine the factors that impact HIV antibody testing behavior among Latinas by empirically testing the constructs and pathways found in the theory of planned behavior (Ajzen, 1991) and extending the theoretical model to include 66 factors such a hypothesized understandin the theory of implications A1111 extensively Madden 81 applied to ‘ mOdeling. CODSidGrin Study are . 10 HIV 3: Ir indicatec intentigr more llls' haVe al C factors such as acculturation, perceived HIV risk, and current health status. It was hypothesized that this extended model would provide a more comprehensive understanding of the factors that influence Latinas’ HIV antibody testing behavior than the theory of planned behavior model. The following section will discuss the results and implications of this study. The Extended Model of the Theory of Planned Behavior Although specific components of the theory of planned behavior model have been extensively researched (Ajzen, 1991; Chan and F ishbein, 1993; Fisher et al., 1995; Madden et al., 1992), the model as a whole has not been empirically examined when applied to Latinas nor has the model been adequately analyzed using structural equation modeling. More importantly, this study contributes to the theory of planned behavior by considering culture, perception of risk, and current health status. The results from this study are the first to lend empirical support to the theory of planned behavior as it relates to HIV antibody testing behavior among Latinas. Major Findings Pathway from attitudes toward HIV antibody testing to intention In accordance with the theory of planned behavior, the results of this study indicated a significant relationship between attitudes toward HIV antibody testing and intention to be tested. Latinas with positive attitudes toward HIV antibody testing were more likely to intend to get tested than those with negative attitudes. Previous studies have also found that attitudes toward a behavior is a strong predictor of AIDS preventive 67 behavior su et al., 1995 '. examined ti: behavior. the salient l relying on study, the beliefs th T increase inten-e “iOmer PQSi‘ti Witty Lari DOS \Q- behavior such as HIV antibody testing and condom use (Chan and Fishbein,] 993; Fisher et al., 1995; Godin et al., 1997; Wilson et al., 1996). To date, however, no study has examined this relationship among Latinas as prescribed by the theory of planned behavior. Current findings lend support to previous investigations and closely examine the salient beliefs that influence Latinas’ attitudes toward HIV antibody testing. By relying on salient beliefs that were identified during the elicitation research phase of this study, the present investigation provides culturally appropriate information regarding the beliefs that impact Latinas’ attitudes toward HIV antibody testing. The present study provides insights for designing effective interventions to increase Latinas’ intentions to get tested. Most importantly, the data suggest that an intervention should focus primarily upon attitudinal considerations. The majority of women in this sample believed that getting tested for HIV antibodies would result in positive outcomes. Based on the analysis of the behavioral beliefs underlying women’s attitudes toward HIV antibody testing, it is suggested that intervention messages targeting Latinas should attempt to further strengthen the belief that getting tested will have positive health consequences (e. g., getting treatment early in the disease process in order to prevent or delay the early onset of AIDS, and receiving better treatment options and prognosis) and would be consistent with a positive self-image (e.g., would show that they are interested in their health, and the well being of their partner and children). If someone perceives more advantages than disadvantages to taking the test, they are more likely to have a positive attitude and, consequently, to express a positive intention to be tested 68 (Ajzen. 199 counseling; test. By dirt the interim Sucl‘. attributed to Counseling. negative or l 31.,1997), ; antibodies, resUlts, whe] this Sample l HIV’EAIDS a POSititte attir which high] the perCEptj Latinas reg engaged in Th (Ajzen, 1991; F ishbein, 1990). Therefore, it follows that emphasis should be on counseling and educating women about the advantages and disadvantages of taking the test. By directing an intervention at these beliefs, one should increase the likelihood that the interventions will be successful. Such an overwhelming positive attitude toward testing in this sample may be attributed to the number of women who have been exposed to HIV antibody testing and counseling. Researchers have found that having been tested previously and receiving negative or unknown results was associated with greater intention to get tested (Godin et al., 1997). Among the present sample, 60% of women were tested previously for HIV antibodies. Of those that were tested, only 2% reported that they did not find out the results, whereas the rest were HIV seronegative. Since more than half of the women in this sample have been tested, it is likely that they have received information regarding HIV/AIDS and the benefits of HIV antibody testing and consequently developed more positive attitudes which can increase their intention to be tested. This finding suggests that women who have not yet been tested could benefit from counseling or education, which highlights the positive consequences of knowing their HIV serostatus: In addition, the perception that HIV antibody testing can alleviate some of the anxiety experienced by Latinas regarding their unknown status, particularly for those that believe that they have engaged in HIV-risk behaviors, should be strengthened. Sixty-one percent of the women stated that getting tested would give them “peace of mind.” This finding has implications for already existing counseling strategies and 69 policies. It i ‘ specifically t inota\ impr interventio: forming L: other at ri one popL P0pulati intervet b)’ the \ES\et Con app re {i the policies. It is recommended that such interventions be evaluated and designed specifically for Latinas. As these results indicate, the salient beliefs of Latinas are of pivotal importance for the development of culturally appropriate and effective interventions and policies. The salient beliefs that are prominent and instrumental in forming Latinas’ attitudes toward HIV antibody testing may be different from those of other at risk populations. It is no longer appropriate or ethical to implement programs to one population that were designed solely by relying on information obtained from other populations. The beliefs identified in this study can and should be used to develop future interventions specifically for Latinas. Pathway from subjective norms to intention Findings from the present study reveal a lack of support for relationships outlined by the extended theory of planned behavior between subjective norms and intention to be tested for HIV antibodies. The pathways between Immediate Farnily Norms and Community Norms and intention to be tested were not statistically significant. It appeared that in this sample, Latinas’ perceived approval or disapproval by important referents and motivation to comply with their wishes did not have a significant impact on their intentions to be tested for HIV antibodies. According to Ajzen (1991) the relative importance of subjective norms is expected to vary across behaviors, situations, populations, and individuals. The theory assumes that the relative influence of attitude toward the behavior and subjective norms depends in part on the intention under investigation. For some intentions, attitudinal 70 considerat intentions Vallerand Farley, Lt reasoned than was the theor It was h} family a] on inten testing l (Phillip: Subjecti Conflict femalle . Sublecn amOng ‘0 HIV HUI-11,18 ( considerations are more important than normative considerations, while for other intentions normative considerations predominate (Ajzen, 1988; F ishbein, 1990). Vallerand, Deshaies, Cuerrier, Pelletier, & Mongeau (1992) cite a meta analytic study by Farley, Lehman, and Ryan (1981) where one out of every 5 studies utilizing the theory of reasoned action found that attitudes toward behavior was a stronger predictor of intention than was subjective norms. Present findings, therefore, do not violate the expectations of the theory of planned behavior but do not lend support to the present study’s hypotheses. It was hypothesized that Latinas who perceived that their important referents (immediate family and community members) approved of their getting tested would be more likely to intend to get tested. To date, the present study is the first to examine the influence of subjective norms on intention to be tested among Latinas. Previous studies that examined HIV antibody testing behavior or intentions among Latinas have not measured subjective norms (Phillips, 1993; Sabogal & Catania, 1996). Studies that examined the influence of subjective norms on AIDS preventive behaviors among other populations have produced conflicting results. For example, Fisher et al. (1995) found that among a sample of White female college students, intention to be tested was a function of both attitudes and subjective norms. Dorr, Krueckeberg, Strathman, & Wood (1999), however found that among another sample of predominantly White college students, norms were not related to HIV testing. Montoya (1997) found that among women the impact of subjective norms on the intention to ask her partner to use a condom was significant. 71 of the ap distant f.‘ leaders). importar interpret anonymt asking a interpers In fact, c SOCial CC believed behavi-Q, that is 01 SignifiCa S the pole] who See farm‘iy IT example appmpn‘. In the present sample, Latinas’ intention were not influenced by their perceptions of the approval or disapproval from immediate family (e.g., parents and siblings) or distant family/community members (e.g., grandparents, friends, coworkers, religious leaders). Present findings may be explained by a number of arguments. First, it is important to consider the nature of the behavior or visibility of the behavior when interpreting the present findings. HIV antibody testing can be done in solitude, anonymously or confidentially. It can be kept invisible to important referents. Unlike asking a partner to use a condom, HIV antibody testing does not take place within an interpersonal context where performance requires the cooperation of a significant other. In fact, one can get tested without the knowledge of anyone in one’s immediate or distant social context. Not all AIDS preventive behaviors are overtly visible. Therefore, it is believed that subjective norms failed to have an impact on intention because testing behavior is not a clearly visible behavior that is dependent on the cooperation of others; that is one could engage in the behavior without having to rely on the approval of significant others. Second, although the perceptions and approval of significant others are important, the potential benefits of getting tested may outweigh the normative pressure. Women who see themselves as greatly benefitting from getting tested despite the disapproval of family members may ignore the perception of family members and get tested. For example, a woman who believes that getting tested can assist her in obtaining more appropriate medical treatment and improve her health may not abide or be influenced by 72 her family IE tested, ther- referents. Thi findings. T (Siegel et a affected tht IESted for ] subjective more acct Latinas u antibod’16 appTOVa] may Plat their far inClUde edUCate an inch her family’s disapproval of her getting tested and gets tested. The benefits of getting tested, therefore, may have a greater influence than going against the wishes of important referents. Third, the level of education of the present sample may account for current findings. The women in this study were more educated than those of previous studies (Siegel et al., 1997). Level of education of the present sample (M=l3 yrs) may have affected their level of independence and knowledge regarding the process of getting tested for HIV antibodies, which may have in turn impacted the relationship between subjective norms and intention. As a result of their level of education, they may have more access to or awareness of health care facilities that offer HIV antibody testing than Latinas who are not as well educated and who may lack the skills to get tested for HIV antibodies. This sample’s increased knowledge and skills may render the assistance or approval of significant others less crucial. In addition, Latinas who are well educated may place more emphasis on individualism and personal attitudes and less reliance on their family’s approval. To further elucidate this interaction, future investigations should include Latinas that represent all levels of education. By failing to include highly- educated Latinas, research will continue to produce findings that may not be applicable to an increasing number of Latinas in the United States. Fourth, Vallerand et al. (1992) argue that the lack of influence of subjective norms may be the result of the problematic measurement of subjective norms. Vallerand et al. suggest that if subjective norms were to measure the consequences of going against the 73 \VlSlICS of s discrepant. subjective focus direc more remc (Vallerand Th Preventior OanTTTtat pret-iouS a the behav overarchi hnponan. are frOm 19961 It influenC< be deper studied. examine inten‘ep be \.i e\‘_i wishes of significant others, the influence of attitudes and subjective norms would be less discrepant. The attitude measure focuses more directly on behavioral consequences than subjective norms and thus is more likely to be related to behavioral intention. Attitudes focus directly on the consequences of action whereas the subjective norm deal with a more remote element, namely perceptions of what significant others think one should do (V allerand et al., 1992). This finding has great implications for the evaluation and development of prevention programs. Based on current findings, programs that emphasize the influence of normative pressure on HIV testing are likely to fail. The present findings contradict previous assumptions regarding the overwhelming importance of family’s approval on the behavior of Latinas. As evident in the literature, behavioral scientists have made overarching assumptions about the homogeneity of Latinas and consequently the importance of norms by mostly studying a select group of Latinas, most often those who are from impoverished or underpriviledged communities (Comas -Diaz, 1990; Peragallo, 1996). Investigators too often make the assumption that all Latinas are equally influenced by or rely on the approval of family members. The influence of norms may be dependent on the behavior in question, the population, and the individual being studied. Present findings question such practice and invite researchers to more closely examine the appropriateness of the data used to create policies and prevention interventions. Clearly, programs that have been used on other populations can no longer be viewed as appropriate for use with Latinas. 74 Inc modified b1 promoting‘ associated ‘ great impliu overall cor promote H not surpris C0mmunit Panaliing conseque scientists 0““ Salt: metnberE COnU‘OL , making . deVelop In conclusion, these findings strongly suggest that current prevention efforts be modified by focusing on individual level prevention interventions when it comes to promoting HIV antibody testing among Latinas. Latinas’ decision to get tested was not associated with the subjective norms of immediate or distant referents. This finding has great implications when we consider how much prevention has emphasized looking at overall community norms and mass media campaigns at encouraging significant others to promote HIV antibody testing. In lieu of the literature on Latinas, the present finding is not surprising. Latinas have often described themselves as private individuals and community members should not be privy to information that is personal, such as partaking in high risk behaviors. This would imply a number of psychological consequences such as shame, humiliation, and a lack of protective barriers. Behavioral scientists and counselors should not fail to look at Latinas as individuals who have their own salient beliefs that may be in some accordance with the beliefs of their family members, but not always driven by them. If the behavior in question is under attitudinal control, the use of social pressure or policies that emphasize the couple as a decision making force are unlikely to lead to behavioral change (F ishbein 1990). Before developing a behavior change program for some p0pulation, it is essential to determine the relative importance of attitudinal and normative considerations for the intention one wishes to change in the population of interest. Variations in the relative importance of attitudes and norms as determinants of intentions further help to explain why many mass media campaigns and other types of interventions have been unsuccessful. 75 Pathan 1 Pet intentions. control OVf control or. antibodies At useful as - Control 0‘ Predictim research ' intenIIOn behaViOr Comm} 0 that Perc Ihis 3am] VOllliQnE Pathway from perceived behavioral control to intention Perceived behavioral control over getting tested was not significantly related to intentions. Overall, Latinas in this sample reported having high perceived behavioral control over HIV antibody testing. Seventy-six percent stated that they had complete control over getting tested and 73% indicated that it would be very easy to get an HIV antibodies test if they wanted to. According to Ajzen (1991), perceived behavioral control should become less useful as volitional control over the behavior increases. When an individual has complete control over the behavior, perceived behavioral control is not expected to impact the prediction of intention or behavior (Aj zen, 1991; Madden et al., 1992). The current research study is the first to examine the impact of perceived behavioral control on intention to be tested among Latinas. Present findings support the theory of planned behavior, but not the study’s hypothesis. Latinas were hypothesized to not have complete control over getting tested due to financial and social barriers; therefore it was assumed that perceived behavioral control would be negatively associated with intentions. Among this sample of Latinas, it appears that they perceived themselves as having complete volitional control over HIV antibody testing, hence their intention to get tested was not influenced by perceived behavioral control. Previously, Godin et al. (1997) found that among gay men, perceived behavioral control did influence intention to be tested. Men who perceived HIV antibody testing as “easy” were more likely to intend to get tested. Several important differences may 76 _,_.. account for difference as outline perform 1 questior behax‘tc bfihavi. requisi Ctussti Perce Perce- belie inf: fri e the h account for the present study’s contradictory findings. First, there are measurement differences. The present study measured perceived behavioral control with four questions as outlined by Ajzen (1991) regarding the ease, direct control, and requisites for performing the behavior. Godin et al. measured perceived behavioral control with one question regarding ease or difficulty of carrying out behavioral intentions. Perceived behavioral control involves more than just the level of difficulty regarding performing the behavior. It also deals with the salient beliefs regarding the presence or absence of requisite resources and opportunities as well as control over performing the behavior in question. Hence, the present study may provide a more accurate measurement of perceived behavioral control than that of the previous study. Second, differences in perceived behavioral control beliefs may be influenced by gender and context. These beliefs may be based in part on past experience with the behavior, second-hand information about the behavior, by observing the experiences of acquaintances and friends, and by other factors that increase or reduce the perceived difficulty of performing the behavior in question (Ajzen, 1991). Gay men and Latinas are part of social contexts that may be susceptible targets of discrimination and may have different life experiences based on factors such as gender, ethnicity, social class, and culture. The discrimination may be qualitatively different and experienced differently by various groups. Such experiences may facilitate or hinder their ability to perform the behavior and/or their perceptions of control over getting tested. The majority of Latinas in this sample have had prior experience with HIV antibody testing. Sixty-eight percent of the women in this 77 sample kne conceivab l: behavior u procedure ; liIICW 50mg diagnosed PFCViouSIy advance m filtttre €Xpt ma)" haVe their leVe] resoumes ln POSSeSS‘ a perC-elV'ed this Sam}: ‘estEd. T IntentEm I‘Egarding tested. 