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Psychosocial Predictors of

AIDS Risk Behavior and Drug

Use Behavior in Homeless and

Drug-Addicted Women of Color 1

Adeline Nyamathi, R.N., Ph.D., F.A.AN.; Judith A. Stein, Ph.D.;

and Mary-Lynn Brecht, Ph.D.

INTRODUCTION

The incidence of acquired immunodeficiency syndrome (AIDS) is

increasing more rapidly among women than among men (Centers for

Disease Control and Prevention 1995). Although injection drug use

has been the main vector for human immunodeficiency virus (HIV)

among women, increasing numbers of American women are contracting

HIV as a result of heterosexual contact with an infected partner (Centers for Disease Control and Prevention 1996). African-American and

Latino women account for more than 75 percent of AIDS cases among

women (Centers for Disease Control and Prevention 1993). Unfortunately, little is known about the psychosocial and behavioral factors

influencing the transmission of HIV in these women, the majority of

whom are impoverished and socially disadvantaged (Ickovics and Rodin

1992).

Few theory-based models have been tested to assess the psychosocial

predictors of health-seeking and coping behaviors of impoverished

women of color at risk for AIDS. The purpose of the study described

in this chapter was to examine a causal model of personal resources,

threat appraisal processes, coping styles, and barriers to risk reduction

as predictors of risk behavior among a group of women at high risk.

This study represents a subsample of a larger study designed to assess the

coping skills and health outcomes of homeless and drug-addicted women

of color in Los Angeles (Nyamathi 1991, 1992; Nyamathi et al. 1993a).

Risk behavior was defined to include (1) general AIDS risk behaviors

such as multiple sexual partners, injection-drug-using sexual partners,

and infrequent condom use and (2) specific risky drug use behaviors

such as sharing needles.
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THEORETICAL PERSPECTIVE

The theoretical basis for the proposed hypothetical model includes

key elements of the Comprehensive Health-Seeking and Coping Paradigm (CHSCP) (Nyamathi 1989) and the Health Belief Model

(Rosenstock et al. 1988).

The CHSCP has previously served as a conceptual framework to

guide the assessment and implementation of strategies related to the

coping behaviors and health outcomes of impoverished women of color.

In this model, which has been adapted from the Lazarus and Folkman

(1984) Stress and Coping Paradigm and the Schlotfeldt (1981) HealthSeeking Paradigm, six components are predictors of risk behaviors.

The first five components are personal resources, social resources,

cognitive appraisal, coping behavior, and, in the case of Latinas,

the sociodemographic factor of acculturation to the Anglo culture.

The sixth predictor, barriers to condom use, is derived from the

Health Belief Model (Rosenstock et al. 1988).

Personal resources include self-esteem and lack of emotional disturbance. It is well known that impoverished homeless and drug-abusing

women report low self-esteem and a fair degree of emotional disturbance

(Mondanaro 1987; Wofsy 1987). Researchers have found that women

with higher self-esteem perceive fewer threats in their environment

(Gass and Chang 1989), cope more adaptively (Gutierres and Reich

1988; Tucker 1982), experience less emotional disturbance (Hobfoll

1988, pp. 261-268; La Gory et al. 1990; Nyamathi 1991), use condoms

more often, and exhibit significantly fewer higher risk behaviors

(Nyamathi 1991). Thus, it was hypothesized that women with higher

self-esteem would have less emotional disturbance, perceive fewer threats

in their environment, use more active coping and less avoidant coping,

and report less sexual and drug use behavior and fewer barriers to protective behaviors, such as use of condoms. Moreover, as emotional distress

has been found to be associated with higher levels of threat appraisal

and avoidant coping (Nyamathi et al. 1993a) and higher rates of HIV

risk behavior (Tucker 1982; Nyamathi 1992; Nyamathi et al. 1993a), it

was hypothesized that women with higher emotional disturbance would

report more threat appraisal, more barriers to condom use, more avoidant

coping, and more risky behavior.

