Childhood neglect and adulthood involvement in HIV-related risk behaviors

Child Abuse & Neglect 31 (2007) 39–53

Childhood neglect and adulthood involvement in HIV-related risk behaviors夽 Hugh Klein a,b,∗ , Kirk W. Elifson a , Claire E. Sterk c a

b

Department of Sociology, Georgia State University, Atlanta, GA, USA Kensington Research Institute, 401 Schuyler Road, Silver Spring, MD 20910, USA c Rollins School of Public Health, Emory University, Atlanta, GA, USA

Received 14 August 2002; received in revised form 21 July 2006; accepted 18 August 2006 Available online 4 January 2007

Abstract Objective: Much research has been done to examine the long-term effects of being victimized by sexual, physical, and/or emotional abuse in childhood, but much less research has focused on the impact of childhood neglect experiences. This study examines the role that childhood neglect has on adult women’s involvement in HIV-related risky behaviors. Methods: The data come from a study of 250 “at risk” women living in the Atlanta, GA metropolitan area, most of whom were African American. Data were collected in face-to-face interviews between 1997 and 2000. Multiple regression was used to explore the relationship between childhood neglect experiences, self-esteem, attitudes toward condom use, and involvement in HIV-related risky behaviors. Results: Overall, the model tested received strong support by the study data. Childhood neglect led to reduced selfesteem. Neglect was associated with worsened attitudes toward condom use and women who experienced childhood neglect also reported more involvement in HIV risk behaviors. Conclusions: HIV intervention programs ought to target women who have experienced childhood neglect, as neglect experiences have adverse impacts upon their self-esteem, condom-related attitudes, and HIV risk behavior practices in adulthood. © 2007 Published by Elsevier Ltd. Keywords: Childhood neglect; Self-esteem; Attitudes toward using condoms; HIV risk behaviors; Women

夽 ∗

This research was supported by a grant from the National Institute on Drug Abuse (R01-DA09819). Corresponding author address: Kensington Research Institute, 401 Schuyler Road, Silver Spring, MD 20910, USA.

0145-2134/$ – see front matter © 2007 Published by Elsevier Ltd. doi:10.1016/j.chiabu.2006.08.005