1‘ b). a“ M sample knew someone who had been tested and 58% have been tested themselves. It is conceivable that prior experiences provided them with the necessary skills to repeat the behavior with less obstacles or difficulties. Women who were tested before know the procedure and can exert more control. In addition, the majority of women in this sample knew someone who had been tested before, including individuals who have been diagnosed with HIV/AIDS. Information from individuals known to have been tested previously can also provide them with data about the process of getting tested and advance notice of potential barriers or facilitating factors rendering their experience or future experience with HIV antibody testing less ambiguous. Third, other factors that may have provided women in this sample with a greater perceived behavioral control is their level of education. These well-educated Latinas may have access to wider range of resources that may facilitate getting tested. In conclusion, the more resources and opportunities individuals think they possess, and the fewer obstacle or impediments they anticipate, the greater should be their perceived control over the behavior (Ajzen, 1991; Chan and Fishbein, 1993). Latinas in this sample did not perceive overt obstacles to get tested. These women chose not to be tested. This finding highlights the complexity of HIV antibody testing behavior. Intervention and prevention efforts should examine the perception of individuals regarding the resources and opportunities they have available to them in order to get tested. It is no longer appropriate to assume that all potential barriers may be perceived by all women as actual barriers. 78 As l significant‘ contribute-t Women in i (3496). La consisted d antibodies WOmen iv}: A 1 HIV antib indit-deal to have m biting at 1 L; getting te majonty attitudeS b y per-Ce] Pathway from current health status to intention to be tested As found in a previous study (Phillips, 1993), current health status was not significantly related to intentions. The lack of variance in this sample may have contributed to the lack of significance in the pathway to intention. The majority of women in the sample rated their overall current health status as good (51%)/excellent (34%). Latinas in this sample reported few to no medical problems. The present sample consisted of women that were healthy and would therefore not consider having an HIV antibodies test done in order to address current or chronic health concerns. In order to better understand the impact of current health status, future investigations should include women who may be experiencing medical problems. Pathway from perceived HIV risk to attitudes toward HIV antibody testing A direct positive relationship between perceived HIV risk and attitudes toward HIV antibody testing was not found. Contrary to the hypothesized relationship, individuals who perceived themselves as being at high risk for HIV were not more likely to have positive attitudes toward getting testing than those who identified themselves as being at low risk for HIV. Latinas’ attitudes which are based on salient beliefs regarding the consequences of getting tested for HIV antibodies were not influenced by perceived HIV risk. The majority of Latinas in the present sample did not see themselves at risk for HIV. The attitudes of women who consider themselves to be at high risk for HIV may be influenced by perceived HIV risk, but due to the lack of number of women who endorsed high levels 79 of perceive possibility Prc perceive tl‘ activities 1 Tucker, \‘t‘ Health Int, be at high Stated that the time 01 COUld get i a 10W char in(“Gating an STD, it for HIV, - order to u HIV antit perceptio U crucial in of perceived HIV risk in this sample, the present study was unable to clearly examine this possibility. Present findings, however, support the literature reporting that Latinas do not perceive themselves to be at risk for HIV despite frequent involvement in high risk activities for HIV transmission (McQuiston et al., 1998; Newcomb, Wyatt, Romero, Tucker, Wayment, Carrnona, Solis, Mitchel-Keman, 1998). According to the National Health Interview Survey conducted in 1993, only 1% of Latinos perceived themselves to be at high risk for HIV (Phillips, 1993). Seventy-five percent of Latinas in this sample stated that there was no chance or a low chance that they would be infected with HIV at the time of the interview and 78% stated that there was no or a small probability that they could get HIV in their lifetime. Despite such a high percentage of women reporting no or a low chance of being or getting infected, more than half have been tested for an STD, indicating that at some point in their lives they placed themselves at risk for contracting an STD, including HIV. With only 20% using condoms, many may continue to be at risk for HIV. Factors that determine how Latinas perceive their HIV risk are not yet clear. In order to understand the relationship between perceived HIV risk and attitudes toward HIV antibody testing, researchers must first investigate the factors that influence Latinas’ perception of HIV risk. Understanding the relationship of perceived risk and HIV antibody testing is crucial in the efforts to educate Latinas and increase the number of Latinas who are or may be potentially at risk for HIV to get tested. The necessity for such research is further 80 iiii. highlightec potentially Among La medium ct 1993). Set continuous examined faCtors. Fi has been 1]- Such belie need fum number 0 the numb [0 engag‘ “Omen V mmLmi (New, invoke1 Dar-mers relati 0n highlighted by findings that indicate that approximately two-thirds of individuals who are potentially at risk for HIV neither have been nor plan to be tested (Phillips, 1993). Among Latinos who perceive they have a high chance of having HIV/AIDS or a high or medium chance of getting AIDS, only 29% have been tested or plan to be tested (Phillips, 1993) Several reasons for the lack of perceived HIV risk among Latinas, despite their continuous involvement in high risk activities, are posited and should be further examined. It is argued that Latinas’ perceived HIV risk may be influenced by several factors. First, beliefs that HIV/AIDS is exclusively a Euro-American gay man’s disease has been linked to a decreased perception of risk among Latinas (Newcomb et al., 1998). Such beliefs provide Latinas with a false sense of safety from infection. Latinas may need further education regarding the recent shifts in the infection trends, the increasing number of heterosexual Latinos who are diagnosed with HIV, and the statistics regarding the number of individuals who may be infected but have not yet been tested and continue to engage in high-risk behaviors. Second, being married or in a relationship may provide women with a sense of decreased susceptibility which may be false. It has been noted that Latinas base their own risk on their behaviors and do not include that of their partners (Newcomb et al., 1998; Sabogal & Catania, 1996). As a result of their marital status or involvement in a sexual relationship, they may be at risk for sex-related diseases of their partners (or to which they may have been exposed before marriage to or before the relationship with their current partner). Latinas in a stable relationship may be more 81 tulnerablj themselvc study, Il'l\ assessed. 7 single stat present Sit Third, get among rmw COmpared ConduCted Percentior. Michigan ha\‘e feat] result of c the numb. COnstitmE been note den-““8 t acknowte aggravafi vulnerable to HIV heterosexual transmission because they are the least likely to protect themselves with STD preventive methods (Sabogal & Catania, 1996). In the present study, involvement in a sexual relationship or participation in sexual activities were not assessed, therefore it is not possible to determine whether the women who reported a single status were involved in a sexual relationship at the time of the interview. In the present study both single and married women reported little to no susceptibility to HIV. Third, geographic location may also play a part in the perception of HIV risk, particularly among the present sample. Michigan has a low reported rate of HIV/AIDS cases compared to New York City and Los Angeles, which is where most studies have been conducted with Latinas. This disparity in infection rates may promote a decreased perception of risk. Women may see themselves as less likely to become infected in Michigan than if they lived in other parts of the country where the number of HIV/AIDS have reached epidemic proportions. Fourth, perhaps a low perception of HIV risk is the result of denial. Denial and other psychological defense mechanisms may contribute to the number of Latinos who do not see themselves as being at risk, eventhough they constitute one of the largest growing populations of those infected with HIV. Denial has been noted as an unconscious adaptation /defense used in light of a frightening reality; denying that reality is less dangerous (Weiss, 1993). Latinas may not want to acknowledge the level of threat because it may lead to psychological distress or aggravation of psychopathology. Because Latinas do not see themselves as being at risk, perceived HIV risk is not part of their salient beliefs regarding their consequences of 82 getting tes‘ In t nuances or perceived examined l assessmen “16 preset 0m." prese influence . and “egat' HIV sero} Wists ('5 used P‘érs may haw that uSed C invesm$2 that ane] that, fOr Flirther . factors I getting tested. In addition, current measures of perceived risk may not accurately assess all of the nuances or components of this construct. Most studies used one question to assess perceived risk (Dorr et al., 1999; McQuiston et al., 1998; Phillips, 1993). Prior studies examined risk among those who have already been tested by asking for a retrospective assessment of the individual’s perceived risk prior to getting tested (Dorr et al., 1999). The present study contributes to the field of study by using three questions regarding not only present risk, but also predictions of future risk. Self-reporting bias may also influence the veracity of results. Latinas may not report accurately for fear of rejection and negative judgement on the part of the interviewer. Historically, individuals who are HIV seropostive or have AIDS have been discriminated against and treated differently by society (Silvestre, Kingsley, Rinaldo, Witt, Lyter, & Valdeserri, 1993). The present study used personal interviews and not an anonymous survey. Such method of data collection may have hampered accuracy of reporting among Latinas and perhaps across all studies that used this method of data collection. Clearly, perception of HIV risk remains an area of study that must be further investigated. The current findings have significant implications for prevention strategies that attempt to heighten perceived HIV risk. Researchers must explore the possibility that, for Latinas, perception of risk is not a pivotal deciding factor for getting tested. Further research, including qualitative studies, must be done to better understand the factors that influence Latinas’ perception of HIV risk. Until then, we may continue to 83 inaccurate needs of L Pathwav f intention tl getting te theoretic. great (lei S’tXQtth can on. I99Iy {Stunt Shou 1lter. find Efi‘ inaccurately measure perceptions of HIV risk and unsuccessfully address the preventive needs of Latinas through ill-informed interventions. Pathway from intention to behavior The relationship between intention to be tested for HIV antibodies and HIV antibody testing behavior was statistically significant. Latinas who reported greater intention to be tested were more likely to engage in a greater number of actions toward getting tested. This finding lends strong support to the hypothesized relationship in the theoretical model. According to Ajzen (1 98 8), it is possible to predict behavior with a great deal of accuracy on the basis of intentions to perform the behavior in question. The stronger the intention, the more likely should be its performance. Behavioral intention can only find expression, however, if the behavior is under volitional control (Ajzen, 1991); this is the case with HIV antibody testing. To the extent that a person has the required opportunities and resources and intends to perform the behavior, he or she should succeed in doing so. Such tenets of the theory are strongly supported by the literature and present findings (Fisher et al., 1995; Godin et al., 1997). The present findings indicate that programs that are aimed at increasing the number of Latinas who get tested for HIV antibodies should focus on strengthening their intentions. The present study is the first to acknowledge and examine the multiple steps involved in getting tested. Previous studies exclusively assessed HIV antibody testing behavior by asking one question, “Did you get tested or not?” HIV antibody testing, whether performed at a testing site or at home, requires a series of behavioral steps 84 (starting it that may p HIV antib was tested to provide interventn informatic aPPOImme obtained t “mild not (starting with getting information about the test and ending with obtaining test results) that may provide behavioral scientists with more information regarding the process of HIV antibody testing and assist in prevention planning efforts. Only asking if the person was tested or not fails to capture the complexity of the process of getting tested and fails to provide important information that can be useful in the development of effective interventions. For example, nine of the women in this sample took action to obtain information about HIV testing and potential testing sites, two of them set up appointments to be tested, but a month after the initial interview only one was tested and obtained her results. The previous method of assessing HIV antibody testing behavior would not have enabled researchers to obtain this type of detailed information. Current assessment tool allows for the exploration of successful as well as unsuccessful HIV testing efforts. Present findings raise important questions. For example, what prevented eight of the women from getting tested, particularly the one who set up an appointment? Would they have been more likely to have been tested if their intentions to be tested were strengthened during the time they called for information or when they set up the appointment? If we only focused on those who were successful we would fail to understand those women who are most concerning; those who are at risk but are not able to complete the process of getting tested. Those involved in HIV/AIDS prevention and counseling have been greatly concerned about those who get tested but never return for their test results because some of these women are HIV seropositive and have not made themselves available for fiature counseling and treatment. It is of no benefit to get tested 85 ifone dc importar the parti inforrna process the inte interver Prograr PM relatio; Wl’IO in InVOI \r‘ if one does not receive a diagnosis nor to set up an appointment but not get tested. It is important that researchers focus on the entire process. By closely examining the process, behavioral scientists can address the barriers at the particular point of difficulty. The instrument created for this study provided more information and may serve as a useful tool in understanding the intricacies of the testing process. Future studies can serve to elucidate this process by focusing more closely on the intentions to perform each individual action. Developers of prevention and intervention programs can then utilize this information to better inform their programming efforts and strengthen those intentions that are deemed most problematic. Involvement with Latino culture as a moderator of the relationship between intention and behavior In the present study, involvement with Latino culture did not moderate the relationship between intention to get tested and HIV antibody testing behavior. Latinas who intended to get tested were not less likely to get tested when they were highly involved with Latino culture. Latino culture has been found to both promote and hinder health-related behaviors (F laskerud, Uman, Lara, Romero, & Taka, 1996; Pequenat & Stover, 1999; Suarez & Siefert 1998). Throughout the literature, acculturation has been conceptualized and measured using theories and instruments that do not permit a clear distinction between involvement with host and native culture. To date, no study has ever examined the impact of acculturation on HIV antibody testing utilizing a biculturalism model. The 86 present st culture m of accultu- In “low accu incorpora' Wilt) rcpo less like]: measured UtiliZatio P the Wom Class SOC recehed and resc hO\VE\'e have fa. Latinas eCOnOn anWle high)y present study attempted to clarify the moderating role that involvement with Latino culture might play between intention and behavior through use of a biculturalism model of acculturation. In contrast to the present study, prior studies have reported a strong link between “low acculturation,” which implies a preference for native culture at the expense of not incorporating aspects of the host culture, and lack of HIV preventive behaviors. Those who report “low acculturation” engaged in behaviors that placed them at risk for HIV-- less likely to use condoms. Sabogal and Catania (1996) found that acculturation, as measured exclusively by language use, did not have a direct impact on HIV test utilization of Latinos. Perhaps the hypothesized moderating relationship did not emerge because most of the women in this sample were highly educated and were from a middle to upper-middle class socio-economic background. Latinas residing in the United States have historically received less years of education than other populations and have limited financial income and resources (DHHS, 2000; Marin & Gomez, 1997). The women in this sample, however, were highly involved with Latino culture and were highly educated, this may have facilitated carrying out their intentions and getting tested for HIV antibodies. Latinas who are highly educated and are from a middle to upper-middle class socio- economic background are more likely to speak English fluently and have an increased knowledge of and ability to navigate the health care system. Therefore, despite being highly involved in Latino culture, the women in this sample possessed the necessary 87 resources with testi from Lati andt‘or kn. increased regardles: culture IT Other {Cg study id: farm\\‘0r their fan residing EVOIVed a Latina multi p1, more de impona SamDle resources to carry out their intentions. Several other factors, such as previous contact with testing and sample characteristics, may have also contributed to the lack of impact from Latino culture. The majority of women in this sample have been tested before and/or know someone who has been tested. This may have provided them with an increased self-efficacy and a more permissive environment allowing them to get tested, regardless of their level of involvement with Latino culture. Involvement with Latino culture may be qualitatively different for women residing in Michigan than for those from other regions of the United States. The majority of Latinas interviewed for the present study identified themselves as Mexican-American and had a family history of migrant farrnwork, and spoke English fluently. Many of the women interviewed reported that their families had immigrated from several northern states of Mexico and have been residing in the United States for numerous generations. The concept of Latino culture has evolved and women who live in Michigan may have a different concept of what it is to be a Latina that may differ from those of other Latino subgroups and those residing in multiple cities throughout the United States that are larger and more urban as well as more densely populated with Latinos (e. g., Los Angeles, San Antonio, New York). It is important to assess the context of the population under study. Some of the women in this sample had difficulty differentiating between Latino and American cultures. For this sample, the cultural boundaries was somewhat blurred. Therefore, involvement with Latino culture may indeed moderate the relationship between intention and HIV antibody testing for other subgroups of Latinas, but due to present sample characteristics, such an 88 assessmen ethnicity b these facto of this var evaluated L’nited St; a represer and belleu \ Pt America, precautio to Obtain Suarez (1: Culture S: was met : T with #er failed to cultureS 111W)lt’er assessment could not be made. Latinas are a heterogenous group not only because of ethnicity but they differ in social