Social resources, such as social support, provide another important

dimension influencing health-seeking behaviors and health outcomes.
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Research has shown that women with higher self-esteem have more

available social support (Hobfoll 1988, pp. 261-268; Muhlenkamp and

Sayles 1986) because they are more effective in establishing supportive

relationships and are more likely to perceive support whether it exists or

not. Social support acts as a resource providing encouragement to the

recipient and as such promotes health protection, a sense of belonging,

feelings of personal efficacy (Kobasa et al. 1985; Muhlenkamp and

Sayles 1986), reduced appraisal of threat (Gass and Chang 1989), more

adaptive coping (Gutierres and Reich 1988), and less emotional disturbance (Hobfoll 1988, pp. 261-268; La Gory et al. 1990). Thus, it was

hypothesized that women with greater social support would have higher

self-esteem; use more active coping and less avoidant coping; and report

fewer risk behaviors, less perceived threat, fewer barriers to healthseeking behavior, and less emotional disturbance.

In this study, threat appraisal is defined more personally as degree

of threat of losing self-respect, being considered useless, having insufficient money, and being involved in illegal activities (Nyamathi et al.

1993a). Researchers have demonstrated that persons who perceive

fewer threats in their environment and who cope more adaptively

experience lower levels of emotional distress (Fawzy et al. 1990; Namir

et al. 1987) and engage in fewer risky behaviors (Nyamathi et al.

1993a). The impact of threat appraisal on barriers to condom use

was likewise of interest in this study. Thus, it was further hypothesized

that women with greater threat appraisal would report more barriers

to condom use, more avoidant coping, and more risk behavior.

Coping responses are defined as the cognitive and behavioral efforts

to manage internal or external demands seen as taxing or exceeding the

resources of the person (Lazarus and Folkman 1984). These responses

can be described as active or adaptive coping behaviors that manage

problems or as avoidant behaviors that ease the emotional distress

experienced. Research has outlined the relationship between personal

resources and adaptive coping (Gutierres and Reich 1988; Tucker 1982)

and the relationship of adaptive coping with lower levels of risky

behavior (Nyamathi et al. 1993b) and emotional distress (Fawzy et al.

1990; Namir et al. 1987).

Recent testing of the CHSCP with a subsample of 749 AfricanAmerican women was performed with structural equation modeling

(Nyamathi et al. 1993a). In this study, 45 percent of the variance in
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emotional distress was explained by the model, with self-esteem and

avoidant coping being the strongest predictors; threat appraisal also

contributed significantly. However, only 10 percent of the variance in

risk behavior was explained, with emotional distress being the strongest

predictor. Since only a small amount of variance in risk behavior was

explained, the model was reconfigured with various risk behaviors

conceptualized as outcomes and with emotional distress, renamed

emotional disturbance, hypothesized as a predictor. The current study

differs from the previous study in that it investigates ethnic differences

among both African-American and Latino women and examines a full

latent variable model with emotional disturbance as a predictor rather

than as an outcome variable. Furthermore, to better understand the

factors influencing health and risky behaviors, additional variables were

added to this more elaborate model. These variables, which incorporate

constructs of the Health Belief Model, include perceived susceptibility

to AIDS and perceived barriers to condom use.

Thus, on the basis of empirical evidence and the theoretical perspectives of the CHSCP and the Health Belief Model, specific relationships

among 9 variables (10 for Latinas) were hypothesized and tested within

a causal model of latent constructs. These variables consisted of the

personal resources of self-esteem and lack of emotional disturbance,

social resources of support, threat appraisal, perceived barriers to condom

use, coping behaviors, acculturation, and health outcomes of general

AIDS risk behavior and specific drug use behavior. Although causality

cannot be decisively determined because of the cross-sectional nature

of the data, the specific hypotheses based on the theory and review of

the literature are given below.