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Background and overview Prior to the 1980s, relatively few studies focused on childhood abuse experiences and their longer term impact on people’s lives, primarily because this subject was taboo for discussion. During the past two decades, however, a substantial amount of research has been conducted to assess the long-term impact of early-life experiences with abuse and maltreatment (e.g., childhood neglect). Findings from these investigations have revealed that childhood victimization leads to a wide variety of problems and dysfunctions in people’s lives. Psychologically, childhood maltreatment has been found to be associated with depression (Odonne-Paolucci, Genuis, & Violato, 2001; Zlotnick, Mattia, & Zimmerman, 2001), low self-esteem (Freshwater, Leach, & Aldridge, 2001; Liem & Boudewyn, 1999), anxiety disorders (Ferguson & Dacey, 1997; Neumann, Houskamp, Pollock, & Briere, 1996), intrusive and repetitive thoughts (Briere, 1992; Briggs & Joyce, 1997), and learned helplessness and lessened self-efficacy (Briere, 1992; Genuis, Thomlison, & Bagley, 1991). Typically, these adverse outcomes in adulthood are thought to come about as a result of unresolved trauma that lingers, affecting many key areas of people’s thoughts, feelings, beliefs, and attitudes. Behavioral impacts of childhood maltreatment include seeking an emotional distance from others and dissociation (Ferguson & Dacey, 1997; Neumann et al., 1996), substance abuse (Spak, Spak, & Allebeck, 1998; Wilsnack, Vogeltanz, Klassen, & Harris, 1997), sexual promiscuity (Cavaiola & Schiff, 1988; Odonne-Paolucci et al., 2001), suicide (Brown, Cohen, Johnson, & Smailes, 1999; Odonne-Paolucci et al., 2001), and a variety of compulsive behaviors and addictive personality manifestations such as thrill-seeking, eating disorders, workaholism, and self-mutilation (Briere & Gil, 1998; deGroot & Rodin, 1999; Neumark-Sztainer, Story, Hannan, Beuhring, & Resnick, 2000; Nijman et al., 1999). Much of the initial research focused on sexual abuse (most often) or physical abuse (less often), typically focusing on whether or not an individual experienced the abuse in question. Research is most limited with regard to childhood neglect and its impact, especially when excluding studies that combine abuse and neglect experiences into a single “maltreated” category. Conceptually, this may limit the understanding of the long-term impact of childhood neglect experiences, as the specific type(s) of maltreatment that people experience probably affect them quite differently. Findings from studies examining childhood neglect separately confirm its importance. Most published studies (e.g., Herman, Susser, Struening, & Link, 1997; Horwitz, Widom, McLaughlin, & White, 2001; Lipschitz et al., 1999; Schuck & Widom, 2001; Sheridan, 1995; Walker et al., 1999; Widom, 1999; Widom & Kuhns, 1996) consider behaviors to constitute neglect when young people are treated in manner that is unacceptable by community and professional standards at the time by not being provided with adequate food, clothing, shelter, and/or basic emotional needs like love, encouragement, belonging, and support prior to the age of majority. Neglected children have been found to be nearly twice as likely to develop posttraumatic stress disorder at some point in their lives when compared to non-neglected persons (Widom, 1999). Neglect has been identified as being associated with a greater risk of additional victimization by sexual abuse, physical abuse, and/or emotional abuse (Herman et al., 1997; Newcomb & Locke, 2001; Widom, 1999), a greater risk of becoming homeless as an adult (Herman et al., 1997), an increased risk of attempting suicide and more persistent suicidal ideations (Lipschitz et al., 1999), the development of poor parenting skills (Newcomb & Locke, 2001), a greater risk of becoming involved in prostitution (Widom & Kuhns, 1996), and a greater risk of developing a variety of personality disorders, including antisocial personality disorder, borderline personality, paranoia, passive-aggressiveness, narcissism, and dependent personality disorder (Johnson, Cohen, Brown, Smailes, & Bernstein, 1999).

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The purpose of this paper is to contribute to the existing body of knowledge about the longer term impact of neglect experiences. We explore the effects of childhood neglect in a sample of “at risk” women in the Atlanta, GA metropolitan area and specifically focus on the relationship between childhood neglect experiences and involvement in HIV risk behaviors in adulthood. Based on our previous research, the published literature, and the principal tenets of the Health Belief Model, the Theory of Reasoned Action, and the Theory of Planned Behavior, we chose to focus particular attention on self-esteem and attitudes toward condom use as the two main endogenous or intervening variables. This research contributes to the scholarly literature in a number of ways. First, it focuses on neglect experiences among “at risk” women, a population that has been the subject of very little previous research vis-´a-vis childhood neglect. Second, this research is based on a rich data source that enables us to consider the role that early-life neglect experiences play in adulthood HIV risk practices even when the effects of numerous other types of influences (e.g., psychological functioning, substance use, attitudes toward condom use, among others) are taken into account. Third, the multivariate model derived by this research helps to underscore the importance of childhood neglect not only as a factor having a direct influence on adulthood HIV risk behaviors but also as a factor that has an indirect influence on these behaviors by virtue of its impact upon condom-related attitudes and self-esteem.

Methods Overview and sample The data for this study came from the Female Atlanta Study (Project FAST), which was conducted between August 1997 and August 2000 in the Atlanta, GA metropolitan area. One of the principal goals of this cross-sectional study was to examine life issues and challenges, substance use, psychological and psychosocial functioning, and a variety of HIV-related risk behaviors among adult “at risk” women. “At risk” was defined broadly and included, among others, the following seven characteristics: (1) living in areas known for high rates of drug abuse, (2) being either active users of illegal drugs and/or having an immediate family member who was a substance abuser, (3) being impoverished, (4) lacking adequate medical care and/or health insurance, (5) having a low education level, (6) being unemployed, and (7) having a criminal history. Table 1 shows the proportion of study participants meeting each of these criteria. All of the women met at least one criterion and most of them (67.2%) met four or more of the criteria. In all, 295 women were screened for participation in the study. Twelve women were excluded for failure to meet the eligibility criteria and 33 others elected not to participate once all study-related procedures were explained fully. This left us with a sample of 250 women who became study participants. Most (86%) were African American. The median age was 35 (mean = 35.3, SD = 13.2, range = 18–72). About half (53%) of the women were single, and one-quarter (13%) were married or living as married at the time of their interview. Eligibility In order to participate in the study, in addition to being considered an “at risk” woman, several other eligibility criteria also had to be met. Each woman had to live in one of the study’s catchment areas.