class, level of education, race, and immigration status; these factors may color their concept of Latino culture and consequently the relationship of this variable to their HIV antibody testing behavior. Present findings should be evaluated with caution as they may not be representative of other Latinas residing in the United States. Future research should be conducted with samples of Latinas that include a representative sample of the different variables mentioned above. Involvement with American culture as a moderator of the relationship between intention and behavior Previous research studies have reported that a high level of involvement with American culture is strongly associated with increased knowledge about transmission and precautions against STDs including HIV, increased perception of risk, decreased barriers to obtaining STD checkups, and a higher health locus of control (Newcomb et al., 1998; Suarez & Siefert 1998). It was therefore hypothesized that involvement with American culture should facilitate the process for Latinas to get tested. This hypothesis, however, was not supported by this study’s findings. The present research study is the first to examine the influence of involvement with American culture on Latinas’ HIV antibody testing behavior. Previous research failed to utilize a biculturalism model where the influence of both American and Latino cultures could be ascertained, independently. Latinas in the present sample reported high involvement with American culture. It is argued that American culture for those Latinas 89 sampled I} in large n. American subgroum American not been c economicl addition, - are highly Values th sexual m invesugE Specific assess I} l l(‘nQ‘Wlet medica? employ HIV an SamDie impact sampled is qualitatively different when compared to populations previously interviewed in large metropolitan cities (e.g., Los Angeles and New York)--not the Midwest. American culture may be defined and/or experienced differently by particular ethnic subgroups and individuals. American culture is a global term used to refer to White American culture and may encompass a myriad of values, beliefs, and norms that have not been clearly delineated. Latinas in Michigan are exposed to differences in social, economic, and political environments that guide their perception of American culture. In addition, it may be that the moderating relationship did not emerge because Latinas who are highly involved with American culture may not adhere to specific American cultural values that can directly influence HIV antibody testing behavior such as more liberal sexual norms or less restrictions on disclosure of sexuality. Qualitative research investigating the perceptions, definitions, and experience of American culture among a specific population under study may also be essential in the effort to more accurately assess the impact of culture on HIV antibody testing behavior. It has also been reported that among White Americans there is increased knowledge of the health care system and an increased concern with confidentiality of medical records and discomfort with having test results disclosed to insurance, employers, or partners; this may reduce the number of individuals who seek and obtain HIV antibody testing (Silvestre et al., 1993). Similar to White Americans, Latinas in this sample questioned policies regarding confidentiality and expressed concern about the impact of getting tested for HIV antibodies on their health insurance eligibility and costs. 90 Some exp employer mNMW‘ it Was not potential impact 0: culture a exmlnt Latinas ““35 a pro 30171:: amg \rw. res BS Some expressed fear of being terminated from their employment if tested because their employer may discriminate against having an HIV seropositive employee in his/her place of business and may worry about the potential health care costs and disability pay. Others reported a concern regarding control over medical information and its accessibility to future employers and potential denial of health insurance. Throughout the interviews, it was noted that Latinas were quite concerned about issues of confidentiality and potential discrimination as a result of their decisions regarding their health care. The impact of such concerns may outweigh the influence of involvement with American culture and should be further examined. To date, researchers have not empirically examined the impact of such concerns on the HIV antibody testing behavior among Latinas. In addition, the psychological demands placed on the individual who gets tested may surpass the influences of American culture. Individuals who get tested must undergo a process that can produce discrimination, anxiety, fear, shame, and depression, and, in some cases aggravate pre-existing psychopathology. Siegel et a1 (1998) reported that among Latinas, anxiety was identified as a barrier to getting tested. It is argued that high involvement with American culture may provide women with an increased number of resources that may facilitate HIV antibody testing behavior, but the negative psychological outcomes or factors may outweigh the influence of involvement with American culture. The present research did not assess participant’s level of psychological functioning, therefore, the present argument could not be tested. Future research can 91 assist in u behavior 1 antibody 1 amelioratt antibody 1 results. Tl EXploratit take into issues re] m T hOWet-en them—y of health to Various f Latinaa 1 understai Study die; The PIES. atmibOd v assist in understanding potential moderators between intention and HIV antibody testing behavior by examining psychological factors during each step in the process of HIV antibody testing. Interventions that appropriately and effectively assess, treat, and ameliorate psychological problems that can arise or are present during the process of HIV antibody testing may increase the number of Latinas who get tested and obtain their test results. The present study’s findings highlight the need for further and more detailed exploration of cultural influences on HIV antibody testing. Future research should also take into account differences among Latina subgroups and the potential influence of issues related to social class, education, race, and psychological factors. Overall fit of the extended model The extended theory of planned behavior was an overall excellent fit for the data, however, the original theory of planned behavior model was an ideal fit. The extended theory of planned behavior model incorporates aspects of culture, perceived risk, and health to the theory of planned behavior. It was hypothesized that with the inclusion of various factors noted in the literature as influential to HIV antibody testing behavior for Latinas, the model would better fit the data and'provide a more comprehensive understanding of HIV antibody testing among Latinas. Although results from the present study did not support the current hypothesis, the extended model was an excellent fit. The present study made significant contributions to the increased understanding of HIV antibody testing by being the first to conduct elicitation and prospective investigations, as 92 pres inflt to e' sam prev ani enti beh prescribed by the theory of planned behavior, to empirically determine the factors that influence HIV antibody testing behavior among Latinas. In addition, the study was able to elucidate the relationships that exist among these factors. Perhaps with a larger sample, a clearer understanding, and a more detailed measurement of the constructs previously outlined, the extended model of the theory of planned behavior would also be an ideal fit. Results did not suggest modifications in pathways. The results from this study are the first to lend empirical support to the theory of planned behavior model in its entirety. Present findings provide evidence of the usefulness of the theory of planned behavior as a tool for prevention programming and development. Limaiisms Limitations of this study should be acknowledged. First, given that it was a purposive rather than a random sample, the results of this study cannot be generalized to all women of Latino descent. The methods used to recruit women for this study contribute to this limitation. Churches, social organizations, service providers, and schools within the researcher’s personal network in the state of Michigan, particularly those of mid-Michigan, were utilized to recruit women for this study. Participants also assisted by recruiting additional women from their own personal networks (i.e., snow- balling). Consequently, the findings from this study may be biased toward women of Mexican descent who reside in Michigan. Although these findings may not represent the experiences of all Latinas in the United States, they do provide important information regarding the factors that influence HIV antibody testing. The hypothesized model 93 should finding contribt additior women antibod; or clinic health, \ were no many ha f; IPeSPOHde neVer hau may thi 11 There “-8 name ant should be tested with other populations to determine the generalizability of present findings. Sample size is another limitation of this study. A sample size of 139 may have contributed to the lack of significant findings and limited variance of certain variables. In addition, sample characteristics must also be considered. The present sample consisted of women that were not recruited in settings typically used in studies regarding HIV antibody testing: family planning, obstetrical, STD, or substance abuse treatment centers or clinics. Overall the sample consisted of women who were reportedly in excellent health, which greatly limited the variance on the variable of current health status, and were not seeking HIV antibody testing. Latinas sampled were also well-educated and many had been tested previously or knew someone who had been tested, which may have also biased the results . Another limitation of this study is the use of self-report of behaviors by respondents. Latinas may want to portray themselves as being sexually conservative and never having engaged in HIV high-risk behaviors due to concerns that the interviewer may think that she is promiscuous and/or infected with HIV, thus respond negatively. There was also the concern of confidentiality. Participants were asked to provide their name and contact information in order for the investigator to perform the follow-up interview. The current study took several steps to minimize the potential problem. First, the introduction of the interview protocol clearly states that the study’s goal is to better understand the factors that impact HIV antibody testing behavior and not to encourage or 94 discourage Latinas to get tested. Second, only women with friendly dispositions and previous interviewing experience were brought on to the research project as interviewers. Third, all interviewers participated in training sessions that provided them with skills to develop rapport with the women they interviewed. Fourth, participants were assured that their contact information would be destroyed. These different strategies were utilized to create a safe forum in which participants would feel free to discuss HIV antibody testing behavior without fear of being judged. Despite these measures, confidentiality concerns may still have affected current findings. Finally, the interview protocol included many new measures which may have also contributed to the limitations of this study. Such data are always vulnerable to response biases, validity concerns, and threats to reliability. Some of these measures (i.e., perceived behavioral control and current health status) had only adequate reliability and need further verification. Moderate reliability limits the predictable variance of any measure. This may have accounted for the moderate to modest variance in the outcome measures. Another likelihood is that some critical measures to predict these outcomes were not included. For instance, measures of sexual and drug-related risk taking behaviors were not included. Present findings should therefore be examined with caution based on the stated limitations of this study. Chasm It is well acknowledged that HIV/AIDS is a “preventable disease” (e. g., Gomez and Marin, 1996), yet efforts at preventing the transmission of HIV within the Latina 95 comrr numbt Since couns signifi potent factors model empirit Present HIV an Specifi. Creating to g€t te community have had limited success (e.g., Amaro, 1995; Suarez and Siefert, 1998). The number of new HIV/AIDS cases among Latinas continues to increase at alarming rate. Since the introduction of HIV antibody testing, prevention efforts have focused on counseling and increasing the number of individuals who get tested. It is reported that a significant proportion of Latinas who are infected with HIV have not been tested and are potentially infecting others (CDC, 1997). The purpose of this study was to examine the factors that influence HIV antibody testing among Latinas by analyzing the extended model of the theory of planned behavior. The present research has clear implications for the creation of conceptually-based, empirically targeted HIV/AIDS prevention interventions. It is possible to move from the present findings to the construction, delivery, and evaluation of interventions to promote HIV antibody testing among populations that resemble the Latinas sampled in this study. Specifically, prevention and intervention efforts targeted at Latinas should focus on creating positive attitudes toward HIV antibody testing and strengthening their intentions to get tested. Moreover, in order for interventions to be increasingly effective they should occur at multiple levels: individual, community, and govemmental/policy level. At the individual level, interventions should focus on assessing the woman’s ability and willingness to participate in HIV preventive behaviors (e.g., getting tested, requesting that her partner use condoms) and providing her with counseling and education to foster health-promoting behaviors. As Amaro (1995) and Morales (1995) have noted, interventions must recognize the diversity and heterogeneity among Latinas. 96 lndividud spdnfici behavior gettested l Latina be to live \v preventi‘ auuudes Should e interviei {Eachin‘g preV‘ent exDOSur may inc COUnsel bane, ,, disSerni Individual-level interventions can be particularly successful when developed to meet the specific needs of the woman while considering her psychological fimctioning, risk taking behavior, ethnic and socioeconomic background. For example, a Latina may intend to get tested but does not because she lacks the necessary monetary resources while another Latina believes that getting tested will produce greater psychological distress and prefers to live without knowing. A generic intervention may be inadequate to meet the preventive needs of both of these women. Based on the present findings, Latinas’ attitudes toward testing are instrumental and should be closely examined. Future research should examine the assessment of individual barriers to testing as well as developing interviewing skills among clinicians so that they may become culturally competent and can appropriately and effectively intervene. Community-level interventions, however, may be the primary method for reaching Latinas who are otherwise unavailable or are not reached by individual prevention efforts. Educational programming may provide Latinas with their first exposure to information regarding HIV antibody testing. Community-level interventions may include training Latinas to become HIV/AIDS educators and HIV antibody testing counselors. Individuals who are well-versed in the culture and are well-respected are better received by those in the Latino communities and are able to successfully disseminate information and strengthen positive attitudes and intentions to get tested (Oliva, Rienks, & McDermid, 1999; Suarez & Sierfert, 1998). Finally, govemment-level intervention may facilitate HIV antibody testing by designing legislature that facilitates 97 HIV testing efforts such as continuing financial support for testing and research, enforcing stricter and more efficient confidentiality and privacy laws that protect the rights of those tested as well as those known to be HIV seropositive, and continued training for medical and professional staff including ethnic minorities. Unfortunately a cure for HIV/AIDS does not appear to be in our immediate future, hence both research and clinical efforts must continue to prevent new cases of HIV/AIDS. Although the need for more effective prevention and intervention strategies for Latinas has been stressed (Amaro, 1995; Romero & Arguelles, & Rivero, 1993), research on the applicability of the theory of planned behavior or other models to predict change in AIDS preventive behavior has been limited. The urgent need for AIDS prevention interventions that are effective and the theoretical need for rigorous testing of the behavior change implications of the theory of planned behavior obligate us to pursue such research with all possible haste. 98 APPENDICES 99 APPENDIX A Elicitation Research Questionnaire (English) SECTION A: DEMCLBRAPHIC INFORMATION I would like to start the interview by asking you some general questions. A1. Are you currently married, divorced, separated, widowed or never been married? CI 1.Married CI 3. Separated CI 5. Never been married CI 2.Divorced C14.Wtdowed C] 6. Living together but not married A2. What is the highest grade you completed in school? (Interviewer - Circle the number that applies.) [123456] [78] [9 1011 12] [13 141516][17 18][19 2021] Elementary Jr. High High School College Technical Grad.School A3. Are you currently: Cl 1. Working full-time CI 4. Keeping house C] 2. Working part-time CI 5. In school CI 3. Unemployed CI 6. Other (Specify): A4. What is the total monthly income for your household? A5. What year were you born? What is your age? A6. Would you describe yourself as D Mexican or Mexican-American CI Puerto Rican Cl Cuban or Cuban-American D Dominican or Dominican-American D Other: Please specify A7. Where were you born? Country City A8. Where was your father born? Country City A9. Where was your mother born? Country City A10. How many years have you lived in the United States? 100 A11. Have you ever lived in any other country? D No Cl Yes If no go to Question #12 If yes Where? When did you live there? For how long? A12. What is your religious denomination? CI 1.Anglican Cl 6. Evangelical D 10. Pentecostal D 2.Baptist Cl 7. Lutheran C] 11. Scientology CI 3.Brethren Cl 8. Methodist CI 12. Other: CI 4.Catholic Cl 9. Mormon D 13. None Cl 5.Church of God A13. Do you have any children? CI O.No CI 1.Yes If yes, How many? How old are they? Do they live with you? CI 0.No Cl 1.Yes A14. Have you ever been tested for HIV antibodies? Cl O.No D1.Yes If no go to A 16 A15. What were the results of the HIV antibodies test? CI Positive C] Negative L'J Inconclusive Cl Never went back for the results A16. Have you ever known anyone who has been tested for HIV antibodies? CI 0.No C11 .Yes A17. Have you ever known anyone who is HIV positive? C] 0.No Cl 1.Yes A18. Have you ever known anyone who has AIDS? DO.No D1. Yes 101 SECTION B: HIV ANTIBODY TESTING ELICITATION QUESTIONNAIRE Now I would like to ask you some questions regarding HIV antibody testing. 1 A. B. What do you believe are the advantages and disadvantages of you getting tested for HIV antibodies? What are some of your thoughts and beliefs about getting tested for HIV antibody testing? Are there people or groups who would approve of your being tested for HIV antibodies? Are there any pe0ple or groups who would disapprove of your being tested for HIV antibodies? Does anybody else come to mind when you think about being tested for HIV antibodies? What issues make it easy or difficult for you to get tested for HIV antibodies? 102 APPENDIX A Elicitation Research Questionnaire (Spanish) secofin A: INFORMACION DEMOGRAFICA Quisiera empezar la entrevista con unas preguntas generales. A1. gActualmente es usted casada, divorciada, separada, viuda o nunca se ha casado? Cl 1.Casada Cl 3. Separada CI 5. Nunca he sido casada CI 2.Divorciada D 4. Viuda A2. aCual es el ultimo nivel de educacion que completo? (Entrevistadora- Circule el numero que aplica) [1 2 3 4 56] [7 8] [9 10 1112] [13 14 1516] [17 18] [19 20 21] Primaria Secundaria Preparatoria Universidad Politécnica/ Escuela de posgrado Vocacional A3. Actualmente usted: C] 1. Trabaja a tiempo completo CI 4. Es ama de casa D 2. Trabajaatiempo parcial C1 5. Es estudiante Cl 3. Es desempleada C1 6. Otro (Especifique) A4. aCual es el su profesion o trabajo? aSi es casado, cual es la profesion de su pareja? éSi vive con sus padres, cual es la profesion de sus padres? A5. ¢En que ano nacio? Cual es su edad? A6. Usted se identificara como Cl Mexicana/ Chicana CI Puertorriquena CI Cubana D Dominicana CI Otro: (Especifique) A7. gDonde nacio usted? Pais Cuidad A8. ¢Dénde nacio su padre? Pais Cuidad A9. ¢Donde nacio su madre? Pais Cuidad A10. ¢Cuantos anos ha vivido en los Estados Unidos? 