1. Self-esteem and social resources are associated with less emotional

disturbance and predict less threat appraisal and fewer perceived

barriers to condom use. Self-esteem and social resources are

positively related to each other.

2. The personal resources of self-esteem and social resources predict

more active coping, less avoidant coping, less general AIDS risk

behavior, and less specific drug use behavior.

3. Emotional disturbance predicts more threat appraisal, more

barriers to condom use, more avoidant coping, and greater general

AIDS risk and specific drug use behaviors.
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4. Greater threat appraisal is associated with more barriers to

condom use, more avoidant coping, and greater general AIDS

risk and specific drug use behaviors.

5. Coping style is associated with risk behavior. In particular,

active coping predicts less general AIDS risk and specific drug

use behavior, whereas avoidant coping has the opposite effect.

METHODS

Subjects

Baseline assessments were conducted among a set of AfricanAmerican and Latino women selected for participation in a large-scale

longitudinal research project on AIDS prevention and education. They

were recruited through the directors of homeless shelters and drug recovery programs and were paid $5 to participate in a 60-minute face-to-face

interview (available in both Spanish and English). Subjects were assured

of confidentiality and were interviewed by one of six trained AfricanAmerican and Latino nurses and outreach workers. Interviewers and

respondents were matched by race. The eligibility criteria were that

the subject be (1) between the ages of 18 and 69 and (2) identified as

a drug user, a sexual partner of an injection drug user, a prostitute, or a

homeless individual housed in a shelter or a one-room occupancy building. Ninety-two percent of the women who met study criteria participated in the study. Six hundred ninety-one Latino and 2,019 AfricanAmerican women were available for the latent variable analyses. The

disparity in ethnic groups initially entering the study was due to the

greater number of African-American nurses and outreach workers

trained as interviewers and the smaller number of homeless shelters

that house Latinas.

Preliminary comparisons showed substantive differences between

the ethnic groups in various general AIDS risk behaviors, which are

the focus of this research project. Therefore, it appeared prudent to

analyze the groups separately, especially since the outreach component

was designed to be culturally sensitive and to differ depending on the

ethnicity of the recipient. In addition, the contribution of acculturation

level to the variables under study among the Latinas could be assessed if

the ethnic groups were studied individually. Since the two groups varied

greatly in size, a random set of African-American women was selected
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using a random number generation program (random set n=714) to

make the degrees of freedom and fit indices more comparable between

the two groups when testing the path models. A validation sample was

also derived randomly from the remainder of the African-American

women not included in the original random set (validation n=791)

to test the feasibility and reliability of the parameters and the fit of

the final path model developed for the African-American women.

Analysis of demographic characteristics of the entire sample revealed

that the African-American women reported a mean age of 33, with a

range of 17 to 63 years. The majority were Protestant (75 percent),

unemployed (91 percent), and single (53 percent) or widowed, separated,

or divorced (33 percent). The mean years of education completed was

12. Risky behaviors reported by the African-American women included

using injected drugs (11 percent), using noninjected drugs (70 percent),

trading sex for money or drugs (50 percent), and having a history of

sexually transmitted diseases (STDs) (47 percent).

Latinas who were more acculturated, as indicated by their score

above the median on the Acculturation Scale (Marin et al. 1987),

reported a mean age of 32 (range 18 to 75 years) and were primarily

Catholic (70 percent), unemployed (79 percent), and single (24 percent)

or widowed, separated, or divorced (29 percent). The mean years of

education completed was 11. Risky behaviors included using injected

drugs (34 percent), using noninjected drugs (34 percent), trading sex for

money or drugs (29 percent), and having a history of STDs (25 percent).

Less acculturated Latinas reported a mean age of 31 (range 17 to

75 years) and were Catholic (72 percent), unemployed (88 percent),

and more likely to be married (42 percent). The mean years of

education completed was 7. Fewer reported risky behaviors in terms of

using injected drugs (2 percent), using noninjected drugs (8 percent),

trading sex for money or drugs (10 percent), or having a history of STDs

(14 percent).