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Table 1 Description of the sample (N = 250) Percent of women Race African American All others

86.4 13.6

Age 18–29 30–39 40–49 50 or older

38.0 24.4 24.0 13.6

Marital status Single Married/living as married Separated/divorced All others

52.6 13.4 12.1 21.9

Educational attainment Less than high school High school graduate At least some college

40.4 34.8 24.8

“At risk” criteria Living in drug-infested area Drug user or close relative who abuses drugs Income at/below poverty level Less than high school education Lacking needed medical care or having no medical insurance Unemployed or disabled Criminal history Met 2–3 “at risk” criteria Met 4–5 “at risk” criteria Met 6–7 “at risk” criteria

100.0 68.0 67.4 40.4 42.4 50.0 49.2 26.4 42.4 24.8

She had to be aged 18 or older and be able to conduct her interview in English. In addition, in order to ensure that a noninstitutionalized sample was obtained, women could not be enrolled in a substance abuse treatment program, incarcerated in a prison or jail, or be living in any other institutional setting at the time of their participation. Recruitment Women were recruited into the study by outreach workers, who conducted initial screening interviews “on the street” to confirm potential participants’ eligibility for the study. The initial recruitment was based largely on targeted sampling, including ethnographic mapping (Sterk, 1999; Watters & Biernacki, 1989). The targeted neighborhoods were chosen because of their concentration of “at risk” women. These communities were “hot spots” of local drug activity characterized by frequent drug sales and widespread drug use. Within these community “hot spots,” the outreach workers targeted places where “at risk”

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women were known to gather (e.g., laundromats, stores, playgrounds, churches, and activity centers), so as to maximize their recruitment efforts. As the study progressed, a chain referral sampling technique was used to identify additional participants. After completion of the interview, each woman was asked to refer the research team to other women who might be interested in participating in the study. On average, interviews took 2 hours to complete. At the completion of the interview, each woman was paid $15 for her participation and offered referrals to local health/social service agencies, as appropriate. The conceptual model Figure 1 presents the conceptual model being examined and tested in this study. On the left side of the model, neglect experiences prior to the age of 18 are considered. There are two levels of intervening, or endogenous, measures in the middle of the model. The first of these is self-esteem; the other pertains to beliefs and attitudes toward condom use. On the right, the outcome measure, which is the number of HIV-related risk behaviors practiced during the preceding year, is presented. All of the hypothesized relationships are based on previous research findings in the published literature, as well as the tenets of the theory of reasoned action/theory of planned behavior (Ajzen, 1992; Brown, 1999) and social cognitive theory (Bandura, 1986, 1999). Some elements from the health belief model (Brown, 1999; Fisher & Fisher, 2000) are also evident in the model used to guide the present research (e.g., sociodemographic factors preceding belief and attitudinal measures, self-efficacy as one of the key predictors of behavior, actual behavior as the principal outcome measure). By adopting this model, we hypothesize that women who experienced childhood neglect will (1) demonstrate lower self-esteem than their non-neglected counterparts, (2) have more oppositional feelings about using condoms than non-neglected women, and (3) engage in riskier HIV-related behaviors than non-neglected women. As Figure 1 shows, other factors besides neglect are also hypothesized to influence the outcome measures in question. These include a variety of demographic-type characteristics, measures of psychosocial functioning, and substance use-related variables. As we conceptualize it in the present research, neglect experiences will lead to deterioration of women’s self-esteem levels. Reduced selfesteem, in turn, will influence their attitudes toward condom use in a detrimental way, and these negative attitudes toward condom use are anticipated to be associated with greater involvement in HIV-related risk behaviors. Measures used All of the data in Project FAST were based on self-reports. The principal independent variable used in these analyses indicated whether or not respondents had been a victim of neglect prior to the age of 18. As with other published studies that have examined neglect-related outcomes (e.g., Herman et al., 1997; Horwitz et al., 2001; Lipschitz et al., 1999; Schuck & Widom, 2001; Sheridan, 1995; Walker et al., 1999; Widom, 1999; Widom & Kuhns, 1996), we considered neglect as the experience in which people were treated in manner that was unacceptable by community and professional standards at the time by not being provided with adequate food, clothing, shelter, and/or basic emotional needs like love, encouragement, belonging, and support prior to the age of majority. This construct was assessed using four items from Bernstein et al.’s (1994) Childhood Trauma Questionnaire, each of which was scored “never true,” “rarely true,” “sometimes true,” “often true,” or “very true.” Neglect was said to have occurred if