103 A11. gAlguna vez a vivido usted en otro pais? C1 Si Cl No Si Ia respuesta es “no” pase a la pregunta #12 gDonde? aCuando vivio usted ahi? (;Por cuanto tiempo? A12. gCual es su denominacion religiosa? Cl 1.Anglicana Cl 6. Evangelista D 11. Cientologia CI 2.Bautista CI 7. Luterana Cl 12. Otra CI 3.Brethren D 8. Metodista (Especifique) Cl 4.Catolica CI 9. Mormona C1 13. Ninguna CI 5.lglesia de Dios CI 10. Pentecostal A13 5Usted tiene hijos? C1 0. No C] 1. Si Si la respuesta es “SI” aCuantos hijos tiene usted? aCuantos anos tiene? (;Su(s) hijo(s) o hija(s) viven con usted? CI 0. No D 1.Si A14. gse ha hecho la prueba del virus del SIDA? CI 0.No - Pase a la pregunta 16 C1 1.Si A15. aCuales fueron los resultados de la prueba de VIH/SIDA? CI Positivo CI Negativo E] lnconcluso CI Nunca regrese para recibir los resultados A16. gAlguna vez usted a conocido alguien que se tomado la prueba de VlH/SIDA? C1 0. No C] 1.Si A17. gAlguna vez usted a conocido alguien que tiene el virus VIH? Cl 0. No D 1.Si A18. gAlguna vez usted a conocido alguien que tiene SIDA? CI 0. No C] 1.Si 104 SECCION B: HIV ANTIBODY TESTING ELICITATION QUESTIONNAIRE Ahora quisiera hacerle unas preguntas acerca de la prueba de VlH/SlDA. 1. A. gEn su opinion, cuales son la ventajas y desventajas para usted hacerse la prueba de VIHISIDA? B. LCual es su opinion, creencias, o pensamientos acerca de la prueba de VIHISIDA? 2 A. (gHay grupos de personas o gente en especifico que aprovarian que usted tomara la prueba de VIHISIDA? cQuienes son esas personas? (Por favor no de el nombre de la persona solamente describa su relacion con esa persona. Por ejemplo, hermana, primo, padre etc.) B. éHay grupos de personas o gente en especifico que NO aprovarian que usted tomara Ia prueba de VIHISIDA? éQuienes son esas personas? (Por favor no de el nombre de la persona solamente describa su relacion con esa persona. Por ejemplo, hermana, primo, padre etc.) C. gHay algun otra persona que le viene a la mente cuando usted piensa en la prueba de VIHISIDA? 3. (Que temas o situaciones Ie harian mas facil o mas dificil tomar la prueba de VIHISIDA? 105 APPENDIX B (English) CONSENT FORM FOR THE ELICITATION RESEARCH STUDY Informed Consent Agreement Form mg This project is interested in understanding the factors that influence Latinas to get tested for HIV antibodies. Expe_n'mental Procedures Participation in the study will involve answering a series of questions relating to your beliefs and attitudes toward HIV antibody testing. This study is being conducted by Diana Morrobel, as part of her doctoral dissertation under the supervision of Anne Bogat, Ph.D., Professor of Psychology at Michigan State University. As a participant you will be asked to complete several questionnaires which will take 30-35 minutes to complete. Your responses will be totally anonymous and confidential. Please do not put your name on the questionnaire. 1. This study has been thoroughly explained to you including what your participation involves. ' 2. Your participation is voluntary and you may withdraw from participating at any time without penalty. 3. You certify that you are 18 years of age or older. 4. Confidentialig Your individual responses to the survey will be kept strictly confidential and anonymous. Study results will be presented in a summary format only, without reference to responses given by individual participants. 5. A summary of the study results will be made available to you at your request once the study is completed, within the restrictions outlined in section (4) above. You may request this summary by contacting Diana Morrobel at the address listed at the end of this document. 6. You will be paid $10 for your participation in the study at the completion of the interview. 7. Risks/Benefits Your participation in this study does not guarantee any benefits to you beyond what is stated in sections (5) and (6) above. 8. You have read the material above, and any questions you may have asked have been 106 answered to your satisfaction. WM If you have questions or want to discuss any feelings about your participation in this study, you can contact Diana Morrobel at (517) 355-9561 (MSU Department of Psychology, 129 Psychology Research Bldg., East Lansing, MI 48824 If you have any questions about your rights as a participant in a research study, you can contact Dr. David E. Wright at (517) 35 5—21 80 (MSU University Committee on Research Involving Human Subjects). You understand that by completing this interview you are indicating your voluntary agreement to participate in this research project. Participant’s signature Date 107 APPENDIX B CONSENT FORM FOR THE ELICITATION RESEARCH STUDY (Spanish) Forma de Consentimiento Inforrnado Proposito A los investigadores de este proyecto les interesa los factores que influencian a Ias latinas hacerse Ia prueba para anticuerpos del VIH (SIDA). Procedimientgs Experimentales Participacion en este estudio incluye el contestar una serie de preguntas relacionado a sus creencias y actitudes hacia la prueba para anticuerpos del VIH (SIDA). Este estudio es dirigido por Diana Morrobel, como parte de su tesis doctoral, bajo la supervision de Anne Bogat, PhD, Profesora de Psicologia en Michigan State University. Como participants, 1e pediran a Usted que complete unos cuestionarios, que durara de 30- 35 minutos. Sus respuestas seran totalmente anonimas y confidenciales. Por favor, no escriba su nombre en el cuestionario. 1. Se me ha explicado este estudio completamente. Usted entiende la descripcion que ha sido proveido y todo lo que su participacion incluye. 2. Usted comprende que su participacién es voluntaria y que puede rehusar a participar en cualquier momento sin tener que ser arnonestada. 3. Usted certifica que es mayor de 18 afios. 4. Confidencialidad. Usted entiende que sus respuestas a1 cuestionario seran mantenidas estrictamente anonimas y confidenciales. Los resultados del estudio seran presentados solamente en forma sumaria, sin referencia a las respuestas de participantes individuales. 5. Usted entiende que un sumario del estudio puede ser adquirido si Usted lo pide. El sumario seré disponible al terminar 1a investigacion , conformando con Ias restricciones detalladas en la seccién (4). Usted puede obtener este sumario contactando a Diana Morrobel a la direccién escrita al final de este documento. 6. Usted entiende que recibira $10 por su participacion en este estudio a1 completar la entrevista. 7. Usted ha leido el material mencionado arriba, y se le ha contestado a su satisfaccion cualquier pregunta que tenia. Infonnacign de Contacto 108 Si Usted tiene preguntas o quiere hablar de cualquier sentimiento sobre su participacién en este estudio, puede ponerse en contacto con Diana Morrobel a (517) 355-9561 (MSU Department of Psychology, 129 Psychology Research Bldg., East Lansing, MI 48824) Usted entiende que al completar y entregar este cuestionario, 0 al completar una entrevista, esta indicando su acuerdo voluntario para participar con este proyecto de investigacién. Firma Fecha 109 APPENDIX C Prospective Research Questionnaire (English) Latinas and Health Related Behaviors Structured Interview Michigan State University Participant ID#: Interviewer lD#: Researchers at Michigan State University are currently conducting a study to examine the influence of culture on seeking HIV antibody testing. You have been asked to participate in this study because you have been identified as a Latina over the age of 18 years. In this interview, you will be asked about your cultural background, your health, and your beliefs and attitudes toward HIV antibody testing. You can decline to answer any question and you may discontinue your participation at any time before, during or after the interview. You can also ask questions at any time before, during or after the interview. This interview is completely confidential and nothing you say will be attributed to you directly. The information you provide today will be used by Diana Morrobel, a doctoral student in Clinical Psychology at Michigan State University, to complete her doctoral dissertation. Do you have any quesfions? INTERVIEWER: Review consent form with participant and provide her with a copy. 110 SECTION A: DEMOGRAPHIC INFORMATION I would like to start the interview by asking you some general questions. A1. Are you currently married, divorced, separated, widowed or never been married? C] 1.Married C1 3. Separated Cl 5. Never been married CI 2.Divorced D 4. Widowed Cl 6. Living together but not married A2. What is the highest grade you completed in school? (Interviewer - Circle the number that applies.) [12345 6] [7 8] [9101112][13141516][17 18][19 20 21] Elementary Jr. High High School College Vocational Graduate School A3. Are you currently: CI 1. Working full-time CI 4. Keeping house CI 2. Working part-time C] 5. In school CI 3. Unemployed CI 6. Other (Specify): A4. What is your occupation? If married, what is your spouse’s occupation? If you live at home with your parents, what are your parents’ occupations? A5. What year were you born? What is your age? A6. Where were you born? Country State A7. Where was your father born? Country State A8. Where was your mother born? Country State A9. Would you describe yourself as D Mexican or Mexican-American D Puerto Rican D Cuban or Cuban-American Cl Dominican or Dominican-American D Other: Please specify A10. How many years have you lived in the United States? 111 A11. Have you ever lived in any other country? [3 No CI Yes If yes Where? When did you live there? How long? _ If no go to Question #12 A12. How long have you lived in Michigan? A13. What is your religious denomination? CI 1.Anglican CI 6. Evangelical CI 10. Pentecostal CI 2.Baptist CI 7. Lutheran D 11. Scientology CI 3.Brethren CI 8. Methodist CI 12. Other: CI 4.Catholic CI 9. Mormon D 13. None CI 5.Church of God A14. Do you have any children? Cl O.No CI 1.Yes If yes, How many? How old are they? Do they live with you? Cl O.No C1 1.Yes A15. Have you ever known anyone who has been tested for HIV antibodies? 0 O.No D1.Yes A16. Have you ever known anyone who is HIV positive? D O.No Cl 1.Yes A17. Have you ever known anyone who has AIDS? C10.No C11. Yes 112 SECTION B: BICULTURALISM Now I would like to ask you a few questions about your cultural background. Please answer the following questions with the response that best describes you. B1. How much do you enjoy speaking Spanish: tremendous enjoyment ............................. 1 quite a bit of enjoyment ............................ 2 not too much enjoyment, or ...................... 3 no enjoyment? .......................................... 4 Does not speak Spanish ............................ 5 82. How much do you enjoy speaking English: tremendous enjoyment .............................. 1 quite a bit of enjoyment ............................. 2 not too much enjoyment, or ....................... 3 no enjoyment? ........................................... 4 Does not speak English ............................. 5 B3. How much are Latino values a part of your life: very much a part ....................................... 1 a good part ............................................... 2 a small part, or ......................................... 3 no part at all? ............................................ 4 B4. How much are American values a part of your life: very much a part ....................................... 1 a good part ............................................... 2 a small part, or .......................................... 3 no part at all? ............................................ 4 85. How many days a week would you like to eat Spanish food? (Days per week) B6. How many days a week would you like to eat American food? (Days per week) B7. How proud are you of being Latina: very proud ................................................ 1 fairly proud ............................................... 2 not too proud ............................................ 3 not proud at all, or ..................................... 4 do you feel ashamed? ............................... 5 113 88. How proud are you of being American: very proud ................................................. 1 fairly proud ................................................ 2 not too proud ............................................. 3 not proud at all, or ..................................... 4 do you feel ashamed? ................................ 5 89. How comfortable would you be in a group of Americans who don’t speak Spanish: very comfortable ......................................... 1 fairly comfortable ........................................ 2 not too comfortable, or .............................. 3 not comfortable at all? ................................ 4 810. How comfortable would you be in a group of Latinos who don’t speak English: very comfortable ......................................... 1 fairly comfortable ........................................ 2 not too comfortable, or ................................ 3 not comfortable at all? ................................. 4 811. How important is it to you to raise your children with Latino values: (If the participant has no children ASK) If you had children, how important would it be to you to raise them with Latino values: very important ............................................ 1 fairly important ........................................... 2 not too important ....................................... 3 not important at all ..................................... 4 812. How important is to you to raise your children with American values: (If participant has no children ASK) If you had children, how important would it be to you to raise them with American values: very important ............................................ 1 fairly important ........................................... 2 not too important ....................................... 3 not important at all? ................................... 4 813. How much do you enjoy Spanish TV programs: very much .................................................. 1 quite a bit ................................................... 2 not too much, or ........................................ 3 not at all? ................................................... 4 Do not watch Spanish TV .......................... 5 114 814. How much do you enjoy American TV programs: very much .................................................. 1 quite a bit ................................................... 2 not too much, or ........................................ 3 not at all? ................................................... 4 Do not watch American TV ....................... 5 815. How important is it to you to celebrate holidays in the “Latino” way: very important ........................................... 1 fairly important .......................................... 2 not too important, or ................................ 3 not important at all? .................................. 4 816. How important is it to you to celebrate holidays in the American way: very important ........................................... 1 fairly important .......................................... 2 not too important, or ................................ 3 not important at all? .................................. 4 817. V\fith respect to kindness and generosity, do you think Latinos are: very kind and generous ............................. 1 fairly kind and generous ............................ 2 a little kind and generous, or ..................... 3 not kind and generous at all? ..................... 4 818. VIfith respect to kindness and generosity, do you think Americans are: very kind and generous ............................. 1 fairly kind and generous ............................ 2 a little kind and generous, or ..................... 3 not kind and generous at all? ..................... 4 SECTION C: CURRENT HEALTH STATUS Now I would like to ask you a few questions about your health. C1. How would you rate your overall health? [1] Excellent [2] Good [3] Fair [4] Poor 115 C2. Are you currently using any of the following forms of birth control? (Interviewer - Show Card A and read off responses. Check all that apply.) . Birth control pills D 6. IUD/Intrauterine Device D 11. Depro Provera . Condoms D 7. Rhythm method D 12. Norplant . Diaphragm D 8. Female sterilization D 13. No Method . Douching after intercourse D 9. Male sterilization D14. Other: SpermicidelCreams/Jellies D 10. Withdrawal method CI DUDE] #wN—s S" CS. Have you ever been pregnant? D O. No D 1. Yes C4. Are you currently pregnant? Do. No D1. Yes C5. Have you been hospitalized within the last year for a medical condition? Do. No “ D1. Yes C6. Have you experienced major medical problems in the last year? Do. No D1. Yes C7. Have you ever been tested for the AIDS virus? D 0. No - Go to question CS D 1. Yes - D 2. Doesn’t know - Go to question C9 D 3. Not sure - Go to question C9 08. Did the test show that you were HIV positive? D 0. No D 1. Yes D 2. Doesn’t know D 3. Not sure 09. Have you ever been tested for STDs (i.e., sexually transmitted diseases)? D 0. No D 1. Yes D 2. Doesn’t know D 3. Not sure 116 C10. Have you ever had any of the following sexually transmitted diseases? D Syphillis D Gonorrhea D Hepatitis A-G D Oral fungus D Anal sores 011. V\fithin the last year have you had recurrent infections that have not responded to medications or treatment? D0. No D1. Yes C12. Have you been diagnosed with PlD (Pelvic inflammatory disease) in the last year? D0. No D1. Yes C13. Have you had an abnormal pap smear in the last year? D0. No D1. Yes C14. Have you sought medical treatment for any health problems in the last year? Do. No D1. Yes Please indicate which of the following PHYSICAL SYMPTOMS, if any, you have experienced during the PAST YEAR (check all that apply): C15. Thrush, candida, or white patches in the mouth or throat for at least 2 weeks __ C16. Unintentional weight loss of at least 10 pounds (not related to dieting) C17. Diarrhea that lasted at least 2 weeks _ 018. Sweating at night for at least 2 weeks _ 019. Hairy leukoplakia (a white coating) on the tongue _ C20. A new or unusual dry cough lasting at least 2 weeks _ 021. Persistent sore mouth or throat lasting at least 2 weeks _ 022. An unusual bruise, bump, or skin discoloration that lasted at least 2 weeks __ 023. Persistent fatigue for at least 2 weeks _ 024. Persistent or recurring fever of a least 100 degrees for at least 2 weeks _ 025. Tender or enlarged glands or lymph nodes (not counting groin) __ 117 026. Herpes zoster (shingles) _ 027. Persistent shortness of breath for at least 2 weeks _ 028. A new skin rash that lasted at least 2 weeks _ 029. Persistent, frequent, or unusual headaches for at least 2 weeks _ 030. Blurred vision, light flashes, or other unusual vision problems for at least 2 weeks __ SECTION D: PERCEIVED HIV RISK Now I am going to ask you some questions about your risk for HIV infection. D1. Would you say your chances of being infected with HIV right now is high, medium, low or no chance at all? D1. High D2. Medium D3. Low D4. No chance at all D2. What are the chances that you will get the AIDS virus (HIV) sometime in your lifetime? D1. Very good chance D2. Some chance D3. Small chance D4. No chance D3. How would you rate your level of concern about being infected with HIV or getting AIDS? D1. High D2. Medium D3. Low D4. Not at all concerned 118 HIV ANTIBODY TESTING QUESTIONNAIRE FOR LATINAS Now I would like to ask you some questions about your beliefs and attitudes toward HIV antibody testing. I. Intention 1. How likely is it that you intend to be tested for HIV antibodies within the next month? Unlikely I I I I I Z Likely 1 2 3 4 5 6 7 Extremely Quite Slightly Neither Slightly Quite Extremely II. Attitude toward getting tested for HIV antibodies 1. Your getting tested for HIV antibodies within the next month is Foolish : : : : : : Wise -3 -2 -1 0 1 2 3 Extremely Quite Slightly Neither Slightly Quite Extremely Unpleasant : : : : : : Pleasant -3 -2 -1 0 1 2 3 Extremely Quite Slightly Neither Slightly Quite Extremely Bad : : : : : : Good -3 -2 -1 0 1 2 3 Extremely Quite Slightly Neither Slightly Quite Extremely Useless : : : : : : Useful -3 -2 .