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Figure 1. Conceptual model being tested.

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the person responded “sometimes true,” “often true,” or “very true” to any of the following items: (1) When I was growing up, I didn’t have enough to eat. (2) When I was growing up, my parents were too drunk or high to take care of the family. (3) When I was growing up, I had to wear dirty clothes. Neglect was also said to have occurred if the person responded “never true” or “rarely true” to the item (4) When I was growing up, I knew that there was someone to take care of me and protect me. Other independent variables were examined as well. Demographic variables included age (coded as a continuous variable), race (coded as African American or any other race), educational attainment (an ordinal measure indicating less than a high school education, high school graduate or equivalent, and at least some college), marital status (coded as married or living as married vs. all other marital status groups), religiosity (a continuous variable measured as the interaction between frequency of worship service attendance and the amount of perceived impact of one’s religion upon one’s behavior), and the number of money-related problems experienced (a continuous variable). Psychosocial measures included depression (a continuous scale measure based on the Depression and Anxiety Stress Scale 42 [DASS 42] developed by Lovibond and Lovibond (1995)) (Cronbach alpha = .86), level of coping with everyday stresses (a continuous scale measure derived from the Ways of Coping Questionnaire (Folkman & Lazarus, 1988) (Cronbach alpha = .63), and assertiveness (a continuous measure derived from 13 items) (Cronbach alpha = .78). Four substance use-related measures were also examined: living with any person(s) using illegal drugs (coded yes/no), the amount of alcohol used (a continuous measure constructed by multiplying the average number of drinks consumed per occasion by the number of days using alcohol during the preceding month), the amount of illegal drugs used (a continuous measure constructed by summing the quantity-frequency amount of nine different drug types), and the number of drug problems experienced (a continuous scale measure based on responses to 11 items indicating substance abuse and substance dependency, as specified in the DSM-IV [American Psychiatric Association, 1994]) (Kuder-Richardson-20 = .91). Self-esteem was assessed using a shortened version of Rosenberg’s (1965) self-esteem scale. The shortened version consisted of seven of the original ten items, with responses of “never,” “rarely,” “sometimes,” “often,” or “almost always” indicating how often the person felt that each statement was true for her during the previous 90 days. This scale measure was found to be reliable, with a Cronbach alpha coefficient of .84. Condom attitudes were assessed using eight individual items scored on a five-point Likert scale. These items were items taken from a modified and abridged version of the Attitudes Toward Condom Scale developed by Brown (1984). These included measurements of the partner’s willingness to use condoms, the person’s own feelings about using condoms, embarrassment surrounding condom use, and so forth. The summative scale measure used in these analyses was found to be reliable, with a Cronbach alpha coefficient of .79. The main outcome measure used in these analyses examined how many different types of risky behavior the person reported practicing during the year prior to interview. Scores could range from 0 to 8, with one point being added to the scale for each risk behavior reported during the preceding year. Scale items, which were derived from the Centers for Disease Control and Prevention’s approach to quantifying HIV risk, included having sex while the respondent herself and/or her partner was high on alcohol or other drugs; having sex with an injection drug user; having anal intercourse; having sex with a man who may have had sex with other men; trading sex for drugs, gifts, or money; using drugs, gifts, or money to procure sex; having multiple-partner sex; and having unprotected sex. The composite HIV risk behavior measure had a Kuder-Richardson-20 reliability coefficient of .61, indicating an adequate level of reliability for analytical purposes.

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Analysis Multiple regression was used as the analytical technique for this research, with separate equations derived for the dependent variable and the two endogenous variables. Initially, the bivariate relationships for the measures listed above (and hypothesized to be relevant to the outcomes involved) were tested. When the independent variable was dichotomous in nature, this involved the use of Student’s t tests. When the independent variable was categorical in nature or ordinal with fewer than five response categories, the bivariate analyses entailed the use of χ2 tests. When the independent variable was continuous in nature, the bivariate relationships were examined via simple regression. All variables found to be related significantly (p < .05) or marginally (.15 > p > .05) to the dependent measure in question were chosen for entry into three separate multivariate equations. As Figure 1 depicts, self-esteem, condom-related attitudes, and number of HIV risk behaviors practiced served as the dependent measures for these analyses. Below, results are reported as significant when p < .05. In Figure 2, standardized coefficients (i.e., beta values) are presented so that relative effect sizes can be noted and compared. For the sake of simplicity in understanding the results, only statistically significant relationships are reported.

Results Thirty-five percent of the women who participated in Project FAST reported having been neglected during their childhood and/or adolescent years. Figure 2 displays the results of the analysis, and through its use and reporting of beta values, facilitates comparisons of the relative contribution of each predictor measure. Five variables (presented below in descending order of their predictive power) were found to be predictors of the endogenous variable, self-esteem. First, the more drug-related problems women experienced, the lower their self-esteem tended to be (p < .001). Moreover, women who had been neglected during their childhood and/or adolescent years reported lower self-esteem than women who had not been neglected (p < .001). The data revealed that the more religious women were, the greater their self-esteem tended to be (p < .001). Furthermore, women experiencing more financial problems had lower levels of self-esteem than their counterparts experiencing no financial difficulties or fewer such difficulties (p < .01). Finally, African American women had higher self-esteem than women belonging to other racial groups (p < .05). Together, these variables explained 32.5% of the variance in self-esteem. Our analyses revealed four variables that were significant predictors of condom-related attitudes (Figure 2). Women with higher self-esteem had more positive attitudes toward condom use than those whose self-esteem levels were lower (p < .01). The more drug-related problems women experienced, the more negative their attitudes were regarding the use of condoms (p < .001). Women who had been neglected prior to adulthood had more negative attitudes toward using condoms than their non-neglected counterparts (p < .001). Lastly, younger women had more negative attitudes toward using condoms than their older counterparts (p < .001). Together, these predictors explained 24.5% of the variance in women’s condom-related attitudes. Finally, five variables were identified as being predictors of women’s involvement in HIV risk behaviors (Figure 2). First, women who were more capable of coping with everyday stress reported fewer HIV risk behaviors (p < .001). Second, the more favorable women’s attitudes were regarding the use of condoms, the less their HIV risk behavior involvement tended to be (p < .001). Third, younger women reported more engaging in HIV risk behaviors than their older counterparts (p < .001). Fourth, women who lived

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Figure 2. The relationship of neglect to self-esteem, condom-related attitudes, and HIV risk.

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with at least one substance abuser reported more involvement in risky practices than those who did not live with a drug abuser (p < .01). Finally, neglected women engaged in fewer risk behaviors than their non-neglected counterparts (p < .05). Together, these measures explained 27.3% of the variance.