-1 0 1 2 3 Extremely Quite Slightly Neither Slightly Quite Extremely Harmful : : : : : : Beneficial -3 -2 -1 0 1 2 3 Extremely Quite Slightly Neither Slightly Quite Extremely 2. Overall, how would you rate your attitude toward you getting tested for HIV antibodies? Negative : : : : : : Positive -3 -2 -1 0 1 2 3 Extremely Quite Slightly Neither Slightly Quite Extremely 119 III. Behavioral Beliefs 1 . If you got tested for HIV antibodies within the next month, how likely is it that you will contact the place where you were tested so you could know your HIV status? Unlikely I : I I : : Likely 1 2 3 4 5 6 7 Extremely Quite Slightly Neither Slightly Quite Extremely 2. If you got tested for HIV antibodies within the next month, how likely is it that you will protect your partner from contracting HIV from you? Unlikely . . . . . : Likely 1 2 3 4 5 6 7 Extremely Quite Slightly Neither Slightly Quite Extremely 3. If you got tested for HIV antibodies within the next month, how likely is it that you will get treatment if your test results indicate that you are HIV positive? Unlikely . . I : . : Likely l 2 3 4 5 6 7 Extremely Quite Slightly Neither Slightly Quite Extremely 4. If you got tested for HIV antibodies within the next month, how likely is it that you will maintain/safeguard your health? Unlikely : . . : : : Likely l 2 3 4 5 6 7 Extremely Quite Slightly Neither Slightly Quite Extremely 5. If you got tested for HIV antibodies within the next month, how likely is it that you will change your lifestyle? Unlikely . . : : : : Likely l 2 3 4 5 6 7 Extremely Quite Slightly Neither Slightly Quite Extremely 6. If you got tested for HIV antibodies within the next month, how likely is it that HIV infection will be detected early? Unlikely : . : : : : Likely l 2 3 4 5 6 7 Extremely Quite Slightly Neither Slightly Quite Extremely 7. If you got tested for HIV antibodies within the next month, how likely is it that you will prevent others from getting HIV from you? Unlikely . . . . : : Likely l 2 3 4 5 6 7 Extremely Quite Slightly Neither Slightly Quite Extremely 120 8. If you got tested for HIV antibodies within the next month, how likely is it that you will prevent giving HIV to your unborn baby (now or in the future)? Unlikely . . . . . : Likely l 2 3 4 5 6 7 Extremely Quite Slightly Neither Slightly Quite Extremely 9. If you got tested for HIV antibodies within the next month, how likely is it that you will receive information about the signs of HIV infection? Unlikely : . . . : : Likely I 2 3 4 5 6 7 Extremely Quite Slightly Neither Slightly Quite Extremely 10. If you got tested for HIV antibodies within the next month, how likely is it that you will have peace of mind? Unlikely 2 I I 3 2 2 Likely l 2 3 4 5 6 7 Extremely Quite Slightly Neither Slightly Quite Extremely l 1. If you got tested for HIV antibodies within the next month, how likely is it that it you will prepare for the future? Unlikely . . : : : : Likely I 2 3 4 5 6 7 Extremely Quite Slightly Neither Slightly Quite Extremely 12. If you got tested for HIV antibodies within the next month, how likely is it that you will experience psychological problems? Unlikely . . . : : : Likely 1 2 3 4 5 6 7 Extremely Quite Slightly Neither Slightly Quite Extremely 13. If you got tested for HIV antibodies within the next month, how likely is it that you will feel depressed? Unlikely . : : : : : Likely I 2 3 4 5 6 7 Extremely Quite Slightly Neither Slightly Quite Extremely 14. If you got tested for HIV antibodies within the next month, how likely is it that taking the test will reflect negatively on you as a person? Unlikely . . . . : : Likely l 2 3 4 5 6 7 Extremely Quite Slightly Neither Slightly Quite Extremely 121 15. If you got tested for HIV antibodies within the next month, how likely is it that you will feel stressed and worried? Unlikely : : : : I : Likely l 2 3 4 5 6 7 Extremely Quite Slightly Neither Slightly Quite Extremely 16. If you got tested for HIV antibodies within the next month, how likely is it that you will feel isolated or alone? Unlikely : . : I : : Likely l 2 3 4 5 6 7 Extremely Quite Slightly Neither Slightly Quite Extremely 17. If you got tested for HIV antibodies within the next month, how likely is it that you will change how you look/perceive yourself? Unlikely . . . I : : Likely l 2 3 4 5 6 7 Extremely Quite Slightly Neither Slightly Quite Extremely 18. If you got tested for HIV antibodies within the next month, how likely is it that you will be scared or worried about how long you have to live? Unlikely I . . . . : Likely l 2 3 4 5 6 7 Extremely Quite Slightly Neither Slightly Quite Extremely 19. If you got tested for HIV antibodies within the next month, how likely is it that you will have difficulty telling your family? Unlikely . . . : : : Likely 1 2 3 4 5 6 7 Extremely Quite Slightly Neither Slightly Quite Extremely 20. If you got tested for HIV antibodies within the next month, how likely is it that you will be rejected by people at work or society in general? Unlikely . . . . . : Likely 1 2 3 4 5 6 7 Extremely Quite Slightly Neither Slightly Quite Extremely 21. If you got tested for HIV antibodies within the next month, how likely is it that you will fear that your health insurance will be cancelled? Unlikely . . I Z : : Likely l 2 3 4 5 6 7 Extremely Quite Slightly Neither Slightly Quite Extremely 22. If you got tested for HIV antibodies within the next month, how likely is that you will receive results indicating that you are HIV positive? Unlikely . . . . : : Likely l 2 3 4 5 6 7 Extremely Quite Slightly Neither Slightly Quite Extremely 122 IV. Outcome Evaluations 1. Contacting the place where you were tested so you could know your HIV status is Bad : : : : : : Good -3 -2 -1 0 1 2 3 Extremely Quite Slightly Neither Slightly Quite Extremely 2. Helping protect your partner from contracting HIV from you is Bad : : : : : : Good -3 -2 -1 0 l 2 3 Extremely Quite Slightly Neither Slightly Quite Extremely 3. Getting treatment if you are HIV positive is Bad : : : : : : Good -3 -2 -l O l 2 3 Extremely Quite Slightly Neither Slightly Quite Extremely 4. Maintaining/safeguarding your health is Bad : : : : : : Good -3 -2 -I 0 l 2 3 Extremely Quite Slightly Neither Slightly Quite Extremely 5. Changing your lifestyle is Bad : : : : : : Good -3 -2 - 1 0 l 2 3 Extremely Quite Slightly Neither Slightly Quite Extremely 6. Detecting HIV infection early is Bad : : : : : : Good -3 -2 - I 0 1 2 3 Extremely Quite Slightly Neither Slightly Quite Extremely 7. Preventing others from getting HIV from you is Bad : : : : : : Good -3 -2 -l 0 1 2 3 Extremely Quite Slightly Neither Slightly Quite Extremely 123 8. Preventing giving HIV to your unborn baby now or in the future is Bad : : : Good -3 -2 -1 0 l 2 Extremely Quite Slightly Neither Slightly Quite Extremely 9. Receiving information about the signs of HIV infection is Bad : : : Good -3 -2 -1 0 l 2 Extremely Quite Slightly Neither Slightly Quite Extremely 10. Having peace of mind is Bad : : : Good -3 -2 -l 0 1 2 Extremely Quite Slightly Neither Slightly Quite Extremely 11.Planning for the future is Bad : : : Good -3 -2 -1 0 l 2 Extremely Quite Slightly Neither Slightly Quite Extremely 12. Experiencing psychological problems is Bad : : : Good -3 -2 -l 0 1 2 Extremely Quite Slightly Neither Slightly Quite Extremely 13. Feeling depressed is Bad : : : Good -3 -2 -I 0 1 2 Extremely Quite Slightly Neither Slightly Quite Extremely 14. Having a negative reflection of myself as a person is Bad : : : Good -3 -2 -1 0 l 2 Extremely Quite Slightly Neither Slightly Quite Extremely 15. Feeling stressed or worried is Bad : : : Good -3 -2 -l 0 1 2 Extremely Quite Slightly Neither Slightly Quite Extremely 124 16. Feeling isolated or alone is Bad Good -3 -2 -1 O l 2 Extremely Quite Slightly Neither Slightly Quite 17. Changing how you look/perceive yourself is Bad Extremely Good -3 -2 -l 0 l 2 Extremely Quite Slightly Neither Slightly Quite 18. Feeling scared or worried about how long you have to live is Bad Extremely Good -3 -2 - l 0 I 2 Extremely Quite Slightly Neither Slightly Quite 19.Having difficulty talking with your family is Bad Extremely Good -3 -2 - I 0 1 2 Extremely Quite Slightly Neither Slightly Quite 20. Being rejected by people at work or society in general is Bad Extremely Good -3 -2 -1 0 l 2 Extremely Quite Slightly Neither Slightly Quite 21.Fearing having your health insurance canceled is Bad Extremely Good -3 -2 -l 0 l 2 Extremely Quite Slightly Neither Slightly Quite 22.Receiving results indicating that you are HIV positive is Bad Extremely Good -3 -2 -I 0 l 2 Extremely Quite Slightly Neither Slightly Quite 125 Extremely V. Subjective Norm 1. If you got tested for HIV antibodies within the next month, most people who are important to you would Approve : : : : : . Disapprove Strongly Moderately Mildly Neither Mildly Moderately Strongly VI. Normtive Beliefs Note: Please write “not applicable” next to the items that ask about individuals that are not present in the participants life. 1. If you got tested for HIV antibodies within the next month, most members of your family would Approve : : : : : : Disapprove Strongly Moderately , Mildly Neither Mildly Moderately Strongly 2. If you got tested for HIV antibodies within the next month, your mother (or the person who is a mother figure in your life) would Approve : : : : : : Disapprove Strongly Moderately Mildly Neither Mildly Moderately Strongly 3. If you got tested for HIV antibodies within the next month, your father (or the person who is a father figure in your life) would Approve : : : : : : Disapprove Strongly Moderately Mildly Neither Mildly Moderately Strongly 4. If you got tested for HIV antibodies within the next month, your sister(s) would Approve : : : : : : Disapprove Strongly Moderately Mildly Neither Mildly Moderately Strongly 5. If you got tested for HIV antibodies within the next month, your brother(s) would Approve : Disapprove Strongly Moderately Mildly Neither Mildly Moderately Strongly 6. If you got tested for HIV antibodies within the next month, your grandparents would Approve : : : : : . Disapprove Strongly Moderately Mildly Neither Mildly Moderately Strongly 126 7. If you got tested for HIV antibodies within the next month, your husband/boyfriend would Approve : : : : : : Disapprove Strongly Moderately Mildly Neither Mildly Moderately Strongly 8. If you got tested for HIV antibodies within the next month, most of your aunts and uncles would . Approve : : : : : : Disapprove Strongly Moderately Mildly Neither Mildly Moderately Strongly 9. If you got tested for HIV antibodies within the next month, most of your friends would . Approve : : : : : . Disapprove Strongly Moderately Mildly Neither Mildly Moderately Strongly 10. If you got tested for HIV antibodies within the next month, most of your co- workers would . Approve : : : : : : Disapprove Strongly Moderately Mildly Neither Mildly Moderately Strongly 11. If you got tested for HIV antibodies within the next month, most members of your church would . Approve : : : : : . Disapprove Strongly Moderately Mildly Neither Mildly Moderately Strongly 12. If you got tested for HIV antibodies within the next month, your local priest or pastor would . Approve : : : : : : Disapprove Strongly Moderately Mildly Neither Mildly Moderately Strongly 13. If you got tested for HIV antibodies within the next month, God would Approve : : : : : . Disapprove Strongly Moderately Mildly Neither Mildly Moderately Strongly 127 VII. Motivation to comply 1. Generally speaking, you do what your family wants you to do. Not at all : : : : : : Very much 1 2 3 4 5 6 7 2. Generally speaking, you do what your mother (or mother figure in your life) wants you to do. Not at all : : : : : : Very much I 2 3 4 5 6 7 3. Generally speaking, you do what your father (or father figure in your life) wants you to do. Not at all : : : I : : Very much 4. Generally speaking, you do what your sister(s) wants you to do. Not at all : : : : : : Very much I 2 3 4 5 _ 6 7 5. Generally speaking, you do what your brother(s) wants you to do. Not at all : : : I : : Very much 1 2 3 4 5 6 7 6. Generally speaking, you do what your grandparents want you to do. Not at all I . t : : : 2 Very much 1 2 3 4 5 6 7 7. Generally speaking, you do what your husband/boyfriend wants you to do. Not at all 2 I : : : I Very much I 2 3 4 5 6 7 8. Generally speaking, you do what your aunts and uncles want you to do. Not at all : : : : : : Very much 128 9. Generally speaking, you do what your friends want you to do. Not at all I t : : : : Very much I 2 3 4 5 6 7 10. Generally speaking, you do what your co-workers want you to do. Not at all : : : I : : Very much 1 2 3 4 5 6 7 11. Generally speaking, you do what most members of your church want you to do. Not at all : : : : : Very much 1 2 3 4 5 6 7 12. Generally speaking, you do what your priest or pastor wants you to do. Not at all : : . . . Very much I 2 3 4 5 6 7 13. Generally speaking, you do what God wants you to do. Not at all : ' ' ' ' Very much I 2 3 4 5 6 7 VIII. Perceived behgviorafl cor_1trol 1. It is mostly up to you whether or not you get tested for HIV antibodies during the next month. True : : : : : : False Extremely Quite Slightly Neither Slightly Quite Extremely 2. If you wanted to, you could easily be tested for HIV antibodies during the next month. Strongly : : : : : : Strongly Disagree I 2 3 4 5 6 7 Agree 3. For you to get tested for HIV antibodies during the next month is Easy : : : : : : Difficult Extremely Quite Slightly Neither Slightly Quite Extremely 129 4. How much control do you have over getting tested for HIV antibodies in the next month? No : : : : : : Complete Control I 2 3 4 5 6 7 Control Perceived belgjoral control beliefs 1. You would be more likely to get tested if there was a testing center near to your home. Strongly : : : : : : Strongly Disagree 1 2 3 4 5 6 7 Agree 2. You would be more likely to get tested if there was a place that did not consider testing as something negative or where the staff did not look down on you. Strongly : : : : : : Strongly Disagree 1 2 3 4 5 6 7 Agree 3. You would be more likely to get tested for HIV antibodies if the test was free. Strongly : : : : : : Strongly Disagree 1 2 3 4 5 6 7 Agree 4. You would be more likely to get tested if the test was anonymous. Strongly : : : : : : Strongly Disagree 1 2 3 4 5 6 7 Agree 5. You would be more likely to get tested if the test was confidential. Strongly : : : : : : Strongly Disagree 1 2 3 4 5 6 7 Agree 6. You would be more likely to get tested if you had a blood transfusion in a hospital. Strongly : : : : : : Strongly Disagree 1 2 3 4 5 6 7 Agree 130 7. You would be more likely to get tested if you were more educated or knew more about the test and the virus. Strongly : : : : : : Strongly Disagree 1 2 3 4 5 6 7 Agree 8. You would be less likely to get tested if the testing site is too far away. Strongly : : : : : : Strongly Disagree 1 2 3 4 5 6 7 Agree 9. You would be less likely to get tested if the test is not free or it is too expensive. Strongly : : : : : : Strongly Disagree 1 2 3 4 5 6 7 Agree 10. You would be less likely to get tested if the testing site is not welcoming or friendly toward women. Strongly : : : : : : Strongly Disagree I 2 3 4 5 6 7 Agree 11. You would be less likely to get tested because of what people think about you when they know you took the test. Strongly : : : : : : Strongly Disagree I 2 3 4 5 6 7 Agree 12. You would be less likely to get tested if the test was not confidential. Strongly : : : : : : Strongly Disagree 1 2 3 4 5 6 7 Agree 13. You would be less likely to get tested if you were fearful of an early death. Strongly : : : : : : Strongly Disagree 1 2 3 4 5 6 7 Agree D Stop Here DO NOT CONTINUE TO THE NEXT PAGE! REMIND THE PARTICIPANT THAT SHE WILL BE CONTACTED WITHIN A MONTH TO COMPLETE THE FOLLOW UP INTERVIEW. 131 V. HIV Antibody Testing Behavior Record Today’s Date Interviewer It has been one month since your first interview. Now as the final part of the study, I would like for you to please answer the following questions regarding HIV antibody testing. I will also like to remind you that I am not going to ask you to tell me your HIV status. You also have the right to refuse to answer any questions that you do not wish to answer. Do you have any questions or concerns that you would like to ask or share with me at this time? 1. In the last month, have you tried to get information about HIV antibody tesfing? (1) Yes (0) No ...... Go to Question 2 1A. Which of the following have you done to get more information about HIV antibody testing? Please check all that apply Cl called or visited the local health department Cl called or visited my private doctor’s office Cl called or visited a local clinic Cl called or visited a community agency Cl called an HIV hotline C] called or visited a drug store or pharmacy Cl looked for information through the computer on the internet or electronic mail D Other: Please specify Now I would like to ask you some questions related to one of the ways people can get tested for HIV antibodies. I am going to ask you about getting tested for HIV antibodies at a testing site. A testing site is a place that offers HIV antibody testing. 2. In the last month, have you called or visited a place that offers HIV antibody testing to receive more information? Places such as a local health clinic, health department, doctor’s office, or community agency (1) Yes (0) No 132 3. In the last month, have you made an appointment to be tested for HIV antibodies? (1) Yes (0) No 4. In the last month, did you receive HIV counseling before you were tested? HIV counseling is when an HIV counselor speaks to you about HIV, HIV prevention, your decision to be tested, and the HIV antibody test. (1) Yes (0) No 5. In the last month, did you get tested for HIV antibodies? (1) Yes (0) No ........ Go to Question 9 6. Did you receive HIV counseling after you took the HIV antibody test? (1) Yes (0) No 7. Do you know the results of your test? (1) Yes (0) No Why not? 8. How did you find out the results of your test? Check all that apply CI in person Cl over the phone C1 by mail Now I would like to ask you about taking a Home HIV test. 9. In the last month, did you try to get more information about the Home HIV test? (1) Yes (0) No Go to Question 10 133 9A. Which of the following have you done to get more information about Home HIV antibody testing? Please check all that apply Cl called or visited the local health department Cl called the makers of the test at 1-800 HIV-TEST Cl called or visited a community agency [3 called an HIV hotline Cl called or visited a drug store or pharmacy D looked for information through the computer on the internet or electronic mail Cl Other: Please specify 10. In the last month, did you purchase a home HIV test kit (Home Access Health HIV test kit)? (1) Yes (0) No ................. END INTERVIEW 11. In the last month, did you call the 800 number and listen to information about HIV? (1) Yes (0) No 12. In the last month, did you activate the test kit number? (1) Yes (0) No 13. In the last month, did you listen to and answer automated questions? (1) Yes (0) No 14. In the last month, did you listen to and answer questions with an HIV counselor? (1) Yes (0) No 15. In the last month, did you copy your test kit identification number on the blood sample card? (1) Yes (0) No 16. In the last month, did you mail your blood sample? (1) Yes (0) No 134 17. In the last month, did you call the 800 number and listen to the information message about HIV? (1) Yes (0) No 18. In the last month, did you call the 800 number to get the results of your test? (1) Yes (0) No 19. In the last month, did you receive HIV counseling after you took the Home HIV test? (1) Yes (0) No 20. Do you know the results of your test? (1) Yes (0) No Why not? END OF INTERVIEW THANK YOU FOR PARTICIPATING. 135 APPENDIX C Prospective Research Questionnaire (Spanish) Latinas y su salud Entrevista estructurada Michigan State University ID de la garticigante: Fecha de entrevista: ID del entrevistadora: Investigadores de la Universidad del Estado de Michigan actualmente estan conduciendo un estudio para examinar la influencia de la cultura con respecto a la busqueda de la prueba de VIH/SIDA. Se le ha solicitado participar en este estudio ya usted ha sido identificada como una mujer Latina de 18 anos de edad o mas. En esta entrevista, se Ie preguntara acerca de su formacion cultural, su salud, y sobre sus creencias y‘atitudes acerca de la prueba de VIH/SIDA. Usted puede negarse a contestar cualquier pregunta o dicontinuar su participacién en cualquier momento ya sea antes, durante o después de la entrevista. Puede también hacer preguntas en cualquier momento antes, durante , o después de la entrevista. Esta entrevista es completamente confidencial y nada de lo que usted diga sera atribuido a usted directamente. La informacién que usted provea sera utilizada por Diana Morrobel, estudiante doctoral en Psicologia Clinica en la Universidad del Estado de Michigan para completar su tesis. gTiene alguna pregunta o comentario? Entrevistadora - Favor revisar la forma de consentimiento con la participante, 'proveale una copla y hagales firmar. 136 SECCION A: IanACION DEMOGRAFICA Quisiera empezar Ia entrevista con unas preguntas generales. A1. gActualmente es usted casada, divorciada, separada, viuda o nunca se ha casado? D 1.Casada D 3. Separada D 5. Nunca he sido casada D 2.Divorciada D 4. Viuda A2. g0ual es el nivel educativo mas alto que usted ha completado? (Entrevistadora- Circule el numero que aplica) [1 234 56] [7 8] [9 10 11 12] [13 1415 16] [17 18] [19 20 21] Primaria Secundaria Preparatoria Universidad Politécnica/ escuela de Vocacional posgrado A3. Actualmente usted: D 1. Trabaja a tiempo completo D 4. Es ama de casa D 2. Trabajaatiempo parcial D 5. Es estudiante D 3. Es desempleada D 6. Otro (Especifique) A4. (,0ual es el su ocupacién? gSi es casada, cual es la ocupacion de su pareja? gSi vive con sus padres, cual es la ocupacidn de sus padres? A5. gEn que ano nacio? g0ual es su edad? A6. gDonde nacié? Pais Estado A7. ngnde nacio su padre? Pais Estado A8. gDonde nacio su madre? Pais Estado A9. Usted se identifica como D Mexicana/ Chicana D Puertorriquena D Cubana D Dominicana D Otro: (Especifique) A10. g0uantos afios ha vivido en los Estados Unidos? A11. gAlguna vez a vivido usted en otro pais? D Si D No Si la respuesta es “no” pase a la pregunta #12 gDénde? gCuando vivio usted ahi? gPor cuanto tiempo? 137 A12. gCuanto tiempo usted ha vivido en Michigan? A13. 3,0ual es su formacién religiosa? D 1.Anglicana D 6. Evangelica D 11 . Cientologia D 2.Bautista D 7. Luterana D 12. Otra D 3.Brethren D 8 Metodista (Especifique) D 4.0at6lica D 9. Morrnona D 13. Ninguna D 5.lglesia de Dios D 10. Pentecostal A14 gTiene usted hijos? D 0. No D 1. Si Si la respuesta es “Si” g0uantos hijos tiene? 2,0uantos afios tiene(n)? gSu(s) hijo(s) o hija(s) viven con usted? D 0. No D 1.Si A15. gA conocido a alguien que se hecho la prueba de VIHISIDA? D0.NoD1.Si A16. gAIguna vez ha conocido alguien VIH positivo? DO. NOD 1.Si A17. 5A conocido alguien que tiene SIDA? D 0. No D 1.Si SECCION e: BICULTURALISM Ahora quiziera hacerle algunas preguntas sobre su experiencia cultural. Por favor conteste Ias siguientes preguntas con la respuesta que mejor la describe a usted. 81. g0uanto usted disfruta el hablar espar‘iol un placer immenso .................................. 1 mucho placer .......................................... 2 no mucho placer, o .................................. 3 ningun placer? ......................................... 4 No habla espafiol .................................... 5 138 82. gCuanto usted disfruta eI hablar inglés un placer immenso .................................. 1 mucho placer .......................................... 2 no mucho placer, o .................................. 3 ningr'Jn placer? ......................................... 4 No habla inglés ........................................ 5 83. gCuanto forman los valores Latinos parte de su vida gran parte ................................................. 1 una buena parte ........................................ 2 una pequena parte ................................... 3 ninguna parte? ........................................... 4 84. gCuanto forman los valores Americanos parte de su vida gran parte ................................................. 1 una buena parte ........................................ 2 una pequena parte ............... 3 ninguna parte? .......................................... 4 85. gCuantos dias a la semana a usted Ie gusta comer comida Latina? (Dias a la semana) 86. gCuantos dias a la semana a usted le gusta comer comida Americana? (Dias a la semana) 87. L0uan orgullosa se siente de ser Latina: muy orgullosa ........................................... 1 bastante orgullosa .................................... 2 no muy orgullosa ....................................... 3 ningun orgullo o ......................................... 4 se siente avergonzada? ............................. 5 88. gCuan orgullosa se siente de ser Americana: muy orgullosa ........................................... 1 bastante orgullosa .................................... 2 no muy orgullosa ....................................... 3 ningun orgullo o ......................................... 4 se siente avergonzada? ............................. 5 139 89. (,0uan comoda se sentiria usted entre un grupo de Americanos que no hablan espar‘tol muy comoda ............................................... 1 bastante comoda ........................................ 2 no muy comoda ......................................... 3 totalmente incomoda? ................................ 4 810. g0uan comoda se sentiria usted entre un grupo de Latinos que no hablan inglés muy comoda ............................................... 1 bastante comoda ........................................ 2 no muy comoda ......................................... 3 totalmente incomoda? ................................ 4 811. ¢0uan importante es para usted criar a sus hijos con valores Latinos: (Si Ia participante no tiene hijos PREGUNTE: Si tuviera hijos, cuan importante para usted seria criarlos con valores Latinos:) muy importante ............................................ 1 bastante importante ..................................... 2 no muy importante ....................................... 3 no es importante en absoluto ....................... 4 812. aCuan importante es para usted criar a sus hijos con valores Americanos: (Si Ia participante no tiene hijos PREGUNTE: Si tuviera hijos, cuan importante para usted seria criarlos con valores Americanosz) muy importante ............................................ 1 bastante importante ..................................... 2 no muy importante ....................................... 3 no es importante en absoluto ....................... 4 813. g0uanto disfruta usted de los programas de la television Hispana: mucho ........................................................ 1 bastante .................................................... 2 no tanto, o ................................................. 3 nada? ......................................................... 4 No mira la television Hispana? ................... 5 140 814. LCuanto disfruta usted de los programas de la television Americana: mucho ........................................................ 1 bastante .................................................... 2 no tanto, o ................................................. 3 nada? ......................................................... 4 No mira la television Americana? ............... 5 815. g0uan importante es para usted celebrar los dia festivos de la manera Lafina: muy importante ............................................ 1 bastante importante ..................................... 2 no muy importante ....................................... 3 no es importante en absoluto ....................... 4 816. gCuan importante es para usted celebrar los dia festivos de la manera Americana: muy importante ............................................ 1 bastante importante ..................................... 2 no muy importante ....................................... 3 no es importante en absoluto ....................... 4 817. Con respecto a la bondad y la generosidad, piensa usted que los Latinos son: muy bondadosos y generosos ................... 1 bastante bondadosos y generosos ........... 2 poco bondadosos y generosos, o .............. 3 hi bondadosos ni generosos? ................... 4 818. Con respecto a la bondad y la generosidad, piensa usted que los Americanos son: muy bondadosos y generosos ................... 1 bastante bondadosos y generosos ........... 2 poco bondadosos y generosos, o .............. 3 ni bondadosos ni generosos? ................... 4 141 SECCION C: ESTADO DE SALUD Ahora le voy a hacer algunas preguntas acerca de su salud. 01. (Come usted describiria su estado de salud? D Excelente D Bueno D Regular D Pobre 02. gActualmente utiliza alguno de los siguientes métodos del control de la natilidad/ anticonceptivos? (Entrevistadora- Muestre tarjeta A y lea Ias respuestas. Marque todas las que apliquen.) D 1. Pildoras anticonceptivas D 9. Esterilizacién masculinal D 2. Condones/preservativos vasectomia D 3. Diafragma D 10. Interupcién del coito o f método de retivadalsacar o D 4. Ducha vaginal/Iavarse después de la retirar el miembro/salirse/ relacién terrninar afuera D 5. Espumafjalea/crema espermicida/ tableta espumante D 11. lnyecciones (Depro Provera) D 6. Dispositivo/aparato intrauterino/ D 12. Norplant, el implante T de cobre/espiral/lazo D 13. Ningun método D 7. Ritmo o periodo a salvo D 14. Otro: D 8. Esterilizacion femenina/Iigarse los tubos 03. (Ha estado alguna vez embarazada/encinta? D 0. No D 1. Si 04. gActualmente, esta usted embarazada/encinta? D 0. No D 1. SI 05. (“Ha sido usted hospilizada durante el ultimo afio por una condicién medica? D 0. No D 1. Si 06. gHa tenido usted graves problemas de salud durante el ultimo ano? D 0. No D 1. Si C7. gAlguna vez se ha hecho la prueba del virus del SIDANIH? D 0. No - Pass a la pregunta 09 D 1. Si D 2. No sé - Pase a la pregunta 09 D 3. No estoy segura - Pase a la pregunta 09 142 08. gLos resultados de su prueba de VIH/SIDA fuerén positivos? D 0. No D 1. Si D 2. No sé D 3. No estoy segura 09. (Se ha hecho alguna prueba de enfermedades de transmisién sexual? D 0. No D 1. Si D 2. No sé D 3. No estoy segura 010. gAlguna vez usted ha tenido algunas de estas enfermedades que son transmitidas sexualmente? D Sifilis D Gonorrea D Hepatitis A-G D Hongo oral D Llagas en el ano C11. Durante el Ultimo ano ha tenido usted alguna infeccidn frequente que no ha sido aliviada por medicinas o tratamiento medico? D 0. No D 1. Si 012. gSe le ha diagnosticado con la Enferrnedad de lnflamacién del Pelvis (Pelvic Inflammatory Disease)? D 0. No D 1. Si 013. gHa tenido usted un examen anonnal del Papa Nicolao (Pap Smear)? D 0. No D 1. Si 014. gDurante el Ultimo afio, ha buscado ayuda médica con respecto a algun problema de salud? D 0. No D 1. Si Por favor indique cual de los siguientes sintomas, a tenido durante este ultimo afio (Marque todos los que apliquen). 015. Afta, candida or erupciones blancas en la boca o garganta por al menos 2 semanas 016. Pérdida de peso no intencional de por lo menos 10 libras (no relacionado con la dieta) 017. Diarreas que han durado por lo menos 2 semanas 018. Sudor nocturno que ha durado por lo menos 2 semanas 143 019. Aparicion de una superficie o cubierta blanca de textura peluda en la Iengua (lukoplaquia peluda) 020. __ Tbs seca con una duracion de por lo menos 2 semanas 021. __ Sensacién persistente de dolor en la boca o garganta 022. _ Un golpe, masa o cambio de color no usual en la piel que ha durado por lo menos 2 semanas 023. _ Fatiga o cansancio persistente de por lo menos 2 semanas 024. _ Fiebre persistente o recurrente de 100 grades 0 mas que ha durado por lo menos 2 semanas 025. _ Glandulas o nodulos limfaticos agrandados/inflamados o delicados al toque (sin contar el area vaginal) 026. __ Herpes zoster (culebrilla) 027. ____~_ Falta de aire persistente de por lo menos 2 semanas 028. _ Una nueva erupcién en la piel de por al menos 2 semanas 029. __ Dolores de cabeza no usuales, persistentes o frecuentes con una duracién de al menos 2 semanas 030. Visién borrosa, destellos de luz visuales o cualquier otro problema visual de por lo menos 2 semanas SECCION D: PERSIVIDO RIESGO DE CONTAGIO CON VIH Ahora voy a hacerle unas preguntas acerca de como usted percibe su riesgo de contagio de VIH. D1. Diria que la posibilidad de que usted pueda ser infectada con VIH son: D 1. Alta D 2. Mediana D 3. Baja D 4. No hay posilidad de estar infectada DZ. g0uales son las posibilidades de que usted pueda contraer SIDA(VIH) durante su vida? D 1. Gran posibilidad D 2. Alguna posibilidad D 3. Poca posibilidad D 4. Ninguna posibilidad 144 03. ¢00mo describiria usted su preocupacién de ser infectada por VIH o contraer el SIDA? D 1. Alta D 2. Mediana D 3. Baja D 4. No estoy preocupada SECCION E: CUESTIONARIO DE LA PRUEBA DE VIHISIDA PARA LATINAS Ahora voy a hacerle unas preguntas acerca de sus creencias y actitudes acerca de la prueba de VIHISIDA. I. Intencion: 1. gCual es la probabilidad de que usted intente hacerce Ia prueba de VIHISIDA durante el proximo mes? No probable : Probable -3 -2 -1 0 1 2 3 Extremadamente Muy Un poco Neutral Un poco Muy Extremadamente 145 II. Actitudes acerca de hacerse la prueba de VIHISIDA 1. El hacerse la prueba de VIHISIDA durante el proximo mes es para usted: Tonto Sabio lmprudente -3 '-2 -1 0 1 2 3 Extremadamente Muy Un poco Neutral Un poco Muy Extremadamente Desagradable : : : : : : Agradable -3 -2 -1 0 1 2 3 Extremadamente Muy Un poco Neutral Un poco Muy Extremadamente Malo Bueno -3 -2 -1 0 1 2 3 Extremadamente Muy Un poco Neutral Un poco Muy Extremadamente lnt’rtll 0m -3 -2 -1 0 1 2 3 Extremadamente Muy Un poco Neutral Un poco Muy Extremadamente Dafilno Beneficioso -3 -2 -1 0 1 2 3 Extremadamente Muy Un poco Neutral Un poco Muy Extremadamente III. Creencias acerca del comgortamiento 1. {Si usted se hiciera la prueba de VIHISIDA durante el proximo mes, cuan probable es que usted se ponga en contacto con el lugar donde se hizo la prueba para recibir los resultados? No probable ' -2 -l 0 Muy Un poco -3 Extremadamente Neutral Un poco Probable I 2 3 Muy Extremadamente 146 2. (Si usted se hiciera la prueba de VIHISIDA durante e1 pr6ximo mes, cuan probable es que usted proteje a su pareja de contagiarse con VIH a través de usted? No probable : : : : : : Probable -3 —2 -l 0 l 2 3 Extremadamente Muy Un poco Neutral Un poco Muy Extremadamente 3. (Si usted se hiciera la prueba de VIH/SIDA durante el proximo mes, cuan probable es que usted busque tratamiento si los resultados indicaran que eres VIH positivo? No probable : : : : : : Probable -3 -2 -l 0 I 2 3 Extremadamente Muy Un poco Neutral Un poco Muy Extremadamente 4. (Si usted se hiciera la prueba de VIHISIDA durante el proximo mes, cuan probable es que usted se cuide de su salud? No probable : . . : : : Probable -3 -2 -l 0 I 2 3 Extremadamente Muy Un poco Neutral Un poco Muy Extremadamente 5. (Si usted se hiciera la prueba de VIHISIDA durante el préximo mes, cuan probable es que usted cambio su estilo de vida? No probable : . . . : : Probable -3 -2 -l 0 I 2 3 Extremadamente Muy Un poco Neutral Un poco Muy Extremadamente 6. (Si usted se hiciera la prueba de VIHISIDA durante el pr6ximo mes, cuan probable es que la infeccion de VIH. sea detectada a tiempo? No probable : . . . . : Probable -3 -2 -1 0 l 2 3 Extremadamente Muy Un poco Neutral Un poco Muy Extremadamente 7. (Si usted se hiciera la prueba de VIH/SIDA durante el proximo mes, cuan probable es que prevengas que otros sean contagiados a travez de usted? No probable : . . . . : Probable -3 -2 -1 0 I 2 3 Extremadamente Muy Un poco Neutral Un poco Muy Extremadamente 8. (,8i usted se hiciera la prueba de VIHISIDA durante el proximo mes, cuan probable es que prevengas la transmisién del virus a su bebe (que a1'1n no ha nacido)? No probable : : : : : : Probable -3 -2 -I 0 I 2 3 Extremadamente Muy Un poco Neutral Un poco Muy Extremadamente 147 9. 6Si usted se hiciera la prueba de VIH/SIDA durante el préximo mes, cuan probable es que usted reciba informacion acerca de- los sintomas de VIH/SIDA? No probable : . . . . : Probable -3 -2 -I 0 I 2 3 Extremadamente Muy Un poco Neutral Un poco Muy Extremadamente 10. 6Si usted se hiciera la prueba de VIHISIDA durante el proximo mes, cuan probable es que usted tenga tranquilidad mental o que sienta que se le quito un peso de encima? No probable : : : : : : Probable -3 -2 -l 0 l 2 3 Extremadamente Muy Un poco Neutral Un poco Muy Extremadamente ll. 6Si usted se hiciera la prueba de VIHISIDA durante el proximo mes, cuan probable es que usted tome prepare para el futuro? No probable . . . . : : Probable -3 -2 -I 0 I 2 3 Extremadamente Muy Un poco Neutral Un poco Muy Extremadamente 12. 6Si usted se hiciera la prueba de VIHISIDA durante el proximo mes, cuan probable es que usted experimente o tenga problemas psicologicos o emocionales? No probable . . . Probable -3 -2 -I 0 I 2 3 Exn'emadamente Muy Un poco Neutral Un poco Muy Extremadamente 13.6Si usted se hiciera la prueba de VIHISIDA durante el proximo mes, cuan probable es que usted se sienta deprimida? No probable Probable -3 -2 -l 0 I 2 3 Extremadamente Muy Un poco Neutral Un poco Muy Extremadamente 14.6Si usted se hiciera la prueba de VIHISIDA durante el pr6ximo mes, cuan probable es que eso se vea como un reflejo negativo de su persona? No probable Probable -3 -2 -I 0 I 2 3 Extremadamente Muy Un poco Neutral Un poco Muy Extremadamente 15. 6Si usted se hiciera la prueba de VIHISIDA durante el proximo mes, cuan probable es que usted se sienta con éstres o preocupada? No probable Probable -3 -2 -l 0 l 2 3 Extremadamente Muy Un poco Neutral Un poco Muy Extremadamente 148 16.6Siusted se hiciera la prueba de VIH/SIDA durante el proximo mes, cuan probable es que usted se sienta desolada o sola? No probable : . . . : : Probable -3 -2 -I 0 I 2 3 Extremadamente Muy Un poco Neutral Un poco Muy Extremadamente 17. 6Si usted se hiciera la prueba de VIHISIDA durante el proximo mes, cuan probable es que usted cambie la manera de verse a sf misma? No probable : . . . . : Probable -3 -2 -1 0 1 2 3 Extremadamente Muy Un poco Neutral Un poco Muy Extremadamente 18. 6Si usted se hiciera la prueba de VIHISIDA durante el proximo mes, cuan probable es que usted se sienta con miedo o preocupada acerca de cuanto tiempo le queda de vida? No probable : : : : : : Probable -3 -2 -l 0 I 2 3 Extremadamente Muy Un poco Neutral Un poco Muy Extremadamente 19.6Siusted se hiciera la prueba de VIHISIDA durante el proximo mes, cuan dificil seria para usted decircelo a su familia? No probable : . . . : : Probable -3 -2 -I 0 I 2 3 Extremadamente Muy Un poco Neutral Un poco Muy Extremadamente 20. 6Si usted se hiciera la prueba de VIHISIDA durante el préximo mes, cuan probable es que usted sea rechazada por sus compafieros de trabajo o la sociedad en general? No probable : : : : : : Probable -3 -2 -1 0 I 2 3 Extremadamente Muy Un poco Neutral Un poco Muy Extremadamente 21. 6Si usted se hiciera Ia prueba de VIHISIDA durante el proximo mes, cua es la probabilidad que usted sienta miedo de que su seguro medico sea cancelado? No probable : . . . . : Probable -3 -2 -I 0 I 2 3 Extremadamente Muy Un poco Neutral Un poco Muy Extremadamente 22. 6Si usted se hiciera la prueba de VIHISIDA durante el proximo mes, cuan probable es quelos resultados indiquen que usted es VIH positivo? No probable : . . . . : Probable -3 -2 -I 0 I 2 3 Extremadamente Muy Un poco Neutral Un poco Muy Extremadamente 149 IV. Evaluacion de conseguencias l. Contactar el lugar donde usted se .hizo la prueba para conocer los resultados es: Malo . . . . . . Bueno -3 -2 -I 0 I 2 3 Extremadamente Muy Un poco Neutral Un poco Muy Extremadamente 2. Ayudar o proteger a t1'1 pareja para que no sea contajiado con el virus atra vez de ti es: Malo : : : : : : Bueno -3 -2 -I 0 1 2 3 Extremadamente Muy Un poco Neutral Un poco Muy Extremadamente 3. Si eres VIH positivo recibir tratamiento es: Malo . . . . : : Bueno -3 -2 -I 0 I 2 3 Extremadamente Muy Un poco Neutral Un poco Muy Extremadamente 4. Cuidar t1'1 salud es: Malo . : : : : : Bueno -3 -2 -I 0 I 2 3 Extremadamente Muy Un poco Neutral Un poco Muy Extremadamente 5. Cambiar tu estilo de vida es: Malo . . : : : : Bueno -3 -2 -I 0 I 2 3 Extremadamente Muy Un poco Neutral Un poco Muy Extremadamente 6. Detectar el VIH a tiempo es: Malo . : : : : Bueno -3 -2 -I 0 I 2 3 Extremadamente Muy Un poco Neutral Un poco Muy Extremadamente 7. Prevenir que otros sean contagiados con VIH a travez de usted es: Malo . . . . . : Bueno -3 -2 -I 0 I 2 3 Extremadamente Muy Un poco Neutral Un poco Muy Extremadamente 8. Impedir que t1'1 bebe (que a1'1n no ha nacido) sea contagiado a travez de usted es: Malo : : : : : : Bueno -3 -2 -I 0 I 2 3 Extremadamente Muy Un poco Neutral Un poco Muy Extremadamente 150 9. Recibir informacion acerca de los sintomas de VIHISIDA es Malo . . . . . : Bueno -3 -2 -I 0 I 2 3 Extremadamente Muy Un poco Neutral Un poco Muy Extremadamente 10. Tener tranquilidad mental o sentir que se le quito un peso de encima es: Malo . . . . . . Bueno -3 -2 -l 0 I 2 3 Extremadamente Muy Un poco Neutral Un poco Muy Extremadamente ll. Prepararse para el futuro es Malo . . : : : : Bueno -3 -2 -l 0 l 2 3 Extremadamente Muy Un poco Neutral Un poco Muy Extremadamente 12. Tener/Experimentar problemas. psicologicos o emocionales es Malo . . . . . : Bueno -3 -2 -I 0 l 2 3 Extremadamente Muy Un poco Neutral Un poco Muy Extremadamente l3. Sentirse deprimida es Malo . : : : : : Bueno -3 -2 -I 0 l 2 3 Extremadamente Muy Un poco Neutral Un poco Muy Extremadamente 14. Tener una opinion negativa de mi persona es: Malo . . . . : : Bueno -3 -2 -I 0 I 2 3 Extremadamente Muy Un poco Neutral Un poco Muy Extremadamente 15. Sentirse con estres o preocupada es: Malo . . . : : : Bueno -3 -2 -I 0 l 2 3 Extremadamente Muy Un poco Neutral Un poco Muy Extremadamente 16.Sentirse desolada o sola es: Male . . : : : : Bueno -3 -2 -l 0 I 2 3 Extremadamente Muy Un poco Neutral Un poco Muy Extremadamente l7. Cambiar la manera de verse a si misma es: Malo . . . . : : Bueno -3 -2 -I 0 I 2 3 Extremadamente Muy Un poco Neutral Un poco Muy Extremadamente 151 18. Sentirse con miedo o preocupada acerca de cuanto le queda de vida es: Malo . . . . . . Bueno -3 -2 -1 0 l 2 3 Extremadamente Muy Un poco Neutral Un poco Muy Extremadamente l9. Tener dificultad para hablar con su familia es: Malo . . . . : : Bueno -3 -2 -I 0 I 2 3 Extremadamente Muy Un poco Neutral Un poco Muy Extremadamente 20. Ser rechazada por sus companeros de trabajo o por la sociedad en general es Malo . . . . . . Bueno -3 -2 -I 0 I 2 3 Extremadamente Muy Un poco Neutral Un poco Muy Extremadamente 21. Tener miedo de que su .seguro medico sea cancelado es Malo . . . . . : Bueno -3 -2 -1 0 I 2 3 Extremadamente Muy Un poco Neutral Un poco Muy Extremadamente 22. Recibir resultados que indiquen que usted es VIH positivo es Malo . . . . Bueno -3 -2 -l 0 l 2 3 Extremadamente Muy Un poco Neutral Un poco Muy Extremadamente V. Reglas Suietivas 1. Si usted se hiciera la prueba de VIH/SIDA durante el préximo mes, la mayoria de la gente que es importante para usted estarian . Deacuerdo : : : : : : Desacuerdo Totalrnente Moderada- Levemente Neutral Levemente Moderada- Totalrnente mente mente VI. Creecians Normativas (Nota: Por favor escriba “no aplica” en las pregunta acerca de Ias personas que no estan presente en la vida del participante.) 