Discussion Overall fit of the model As the results shown in Figure 2 demonstrate, the model presented in Figure 1 has strong support in this study. As hypothesized, self-esteem was predicted by some of the demographic variables, by one of the substance use measures, and by childhood neglect. Also consistent with the hypothesized relationships, condom-related attitudes were predicted by one demographic variable (age), by self-esteem, by one of the drug-related variables (number of drug problems experienced), and by neglect. Likewise, the final outcome measure—number of HIV risk behaviors practiced during the preceding year—also had one demographic measure, one psychosocial variable, one substance use-related item, condom-related attitudes, and childhood neglect as its predictors. Thus, our findings indicate that the model presented in Figure 1—a model in which demographic characteristics, childhood neglect, psychosocial variables, and factors relating to substance use are seen as influencing self-esteem, attitudes toward condom use, and involvement in risky behaviors—is borne out in this study of “at risk” women. Furthermore, as the model suggests, self-esteem is influential in determining how women feel about the use of condoms and that, in turn, affects how involved they are in HIV-related risk practices. These findings are consistent with other published studies that have shown a relationship between condom-related attitudes and HIV risk behaviors (Moore & Halford, 1999; Sheeran, Abraham, & Orbell, 1999). They also support previous research demonstrating that low levels of self-esteem underlie greater involvement in HIV risk behaviors (Abel, Hilton, & Miller, 1996; Somlai et al., 2000). The specific role of neglect Among the most interesting and important findings derived in this research are those pertaining to the specific role that childhood neglect experiences play in adversely affecting the outcomes studied. As hypothesized, being neglected led to diminished self-esteem, adhering to more negative attitudes toward condom use, and involvement in a greater number of HIV-related risk behaviors. The present study complements previous research (Johnson et al., 1999; Lipschitz et al., 1999; Widom, 1999) by demonstrating that neglect causes a variety of adverse outcomes among women. Specifically, this research supports findings showing that childhood neglect experiences often result in lowered self-esteem (Peretti, Early, & Chmura, 1998). In many ways, some of the long-lasting consequences of being neglected may be quite similar to those brought about by experiencing other types of maltreatment. Simultaneously, though, there is good reason to believe that neglected persons may suffer adverse consequences that are unique to their experience of being neglected, rather than common to victims of childhood/adolescent maltreatment more generally. We make this supposition—and we would like to point out that this is speculation and interpretation on our part—because there is a fundamental difference between being sexually, physically, and/or emotionally abused and being neglected: the former entail the performance of some specific action(s) whereas the

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latter entails inaction. One of the uniquely harmful aspects of being neglected is the implied message that one does not matter, that one’s needs—like oneself—are insufficiently important to be attended to. In situations of neglect, the people who ordinarily would discipline or take care of the child simply do not care enough about that person to invest the physical or emotional energy required to interact with him/her. Conversely, in situations involving physical or sexual abuse, such an investment is made, albeit inappropriately, dysfunctionally, and in a damaging fashion. By being treated in a manner that conveys no sense of mattering to others and no sense of worth, many neglected persons fail to develop any true sense of self-esteem (i.e., neither poor nor good self-esteem is developed, since the person becomes disinclined to think in terms of him/herself) and, therefore, invest no value in themselves or their futures. Under such circumstances, it is entirely foreseeable that—just as we found in the present research—such persons would think of condoms in a negative way, that they would engage in high rates of risky behaviors, and so forth. To them, taking risks and the future are, ostensibly, irrelevant. For such persons, having sex with someone or engaging in other types of risky behavior may be a way of establishing a human connection—a way of trying to fill the emotional void created by having been neglected. With that in mind, we believe that it is important that additional research focus on the impact of neglect experiences, particularly where comparisons can be made regarding the impact of neglect vis-´a-vis other types of maltreatment experiences. Implications for intervention Our findings have fairly clear implications for persons who are conducting projects focusing on HIV risk reduction or intervention or sexual health enhancement. Our research highlights the value of assessing whether or not study/project participants have been victims of neglect, so that these individuals’ special needs may be noted and anticipated—and hopefully dealt with—early on in their involvement in the project at hand. Conducting this type of assessment can be done in a matter of a few minutes. The present research findings also highlight the importance of identifying persons suffering from low self-esteem and providing such individuals with targeted services to bolster their feelings about themselves. Again, conducting this type of assessment is easy to do and is not time-consuming. By providing special services to help persons with low self-esteem and/or neglect in their backgrounds to deal with their residual emotional and psychosocial issues, public health-oriented projects will, in all likelihood, be more effective at changing the belief and attitude structures that underlie involvement in risky behaviors and more effective at bringing about reductions in the risky behaviors themselves. The published literature suggests that programs that have reported improvements in persons’ self-esteem typically have found attendant reductions in HIV risk behavior involvement (Ferreira-Pinto & Ramos, 1995; Nyamathi & Stein, 1997; Rotheram-Borus, Rosario, Reid, & Koopman, 1995; St. Lawrence et al., 1997). This paper also highlights the importance of changing women’s attitudes toward using condoms and the myriad factors that underlie their opposition regarding the use of sexual protection. Our study is one of many that has found an inverse relationship between condom-related attitudes and involvement in risky behaviors (Moore & Halford, 1999; Nadeau, Truchon, & Biron, 2000; Sheeran et al., 1999). Given this finding, it would be highly beneficial for intervention programs to work specifically to alter women’s feelings about the use of condoms. A variety of approaches for accomplishing this have been found to yield positive outcomes (American Foundation for AIDS Research, 2001; DeZwart, 2002; El-Bassel et al., 2001; Hoffman, Klein, Crosby, & Clark, 1999; Lindberg, 2000; Posner, Pulley, Artz, Cabral, &