1. Si usted se hiciera la prueba de VIH durante el proximo mes la mayoria de los miembros de su familia estarian . Deacuerdo : : : : : : Desacuerdo Totalrnente Moderada- Levemente Neutral Levemente Moderada— Totalrnente mente mente 152 2. Si usted se hiciera la prueba de VIH durante el proximo mes su madre (o la persona que a sido como su madre) estaria Deacuerdo : : : : : : Desacuerdo Totalmente Moderada- Levemente Neutral Levemente Moderada- Totalmente mente mente 3. Si usted se hiciera la prueba de VIH durante el proximo mes su padre (o la persona que a sido como su padre) estaria . Deacuerdo . . . . . . Desacuerdo Totalmente Moderada- Levemente Neutral Levemente Moderada- Totalmente mente mente 4. Si usted se hiciera la prueba de VIH durante el préximo mes su hermana(s) estaria Deacuerdo Desacuerdo Totalmente Moderada- Levemente Neutral Levemente Moderada- Totalmente mente mente 5. Si usted se hiciera Ia prueba de VIH durante el proximo mes su hermana(s) estaria . Deacuerdo . : : : : . Desacuerdo Totalmente Moderada- Levemente Neutral Levemente Moderada- Totalmente mente mente 6. Si usted se hiciera la prueba de VIH durante el proximo mes sus abuelos estarian Deacuerdo Desacuerdo Totahnente Moderada- Levemente Neutral Levemente Moderada- Totalmente mente mente 7. Si usted se hiciera Ia prueba de VIH durante el proximo mes su esposo/novio estaria Deacuerdo Desacuerdo Totalmente Moderada- Levemente Neutral Levemente Moderada- Totalmente mente mente 8. Si usted se hiciera la prueba de VIH durante el proximo mes sus tios y tias estarian Deacuerdo Desacuerdo Totalmente Moderada- Levemente Neutral Levemente Moderada- Totalmente mente mente 153 9. Si usted se hiciera la prueba de VIH durante el proximo mes la mayoria de sus amistades estarian Deacuerdo : : : : : : Desacuerdo Totalmente Moderada- Levemente Neutral Levemente Moderada- Totalmente mente mente 10. Si usted se hiciera la prueba de VIH durante el proximo mes la mayoria de sus compaiieros de trabajo estarian . Deacuerdo : : : : : : Desacuerdo Totalmente Moderada- Levemente Neutral Levemente Moderada- Totalmente mente mente 11. Si usted se hiciera la prueba de VIH durante el proximo mes la mayoria de los miembros de su iglesia estarian . Deacuerdo : : : : : : Desacuerdo Totalmente Moderada- Levemente Neutral Levemente Moderada- Totalmente mente . mente 12. Si usted se hiciera la prueba de VIH durante el proximo mes e1 cura o pastor de su iglesia estaria Deacuerdo : : : : : : Desacuerdo Totalmente Moderada— Levemente Neutral Levemente Moderada- Totalmente mente mente 13. Si usted se hiciera la prueba de VIH durante el proximo mes Dios estaria Deacuerdo : : : : : : Desacuerdo Totalmente Moderada- Levemente Neutral Levemente Moderada- Totalmente mente mente W 1. Generalmente, usted hace lo que su familia quiere que haga No del todo : : : : : : La mayor parte del tiempo 154 2. Generalmente, usted hace lo que su madre (o la persona que a sido como su madre) quiere que haga No del todo : : : : : : La mayor parte del tiempo 1 2 3 4 5 6 7 3. Generalmente, usted hace lo que su padre (o la persona que a sido como su padre) quiere que haga No del todo : : : : : : La mayor parte del tiempo l 2 3 4 5 6 7 4. Generalmente, usted hace lo que su hermana(s) quiere(n) que haga No del todo : : : : : : La mayor parte del tiempo 1 2 3 4 5 6 7 5. Generalmente, usted hace lo que su hermano(s) quiere(n) que haga No del todo : : : : : : La mayor parte del tiempo 1 2 3 4 5 6 7 6. Generalmente, usted hace lo que sus abuelos quieren que haga No del todo : : : : : : La mayor parte ‘ del tiempo l 2 3 4 5 6 7 7. Generalmente, usted hace lo que su esposo/novio quiere que haga No del todo : : : : : : La mayor parte del tiempo 1 2 3 4 5 6 7 8. Generalmente, usted hace lo que sus tios y tias quieren que haga No del todo : : : : : : La mayor parte del tiempo 155 9. Generalmente, usted hace lo que sus amistades quieren que haga No del todo : : : : : : La mayor parte del tiempo l 2 3 4 5 6 7 10. Generalmente, usted hace lo que sus companeros de trabajo quieren que haga No del todo : : : : : : La mayor parte del tiempo 12‘ 3 456 7 ll. Generalmente, usted hace lo que la mayoria de los miembros de su iglesia quieren que haga No del todo : : : : : : La mayor parte del tiempo 1 2 3 4 5 6 7 12. Generalmente, usted hace lo que el cura o pastor de su comunidad quiere que haga No del todo : : : : : : La mayor parte del tiempo 1 2 3 4 5 6 7 l3. Generalmente, usted hace lo que Dios quiere que haga No del todo : : ' ' ' ° La mayor parte del tiempo VIII. Control de comgortamiento persivido 1. La decision de hacerme o no la prueba de VIHISIDA durante el proximo mes es mayormente mia. Cierto . : : : . Falso Extremadamente Muy Un poco Neutral Un poco Muy Extremadamente 2. Si usted quiziera facilmente pudiera hacerse la prueba de VIHISIDA durante e1 proximo mes. Totalmente : : : : : : Totalmente en acuerdo En desacuerdo Extremadamente Muy Un poco Neutral Un poco Muy Extremadamente 156 3. Para usted hacerse la prueba de VIHISIDA durante el proximo mes Facil : : Dificil Extremadamente Muy U11 poco Neutral Un poco Muy Extremadamente 4. 6Cuanto control tiene usted sobre el hacerse la prueba de VIH durante el proximo mes? Ningun : : : : : : Completo Control I 2 3 4 5 6 7 Control IX. Control comgortamental de creencias gersivido l. Seria mas probable que usted se hiciera la prueba si hubiera un sitio cerca de su case donde se la puediera hacer. Totalmente : : : : : : Totalmente en acuerdo En desacuerdo Extremadamente Muy Un poco Neutral Un poco Muy Extremadamente 2. Seria mas probable que usted se hiciera la prueba si hubiera un sitio donde hacerse la prueba no sea considerado como algo negativo o donde la gente no te mire ma] 0 con desprecio. Totalmente : : : : : : Totalmente en acuerdo En desacuerdo Extremadamente Muy Un poco Neutral Un poco Muy Extremadamente 3. Seria mas probable que usted se hiciera la prueba de VIH siesta fuera gratis. Totalmente : : : : : : Totalmente en acuerdo En desacuerdo Extremadamente Muy Un poco Neutral Un poco Muy Extremadamente 4. Seria mas probable que usted se hiciera la prueba si esta fuera anonima. Totalmente : : : : : : Totalmente en acuerdo En desacuerdo Extremadamente Muy Un poco Neutral Un poco Muy Extremadamente 157 5. Seria mas probable que usted se hiciera la prueba siesta fuera confidencial. Totalmente : : : : : : Totalmente en acuerdo En desacuerdo Extremadamente Muy Un poco Neutral Un poco Muy Extremadamente 6. Seria mas probable que usted se hiciera la prueba si usted hubiera recibido una transfusion de sangre. Totalmente : : : : : : Totalmente en acuerdo En desacuerdo Extremadamente Muy Un poco Neutral Un poco Muy Extremadamente 7. Seria mas probable que usted se hiciera la prueba si usted estuviera mas . informada acerca de la prueba y el virus. Totalmente : : : : : : Totalmente en acuerdo En desacuerdo Extremadamente Muy Un poco Neutral U11 poco Muy Extremadamente 8. Seria menos probable que usted se hiciera la prueba si el sitio donde se la puede hacer quedara lejos. Totalmente : : : : : : Totalmente en acuerdo En desacuerdo Extremadamente Muy Un poco Neutral Un poco Muy Extremadamente 9. Seria menos probable que usted se hiciera la prueba siesta no es gratis o costara mucho dinero. Totalmente : : : : : : Totalmente en acuerdo En desacuerdo Extremadamente Muy Un poco Neutral Un poco Muy Extremadamente 10. Seria menos probable que usted se hiciera la prueba si el sitio donde se la puede hacer no es un lugar acogedor o agradable para las mujeres. Totalmente : : : : : : Totalmente en acuerdo En desacuerdo Extremadamente Muy Un poco Neutral Un poco Muy Extremadamente 158 ll. Seria menos probable que usted se hiciera la prueba por lo que la gente pueda pensar de usted si saben que se la hizo. Totalmente Totalmente en acuerdo En desacuerdo Extremadamente Muy Un poco Neutral Un poco Muy Extremadamente 12. Seria menos probable que usted se hiciera la prueba siesta no fuera confidencial. Totalmente Totalmente en acuerdo En desacuerdo Extremadamente Muy Un poco Neutral U11 poco Muy Extremadamente l3. Seria menos probable que usted se hiciera la prueba si usted tuviese miedo de morir a temprana edad. Totalmente ' Totalmente en acuerdo En desacuerdo Extremadamente Muy Un poco Neutral Un poco Muy Extremadamente D Detengase N O PASE HACIA LA PROXIMA PAGINA! RECUERDELE A LA PARTICIPANTE QUE SERA CONTACTADA DENTRO DE UN MES PARA COMPLETAR LA SIGUIENTE ENTREVISTA. 159 X. Comportgmiento sobre la prueba de VIH FechL Entrevistadora: A pasado un mes desde su primera entrevista en (Fecha de la ultima entrevista). Ahora como parte final de este estudio quiziera hacerle algunas preguntas sobre de hacerce la prueba de VIHISIDA. Le recuerdo que no se le va a preguntar los resultados de la prueba. Usted tambien tiene el derecho de negarse a contestar cualquier pregunta. 6Tiene usted alguna pregunta, comentarios o preocupaciones que me quiere preguntar o discutir en este momento? 1. 6Ha tratado de recibir informacién acerca de la prueba de VIH/SIDA durante e1 ultimo mes? (1) Si (0) No ..... Pase a la pregunta #2 1A. 6Cual de la siguientes ha hecho usted para recibir mas informacién acerca de la prueba de VIH/SIDA? Por favor indique con un / todos los que le apliquen. Cl llamé o visté e1 departrnento local de salud Cl llamé o visté la oficina de mi doctor privado D llamé o visté una Clinica local Cl llarné o visté una agencia en la comunidad Cl llamé a una linea telefénica de informacion sobre VIH Cl llame’ o visté una farmacia Cl busque' mas informacion a traves de mi computadora usando el internet 0 sistéma de correo electronico Cl Otro: Especifique Ahora quiziera hacerle unas preguntas relacionadas a una de las formas medianta la cual puede lograr hacerse la prueba de VIHISIDA. Le voy a hacer preguntas acerca de piensa usted sobre hacerce la prueba en un centro o clinica donde hacen ese tipo de pruebas. 2. 6Ha llamado o visitado algun lugar donde se ofrece la prueba de VIH/SIDA durante e1 ultimo mes para recibir mas informacion? (1) Si (0) No ' 3. 6Ha hecho usted alguna cita para hacerse la prueba de VIH/SIDA durante el ultimo mes? (1) Si (0) No 160 4. 6Durante el ultimo mes, ha usted recibido orientacion sobre VIH antes de hacerce la prueba? (Orientacion sobre VIH es cuando un consej ero de VIH te provee con informacion relacionada con el virus, prevencion, y el prueba.) (1) Si (0) No 5. 6Se ha hecho usted la prueba durante el ultimo mes? (1) Si (0) No ......... Pase a la pregunta #9 6. 6Ha recibido consej eria sobre VIH despues de haberce tornado la prueba? (1) Si (0) No 7. 6Sabe los resultados de la prueba? (1) Si (0) No 8. 6Com6 se entero usted de los resultados? Marque con un I a1 lado de todos los que apliquen D personalmente Cl por teléfono Cl por correo Ahora voy a hacerle unas preguntas acerca de hacerse la prueba cacera de VIH. 9. 6Trato de recibir informacién acerca de la prueba cacera de VIH/SIDA durante e1 ultimo mes? (1) Si (0) No ..... Pase a pregunta #10 9A. 6Cual de la siguientes a hecho usted para recibir mas informacion acerca de la prueba cacera de VIH/SIDA? Por favor indique con un / todos los que le apliquen. Cl llamé o visté e1 departmento local de salud Cl llamé los fabricadores de la prueba cacera a1 1-800-HIV-TEST Cl llamé o visté una agencia en la comunidad D llamé una linea telefonica de informacion de VIH Cl llarne' o visté una farmacia D busqué mas informacion a traves de mi computadora usando el internet 0 sistema de correo electronico Cl Otro: Especifique 161 10. 6Compr6 alguna prueba cacera de VIH/SIDA durante el ultimo mes? (1) Si (0) No .................. FINAL DE LA ENTREVISTA 11. 6Ha usted llamado el numero 1-800-HIV-TEST y eschucho la inforrnacion acerca de VIH? (1) Si (0) No 12. 6Haz activado e1 numero de identificacion que trae la prueba cacera durante el ultimo mes? (1) Si (0) No 13. 6Durante e1 ultimo mes ha usted eschuchado o respondido alas preguntas de la grabacién? (1) Si (O) No 14. 6Durante e1 ultimo mes ha usted escuchado y respondio a las preguntas de un consejero(a) de VIH? (1) Si (0) No 15. 6Durante e1 ultimo mes, usted copio el numero de identificacion en la tarjeta para la muestra de sangre? (1) Si (0) No 16. 6Durante el ultimo mes ha usted mandado por correo su muestra de sangre? (1) Si (0) No 17. 6Durante el ultimo mes ha usted llamado a] numero 1-800 y escucho el mensaje de VIH? (1) Si (0) No 162 18. 6Durante el ultimo mes ha usted llamado a1 numero 1-800 para recibir los resultados de su prueba? (1) Si (0) No 19. 6Durante e1 ultimo mes ha usted recibido consejos de VIH despues de haberse hecho la prueba? (1) Si (0) No 20. 6Sabe usted los resultados de su prueba? (1) Si (O) No 6Porqué no? FINAL DE LA ENTREVISTA GRACIAS POR SU PARTICIPACION! 163 APPENDIX D Lafinas Participate in a survey related to health and earn $15. Researchers at Michigan State University are asking for your participation in a study related to Latinas' health and HIV/AIDS. Participation involves completing a survey which takes approximately 30-35 minutes to complete and a brief 5 minute follow up in a month. Your participation is strictly confidential! If you are: . Latina/Hispanic - between the ages of 18-60 . HIV negative or don’t know your status - interested in participating - would like more information please call Diana Morrobel, MA. (800) ***_**** Fax: (517) 432-2476 E-mail: morrobel@pilot.msu.edu (English) 164 APPENDIX D Latinas Gane $15 por contestar un cuestionario sobre su salud. (Spanish) Investigadores de Michigan State University piden su participacic’m en un estudio que pertenece a la salud de latinas y del VIH/SIDA. Para participar, solo necesita completar un cuestionario, que durara aproximadamente 30-35 minutos, y otros 5 minutos durante el mes siguiente para hacerle algunas preguntas. Se mantendra confidencialidad estricta sobre su participacion. Si los siguientes requisitos 1e aplican a Usted: ' tiene entre 18-60 afios... - ha tenido un resultado negativo para la prueba del VIH/SIDA o nunca se ha hecho la prueba... - le interesa participar con este estudio... - quiere mas informacién... ...por favor pongase en contacto con Diana Morrobel, M.A. Llame gratis al numero (888)***-**** Fax: (517) 432-2662 E-mail: morrobel@pilot.msu.edu 165 APPENDIX E (English) CONSENT FORM FOR THE PROSPECTIVE RESEARCH STUDY Informed Consent Agreement Form Purpose: This project is interested in understanding the factors that influence Latinas to get tested for HIV antibodies. Experimental Procedure: Participation in the study will involve answering a series of questions relating to your health, HIV antibody testing, your attitudes and beliefs, and your experiences as a Latina living in the United States. This study is being conducted by Diana Morrobel, as part of her doctoral dissertation under the supervision of Anne Bogat, Ph.D., Professor of Psychology at Michigan State University. As a participant you will be asked to complete several questionnaires which will take 35-45 minutes to complete. One month afier the initial interview, you will be contacted to complete a brief survey related to the first interview. The follow up interview should take 5-15 to complete. Your responses will be kept strictly confidential. 1. This study has been thoroughly explained to you, including what your participation involves. 2. Your participation is voluntary and you may withdraw from participating at any time without penalty. 3. You certify that you are 18 years of age or older. 4. Confidentiali Your individual responses to the survey will be kept strictly confidential. Study results will be presented in a summary format only, without reference to responses given by individual participants. At no time will Diana Morrobel, the principal investigator, reveal your name or any identifying information that may breach your confidentiality. 5. A summary of the study results will be made available to you at your request once the study is completed, within the restrictions outlined in section (4) above. You may request this summary by contacting Diana Morrobel at the address listed at the end of this document. 6. You will be paid $10 for your participation in the first part of the study and $5 when you complete the second part which includes a phone survey after one month has elapsed from the initial interview. 166 7. You give your permission to be contacted one month after this interview for a follow up survey. You give your permission to contact the persons listed in the contact form in the event that the principal investigator is unable to reach you. 8. Disclosure of your HIV serostatus. HIV serostatus is a term used to refer the presence or absence of HIV antibodies. Your HIV serostatus can be positive, negative, or unknown. The only time you will be asked to disclose your HIV serostatus is during the screening interview. You will not be asked to disclose your HIV serostatus during the interview or when you are contacted one month after the initial interview to answer some follow-up questions. 9. Risks and Benefits: Your participation in this study does not guarantee any benefits to you beyond what is stated in sections (5) and (6) above. 10. You have read the material above, and any questions you may have asked have been answered to your satisfaction. Contact Information If you have questions or want to discuss any feelings about your participation in this study, you can contact Diana Morrobel at (517) 355-9561 (MSU Department of Psychology, 129 Psychology Research Bldg., East Lansing, MI 48824 If you have questions about your rights as a participant in this study, you can contact Dr. David E. Wright at (517) 355-2180 (MSU University Committee on Research Involving , Human Subjects). You understand that by completing this interview you are indicating your voluntary agreement to participate in this research project. Participant’s Signature Date 167 APPENDIX E (Spanish) CONSENT FORM FOR THE PROSPECTIVE RESEARCH STUDY F onna de Consentimiento Informado Promsito A los investigadores de este proyecto les interesa los factores que influencian alas latinas hacerse la prueba para anticuerpos del VIH (SIDA). Procedimientos Experimentales Participacion en este estudio incluye e1 contestar una serie de preguntas relacionado a sus creencias y actitudes hacia la prueba para anticuerpos del VIH (SIDA). Este estudio es dirigido por Diana Morrobel, como parte de su tesis doctoral, bajo la supervision de Anne Bogat, PhD, Profesora de Psicologia en Michigan State University. Como participante, 1e pediran a Usted que complete unos cuestionarios, que durara de 35- 45 minutos. Usted sera contactada un mes despues de esta entrevista para contestar una breve serie de preguntas relacionada con la entrevista de hoy. La proxima entrevista solo durara de 5-15 minutos. Sus respuestas seran totalmente anonimas y confidenciales. Por favor, no escriba su nombre en el cuestionario. 1. Se me ha explicado este estudio completamente incluyende los que mi participacion incluye. 2. Su participacion es voluntaria y que puede rehusar a participar en cualquier momento sin tener que ser amonestada. 3. Usted certifica que es mayor de 18 afios. 4. MM. Sus respuestas al cuestionario seran mantenidas estrictamente anonimas y confidenciales. Los resultados del estudio seran presentados solamente en forma sumaria, sin referencia a las respuestas de participantes individuales. En ningun momento Diana Morrobel, la investigadora principal de este estudio revelara, su nombre o cualquier informacion que la indentifique. 5. Un sumario del estudio puede ser adquirido si Usted lo pide. El sumario sera disponible al terminar la investigacion , conformando con las restricciones detalladas en la seccion (4). Usted puede obtener este sumario contactando a Diana Morrobel a la direccion escrita al final de este documento. 6. Usted recibira $10 por su participacion en la primera entrevista y $5 por completar la segunda entrevista un mes despues. 168 7. Usted da su penniso para ser contactada un mes despues de esta entrevista para completar una breve segunda entrevista. Usted da su permiso para que los investigadores de este estudio contacten a las personas en la lista de contactos personales en caso de que la investigadora principal no ha podido ponerse en contacto con usted. WEI. Su estatus de VIH es un tennino que se usa para referir a la presencia o ausencia de anticuerpos de VIH. Su estatus puede ser positivo, negativo, o inconcluso. La unica vez que los investigadores le preguntaran acerca de su estatus sera a1 principio de esta entrevista. Usted no tendra que revelar su estatus ninguna otra vez durante esta entrevista o cuando la contactemos un mes despues para la segunda entrevista. 9. Riesgos y Beneficios Su participacion en este estudio no le garantisa ningun beneficio aparte de esos senalados en las seciones (5) y (6) de este documento. 10. Usted ha leido el material mencionado arriba, y se le ha contestado a su satisfaccion cualquier pregunta que tenia. Went—acts Si Usted tiene preguntas o quiere hablar de cualquier sentimiento sobre su participacion en este estudio, puede ponerse en contacto con Diana Morrobel a (517) 355-9561 (MSU Department of Psychology, 129 Psychology Research Bldg., East Lansing, MI 48824) Si Usted tiene preguntas acerca de sus derechos como participante en este estudio puede ponerse en contacto con Dr. David E. Wright a (517) 355-2180 (MSU University Committee on Research Involving Human Subjects). Usted entiende que al completar y entregar este cuestionario, 0 al completar una entrevista, esta indicando su acuerdo voluntario para participar con este proyecto de investigacion. F irma del participante Fecha 169 (English) Name: Address: Phone number: Best times to call: 1 .Name: Address: Phone number: Best times to call: 2.Name: Address: Phone number: Best times to call: 3.Name: Address: Phone number: Best times to call: APPENDIX F Participant Contact Form Other contact persons: 170 APPENDIX F (Spanish) Informacion acerca de como ponerse en contacto con la participante Nombre: Direccion: Numero de telefono: Mejor hora para llamar: Otras personas a quien podemos llamar: 1 .Nombre: Direccion: Numero de telefono: Mejor hora para llamar: 2.Nombre: Direccion: Numero de telefono: Mejor hora para llamar: 3.Nombre: Direccion: Numero de telefono: Mej or hora para llamar: 171 APPENDIX G 5320mm Comma—0:.— .oqu _3_.o.oo._._. .5323. peace... be beef. ._ ocswi .0550 \t .EoSEom \\ nozoocex. mELoZ 3:00.35 832.2. 2: .532 £552 172 05:3 58:25.. 5.3 52:33»:— 5322. 35.3. ...8....§ >_: 23.3 05.3 5.3 325395. 3.2m 5.3: 39.50 8.2275 3:5... ..o boos... 2...? .355. 3.52%. .m 235 9:32 .56 33:3 82:22. 3.3.3.9.. wanna >5 9 usage. mEoZ 2.8.33 A 3.8. 2. 2 5.2.2:. mean. 2: Ease 063:3‘ va...h Z: 3333.. 173 .0522 3050.883. 8.555 .853... ..o boos... 505:0.xm .m 23...... 9.5.8 .2... 3.3.2. .82.... a. 8.3.2 2.5.. 174 5...... . . 5.8.. 35.2.2. 5 .28... .a .o 8:69 . «an... 5.8.. o. 8.3.2 .238 9:8. >.: 3250 2.6.. .. 3.9.5:"... 8.6 .258 B>-90&9& O. “9:305 . 9.8.. n. 22.3 58.3.5. 5.... .=e...u.._o..:_ .358 o. $5.8. >_: =o........o=_ o. «2...». a5.62 9... 8.7.... ........EEoU .m.._2o..o. 8.820.. 3.222. o. 8.5.... $.58. % 68:”.me = 3.8.. n ...8.._.5 >_: a 2. . .. . _ 958. >=.. .358 c. o. 3.22 3.32 ..o..a....o.= 3.22.2. .55.. 333.5:— Ea 8.3... 958. .2888. o. 33.2 8.808.. 2.8.. n o. 85.8 23.8 0.53 $5.3. 28.. c 5.... .8829...- >_: Base. 853.5. 98.. ~ 2.88.6 E... 50.3.. ”8.5.8.830 .82.... 6. 8.5.2 98.. 3:82.... 4...... 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MOS/Emm 3.33. 8.22.3. .858... .0 been... 0... mo .28.). vacancfl uoN.mo...o.§: .m 8%... omd H... .mU mmd .< tad). 176 MOS/gum mm... .mU 3.8.3. .o.>m..om .858... we boon... .0 flaw... um... .534). 177 APPENDIX H DZEZglraghic Information for Elicitation Research Study Particigants Characteristics _N_ Loam Marital Status Married 6 33 Divorced 3 17 Never been married 9 50 Years of education 0 - 6 years , O 0 7 - 12 years 2 11 13 - 16 years 10 56 17 years and above 6 33 Employment Status Working full-time 8 44 Working part-time 3 17 Student 4 22 Working part-time and going to 3 17 school Place of birth United States 14 79 Puerto Rico 3 17 Dominican Republic 1 6 Language used during interview English 13 72 Spanish 5 28 178 Table 1 (cont’d) Characteristics N 116323.11 B_€=1_igi_0£ Catholic 12 67 Baptist 1 6 None 2 11 Other 3 17 Have children Yes 8 44 No 10 56 Know someone who has been tested Yes 15 83 No 3 17 Know someone who is HIV positive Yes 13 72 No 5 28 Know =someone who has been diagnosed with AIDS Yes ‘ 9 50 No 9 SO 179 Table 2 Demographic Information for Prospective Research Stud! Participants Characteristics N m Marital Status Married 58 42 Divorced 1 1 8 Separated 8 6 Never been married 51 37 Widowed 1 .7 Living Together but not married 10 7 Years of education 0 - 6 years 7 5 7 - 12 years 49 36 13 - 16 years 62 45 17 years and above 20 14 refused to respond 1 .7 Employment Status Working full-time 50 36 Working part-time 18 13 Unemployed 6 4 Homemaker 24 17 Student 25 1 8 Other 4 3 Place of birth United States 95 69 Puerto Rico 17 12 180 Table 2 (cont’d) Characteristics _N_ @9111 Mexico 17 12 Dominican Republic 3 2 Guatemala 3 2 Venezuela 3 2 Language used during interview English 106 76 Spanish 33 24 serum Catholic 72 52 Pentecostal 12 9 Baptist 3 2 Church of God 1 .7 Methodist 1 .7 Mormon 1 .7 None 14 1 O Other 34 25 Have children Yes 87 63 No 52 37 Know someone who has been tested Yes 94 68 No 44 32 181 Table 2 (cont’d) Characteristics N m1 Know someone who is HIV positive Yes 62 45 No 76 55 Know someone who is diagnosed with AIDS Yes 59 42 No 80 58 Recruiting Strategy Posted or distributed flyer 36 26 Church presentation 22 16 Ad in Mi Gente (monthly newspaper) 2 1 Snowball 6 4 Recruited at a community center 43 31 E-mail ad 24 17 182 Table 3 Psychometric Properties of Measures: Meansa Standard Deviationsa and Range Measure Mean _S_D_ Range Perceived HIV Risk (REVRISK) 3.79 1.80 2 to 8 Attitudes toward HIV antibody testing .88 1.50 -3 to 3 (MATT) Immediate Family Norms (IFNORM) -40.23 54.11 -147 to 1029 Immediate Family Norms--Mean -4.80 7.65 (AIFNORM) Community Norms (COMNORM) ~10.12 31.35 -507 to 3549 Community Norms--Mean -2.50 5.90 (ACOMNORM) Perceived Behavioral Control 17.63 4.19 3 to 21 (PCONTROL) Current Health Status (CHEALTH) 2.63 1.25 1 to 7 Intention to be tested for HIV 2.14 1.81 1 to 7 antibodies“ (CEl) Involvement with Latino Culture“ 27.06 3.46 7 to 31 (CLATIN) Involvement with American Culture* 24.50 3.62 7 to 31 (CAMERICA) HIV Antibody Testing Behavior .08 .38 0 to 3 (BEHAVIOR) Note. *Variable was centered prior to SEM analyses. The mean of the variable was subtracted from each observed score. 183 Table 4 Psychometric Properties of Current Health Status Scale Items ILe_ It_ern Corrected Item- Means _S__ Iptal Correlations 1. How would you rate your overall health? 1.82 .72 .08 2. Are you currently using any of the following forms of birth control?+ birth control pills .22 .41 condoms .20 .40 diaphragm O 0 douching after intercourse .04 .19 spermicide/creams/jellies .02 .12 Intrauterine device 0 0 rhythm method .01 .12 female sterilization .13 .34 male sterilization .03 .17 withdrawal method .02 .15 depro provera .06 .23 norplant .01 .12 no method .33 .47 other .02 .15 3. Have you ever been pregnant?+ .66 .48 4. Are you currently pregnant?+ .06 .24 5. Have you been hospitalized within the last .11 .31 .04 year for a medical condition? ++ 6. Have you experienced major medical .1 1 .31 .36 problems in the last year?-H- 184 Table 4 (cont’d) pounds (not related to dieting)++ 185 Scale Items Item Item Corrected Item- Means L Total Correlations 7. Have you ever been tested for the AIDS .64 .54 virus?+ 8. Did the test show that you were HIV .05 .31 positive?+ 9. Have you ever been tested for STDs (i.e., .68 .65 sexually transmitted diseases)?+ 10. Have you ever had any of the following sexually transmitted diseases? + Syphilis .07 .09 Gonorrhea .04 .20 Hepatitis A-G .01 .12 Oral fungus 0 0 Anal sores 0 0 1 1. Within the last year have you had recurrent .06 .23 .38 infections that have not responded to medications or treatrnent?++ 12. Have you been diagnosed with PID (Pelvic .07 .09 -.02 Inflammatory Disease) in the last year?++ 13. Have you had an abnormal pap smear in the .15 .36 -.01 last year?* 14. Have you sought medical treatment for any .48 .50 .41 health problems in the last year? 15. Please indicate which of the following 0 0 0 physical symptoms, if any, you have experienced during the past year: Thrush, candida, or white patches in the mouth or throat for at least 2 weeks ++ 16. Unintentional weight loss of at least 10 .07 .25 .32 Table 4 (cont’d) Scale Items te Ite Corrected Item- Mean S__ Total Correlations 17. Diarrhea that lasted at least 2 weeks ++ .02 .15 .15 18. Sweating at night for a least 2 weeks H .03 .17 .23 19. Hairy leukoplakia (a white coating) on the .07 .09 .16 tongue ++ 20. A new or unusual dry cough lasting at least .03 .17 .30 2 weeks 4+ 21. Persistent sore mouth or throat lasting for at .04 .19 .31 least 2 weeks ++ 22. An unusual bruise, bump, or skin .03 .17 .23 discoloration that lasted at least 2 weeks ++ 23. Have you experienced persistent fatigue for .16 .37 .26 at least 2 weeks during the past year? 24. Persistent or recurring fever of at least 100 0 0 0 degrees for at least 2 weeks ++ 25. Tender or enlarged glands or lymph nodes .04 .19 .10 (not counting groin)-H- 26. Herpes zoster (shingles)++ .07 .09 .16 27. Persistent shortness of breath for at least 2 .05 .22 .23 weeks ++ 28. A new skin rash that lasted at least 2 weeks .04 .19 -.03 H 29. Have you experienced persistent, frequent, .17 .37 .46 or unusual headaches for at least 2 weeks during the past year? 30. Blurred vision, light flashes, or other .04 .20 .13 unusual vision problems for at least 2 weeks ++ Remaining 4 items: a= .44 Scale Mean= 2.63 SD= 1.20 Note. + Item removed prior to analysis because it only provided demographic 186 information. Hltem removed due to low or no variance and/or low item-total correlations. * Item removed due to low factor loadings. 187 Table 5a Psychometric Properties of Involvement with Latino Culture Subscale Scale Items Item Item Corrected Means S_ Item-Total Correlations 1. How much do you enjoy speaking Spanish? (R) 4.31 1.14 .42 2. How much are Latino values a part of your life? 3.56 .67 .52 (R) 3. How many days a week would you like to eat 5.16 1.86 .22 Spanish food?* 4. How proud are you of being Latina? (R) 4.90 .41 .26 5. How comfortable would you be in a group of 3.32 .88 -.14 Americans who don’t speak Spanish?* (R) 6. How important is to you to raise your children 3.77 .54 .49 with Latino values? (R) 7. How much do you enjoy Spanish TV programs? 3.64 1.30 .37 (R) 8. How important is to you to celebrate holidays in 3.38 .81 .43 the “Latino” way? (R) 9. With respect to kindness and generosity, do you 3.47 .69 .24 think Latinos are . (R) Remaining 7 items: a= .72 Scale Mean= 27.06 Scale SD= 3.46 Note. * Item removed from subscale due to low corrected item-total correlations and low factor loadings. (R)= Item was reverse scored. 188 Table 5b Psychometric Properties of Involvement with American Culture Subscale Scale Items Item Item Corrected Means §I_) Item-Total Correlations 1. How much do you enjoy speaking 4.24 .79 .35 English?(R) 2. How much are American values a part of 2.93 .83 .39 your life? (R) 3. How many days a week would you like to 2.99 1.88 .32 eat American food?* 4. How proud are you of being an American? 4.36 .87 .45 (R) 5. How comfortable would you be in a group 3.47 .67 .12 of Latinos who don’t speak English?* (R) 6. How important is to you to raise your 3.15 .83 .62 children with American values? (R) 7. How much do you enjoy American TV 4.15 .90 .38 programs? (R) 8. How important is to you to celebrate 2.86 .90 .55 holidays in the “American” way? (R) 9. With respect to kindness and generosity, do 2.85 .71 .30 you think Americans are . (R) Remaining 7 items: a= .73 Scale mean2 24.50 SD= 3.62 Note. * Item removed from subscale due to low corrected item-total correlations and low factor loadings. (R)= Item was reverse scored. 189 Table 6 Psychometric Properties of Perceived HIV Risk Scale Items Item Item Corrected Item- Means _S_D Total Correlations 1. Would you say your chances of being 1.84 1.03 .56 infected with HIV right now is high, medium, low or no chance at all? (R) 2. What are the chances that you will get 1.94 .86 .55 the AIDS virus (HIV) sometime in your lifetime? (R) 3. How would you rate your level of 2.26 1.20 .14 concern about being infected with HIV or getting AIDS?*(R) Remaining 2 items: a = .88 Scale mean= 3.79 SD= 1.80 Note. * Item removed from subscale due to low corrected item-total correlations. (R) Item was reverse coded. 190 Table 7 Psychometric Properties of Attitudes toward HIV Antibody Testing Scale Items: I_te_m_ 1’t_e_m Corrected Your getting tested for HIV antibodies within the MM _S_Q Item-Total next month is Correlations 1. Foolish to Wise .69 2.00 .69 2 Unpleasant to Pleasant -.04 1.73 .50 3 Bad to Good 1.13 1.74 .75 4. Useless to Useful 1.03 2.14 .70 5 Harmful to Beneficial 1.67 1.58 .75 a= .86 Scale mean= 4.48 SD= 7.38 191 Table 8 Psychometric Properties of Behavioral Beliefs X Outcome Evaluations Scale Scale Items: Item Item Corrected Multiplicative product of Behavioral Beliefs Means §_ Item-Total (unlikely to likely) and Outcome Evaluations Correlations (extremely bad to extremely good) 1. Contacting the place where you got tested 17.11 6.30 .21 so you could know your HIV status is 2. Helping Protect your partner from 17.12 7.04 .31 contracting HIV from you is 3. Getting treatment if your test results 18.71 6.09 .26 indicated that you are HIV positive 4. Maintaining/safeguarding your health is 19.06 4.85 35 5. Changing your lifestyle 9.76 1 1.43 22 6. Detecting HIV infection early is 15.50 6.74 19 7. Preventing others from getting HIV from 18.18 6.16 30 youis 8. Preventing giving HIV to your unborn 17.34 7.11 .35 baby (now or in the future) is 9. Receiving information about the signs of 17.36 5.75 .25 HIV infection is 10. Having peace of mind is 14.37 7.29 .29 11. Preparing for the future is 15.94 7.34 .26 12. Experiencing psychological problems is -5.27 9.23 .39 13. Feeling depressed -6.63 8.26 .46 14. Having a negative reflection of myself as a -5.79 6.86 .41 person is 15. Feeling stressed and worried is -6.52 8.18 .31 16. Feeling isolated and alone is -5.91 6.76 .44 17. Changing how you look at/perceive -1.78 7.83 .32 yourself is 192 Table 8 (cont’d) Scale Items: Item Item Corrected Means S12 Item-Total Correlations 18. Feeling scared or worried about how long -5.17 8.84 .42 you have to live is 19. Having difficulty talking with your family -6.25 9.27 .34 is 20. Being rejected by people at work or society -7.15 7.19 .37 in general is 21. Fearing that your health insurance will be -7.27 6.87 .21 canceled is 22. Receiving results indicating that you are -2.80 5.26 .09 HIV positive is (F .76 Scale mean= 119.90 SD= 66.22 193 Table 9 Subjective Norms (Normative Beliefs X Motivation to Complvl-Items and factor loadings Factor 1: Immediate Family Norms (IFNORM) Multiplicative Product: If you got tested for HIV antibodies within the next month, (referent) would disapprove to strongly approve (X) Generally speaking, you do what . strongly wants you to do. Not at all to Very much 1. Most members of your family. (.86) 2. Mother (or the person who is a mother figure in your life) (.94) 3. Father (or the person who is a father figure in your life) (.87) 4. Sister(s) (.86) 5. Brother(s) (.82) 1 3. God (.5 1) Alpha= .87 (6 items) Item deleted: 7. Husband/boyfriend“ (.79) *Item loaded high on both factors. Factor2: Community Norms (COMNORM Multiplicative Product: If you got tested for HIV antibodies within the next month, (referent) would strongly disapprove to strongly approve (X) Generally speaking, you do what wants you to do. Not at all to Very much 6. Grandparents (.78) 9. Most of your friends (.75) 10. Most of your co-workers (.80) 1 1. Most members of your church (.95) 12. Local priest or pastor (.88) Item deleted: 8. Aunts and Uncles* (.74) Alpha= .87 (5 items) Note. *Item loaded high on both factors. 194 Table 10 Psychometric Properties for Immediate Family Norms Subscale Scale Items: Item Item Corrected Multiplicative Product of Normative Beliefs and Means SD Item-Total Motivation to Comply Correlations 1. Most members of your family. -4.91 9.98 .71 2. Mother (or the person who is a mother -5.88 9.80 .86 figure in your life) 3. Father (or the person who is a father figure -4.73 8.71 .77 in your life) 4. Sister(s) -6.05 8.40 .76 5. Brother(s) -4.16 8.38 .69 7. Husband/boyfriend“ -6.59 10.63 .72 13. God -7.91 12.11 .51 Scale mean= -33.72 SD= 45.08 Remaining 6 items: (F .87 Note. * Item deleted due to high loadings on both factors. 195 Table 11 Psychometric Properties of Communig Norms Subscale Scale Items: 116$ Item Corrected Multiplicative product of Normative Beliefs and m _S_I_)_ Item-Total Motivation to Comply Correlations 6. Grandparents“ -1 .95 8.61 .62 9. Most of your friends -3.84 6.33 .60 10. Most of your co-workers -1.05 6.50 .65 l 1. Most members of your church -1.1 l 7.51 .89 12. Local priest or pastor -2.17 9.57 .72 Remaining 5 items: a= .87 Scale mean= -10.12 SD= 31.35 Note. * Item deleted due to high loadings on both factors, 196 Table 12 Psychometric Properties of Perceived Behavioral Control Scale Scale Items: Item Item Corrected Item- _M._e_a_n§. _SD. m Correlations 1. It is mostly up to you whether or not you 6.49 1.48 .14 get tested for HIV antibodies during the next month.* 2. If you wanted to, you could easily be tested 5.96 2.01 .49 for HIV antibodies during the next month. 3. For you to get tested for HIV antibodies 5.39 2.04 .33 during the next month is easy to difficult 4. How much control do you have over 6.28 1.55 .38 getting tested for HIV antibodies in the next month? a= .60 Scale mean= 17.63 SD= 4.19 Note. * Item removed due to low corrected item-total correlation. 197 Table 13 Psychometric Properties of the HIV Antibody TestingBehgvior Scale Scale Items Item Ite Corrected Item- Means _S_ Total Correlations 1. In the last month, have you tried to get .08 .27 .37 information about HIV antibody testing?* In the last month, have you called or .05 .22 .55 visited a place that offers HIV antibody testing to receive more information? In the last month, have you made an .02 .13 .54 appointment to be tested for HIV antibodies? In the last month, did you get tested for .01 .09 .56 HIV antibodies? Items deleted due to lack of variance: 4. rows 11. 12. 13. 14. 15. 16. In the last month, did you receive HIV counseling before you were tested? Did you receive HIV counseling after you took the HIV antibody test? Do you know the results of your test? How did you find out the results of your test? In the last month, did you try to get more information about the Home HIV test kit? In the last month, did you purchase a home HIV test kit? In the last month, did you call the 800 number and listen to information about HIV? In the last month, did you activate the test kit number? In the last month, did you listen to and answer automated questions? In the last month, did you listen to and answer questions with an HIV counselor? In the last month, did you copy your test kit identification number on the blood sample card? In the last month, did you mail your blood sample? 198 Table 13 (cont’d) Scale Items Item Item Corrected Item- Mzans S_D 19191. Correlations 17. In the last month, did you call the 800 number and listen to the information message about HIV? 18. In the last month, did you call the 800 number to get the results of your test? 19. In the last month, did you receive HIV counseling after you took the Home HIV test? 20. Do you know the results of your test? a= .79 Scale mean= .08 SD= .38 Note. * Item removed due to low corrected item-total correlation. 199 89:98 2mm com tom: 33 xEmE 352330 _o>o_ _od 2.: 8 “=35:me fl cog—otooi _o>o_ mod 2: “a 23anme fl sous—280 ._. fig 2: _2. 8..- 8o. ONT ..2. 2o. 30. ST ST m:. 25. 5:23 2: E- 23. 3.- as.- :o. 57 N8.- 08. _8- m8. 3388 2: 2:.- §. 24:.- NS. as. on. 8.. w:- E? _8520 2: N8. :6- m:. 8o- :SN.. 32.. «8. 8o.- 8558 2: go.- ofl .- on .- 2: .- 2 _ .- 2o.- E- 530 of ma. :5.- RT .5:- --§. 48. _8 2: :o- .8. 08. 3o. mg. 5.85 8.. $8.. ..az- 9:. 8o.- 688a go: of :08. a2- 80,. -808 oo._ inc—m.- mwfi- 8.55% co; :3. flag oo._ v2.52 HOT» _0 EC: MmC ndgofi — QOXENO — Downed—U NOCDENU Std—o ~00 £262.? :COUQ IEOOM ECG-«mm Hume >o- “833.44% E 2an 200 References Abraham, C. & Sheeran, P. (1994). Modeling and Modifying Young Heterosexuals’ HIV-Preventive Behaviour: A Review of Theories, Findings, and Educational Implications. Patient Education and Counseling, 23, 173-186. Ajzen, I. (1988). Attitudes, Personalig, and Behavior. Great Britain: Open University Press. Ajzen, I. (1991). The theory of planned behavior. Organizational Behavior and Human Decision Processes 50 179-211. Ajzen, I. & Fishbein, M. (1980). 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