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Macaluso, 2001; Somlai et al., 1998; Stevens, Estrada, & Estrada, 1998), and we have written more extensively about this subject in another work (Sterk, Klein, & Elifson, 2004).

Potential limitations of this research Before concluding, we would like to acknowledge a few potential limitations of this research. First, the data collected as part of Project FAST were based on uncorroborated self-reports. Therefore, the extent to which respondents underreported or overreported their involvement in risky behaviors is unknown. In all likelihood, the self-reported data can be trusted, as many authors have noted that persons in their research studies (which, like ours, have included fairly large numbers of drug abusers) have provided accurate information about their behaviors (Anglin, Hser, & Chou, 1993; Higgins et al., 1995; Miller, Turner, & Moses, 1990; Nurco, 1985). This has been reported to be the case for self-reported childhood maltreatment information as well (Widom & Morris, 1997; Widom & Shephard, 1996). A second possible limitation pertains to recall bias. Respondents were asked to report about their beliefs, attitudes, and behaviors during the past 30 days, 90 days, or year, depending upon the measure in question. These time frames were chosen specifically (1) to incorporate a large enough amount of time in the risk behavior questions’ time frames so as to facilitate meaningful variability from person to person, and (2) to minimize recall bias. The exact extent to which recall bias affected the data cannot be assessed although other researchers collecting data similar to those captured in Project FAST have reported that recall bias is sufficiently minimal that its impact upon study findings is likely to be small (Jaccard & Wan, 1995). A third possible limitation of these data comes from the sampling strategy used. All interviews were conducted in the Atlanta, GA metropolitan area. There may very well be local or regional influences or subcultural differences between these women and those residing elsewhere that could affect the generalizability of the data. Additionally, the chain referral sampling approach used to identify study participants is not a random sampling strategy, and there may be inherent biases in who was/not identified as potential study participants in Project FAST. A good discussion of the issues pertinent to this concern may be found in Heckathorn (1997), along with strategies that can be employed to minimize any bias that could result from the use of a chain-referral sampling approach. Moreover, with an average age of 35 and quite a few women aged in their 50s and older, it is possible that this sample of “at risk” women was less sexually active than a younger sample of women might have been, and that this age factor may, in turn, equate with a lower overall level of HIV risk than would be seen in a younger sample. Finally, the data used in this research were obtained via a cross-sectional study design. Attributions of causality are always speculative rather than provable whenever this type of research design is used. We tried to be very careful when designing the conceptual model tested in this research to make sure that temporal ordering of relationships was taken into account (where possible), and we also tried to account for this potential source of bias by relying upon the tenets of the theoretical models that underlie our work.

Acknowledgment The authors wish to acknowledge, with gratitude, the contributions made by Katherine Theall to the development of this manuscript.

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R´esum´e/Resumen French- and Spanish-language abstracts not available at time of publication.