Furthermore, differences were apparent between ethnic groups.

African-American women were more likely to report a history of STDs,

use noninjected drugs, and have multiple partners than Latino women.

More acculturated Latinas were more likely to be injection drug users

than African-American women and less acculturated Latinas. On the

other hand, less acculturated Latinas were more likely to be married and

to be less educated than the other women. Finally, both more and less
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acculturated Latinas were more likely to be employed and Catholic than

African-American women.

Measures

Multiple-indicator latent variables or factors were used in this

study. The measures used to construct the latent variables are described

below. The content validity of the scales and measures used in the

interviews was previously established through review and consensus

by a 12-member panel experienced in the areas of AIDS, ethnic/racial

diversity, and coping (for more details, see Nyamathi et al. 1993a).

Before the measurement model (confirmatory factor analysis [CFA])

and path models were tested with structural modeling, preliminary

exploratory factor analyses were conducted to determine the optimum

configuration for each latent construct. Items that were potential

confounders between constructs were eliminated as described below.

Alpha coefficients for constructs are reported in table 1.

Self-Esteem. The self-esteem latent construct was developed using

responses to the Coopersmith (1967) Self-Esteem Inventory. The

inventory was modified slightly to make it more understandable for

this population (Nyamathi et al. 1993a). For instance, responses were

coded “true” and “false” rather than “like me” and “unlike me.” To

avoid overlaps between constructs, the authors deleted four items that

related to the participants’ perception of their family’s social support and

regard for them (e.g., “your family or friends usually think about your

feelings”). Since the authors wanted all constructs to be latent factors

with multiple indicators and factor analysis reported only one eigenvalue

greater than one (eigenvalue 4.0), inventory items were combined

randomly to create four composite indicators (Bentler and Wu 1993).

These indicators were labeled Self 1, Self 2, Self 3, and Self 4.

Social Resources. A social resources construct was indicated by

the subjects’ rating of three attributes of each type of social support:

availability (e.g., “Is there someone you can talk to or someone who will

listen to you?”), use of such support (e.g., “How often did you actually

use this support during the past 6 months?”), and quality of the support

(e.g., “How effective was the support?”). There were seven types of

social support items for each attribute; these were summed to create the

three indicators.
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Summary Statistics

AfricanFactor Loadings* Latinas Americans

Latent and Manifest African- Standard Standard

Variables Latinas Americans Mean Deviation Mean Deviation

Self-esteem

( =0.79, 0.78)†

Self 1 0.66 0.70 1.52 0.28 1.55 0.24

Self 2 0.68 0.61 1.51 0.26 1.45 0.25

Self 3 0.82 0.72 1.50 0.30 1.42 0.30

Self 4 0.58 0.63 1.61 0.26 1.63 0.26

Social resources

( =0.87, 0.86)

Available support 0.91 0.92 1.66 0.37 1.70 0.35

Use support 0.98 0.96 3.03 1.35 3.15 1.32

Quality of support 0.97 0.96 2.92 1.29 3.08 1.28

Emotional disturbance

( =0.85, 0.78)

CES-D 0.85 0.78 2.74 0.72 3.03 0.71

SCL-90 0.67 0.61 1.91 0.75 1.96 0.76

POMS 0.89 0.84 2.49 0.83 2.71 0.91

Threat appraisal

( =0.73, 0.74)

Threat 1 0.70 0.74 2.34 1.24 3.13 1.40

Threat 2 0.66 0.71 2.92 1.08 3.11 1.09

Threat 3 0.70 0.71 2.84 1.04 3.07 1.12

Barriers to condom use

( =0.62, 0.58)

Don’t like 0.47 0.50 2.72 0.85 2.60 0.77

Deny need 0.73 0.68 4.03 1.27 4.23 1.19

Powerless 0.67 0.69 8.18 1.71 9.02 1.94

Active coping

( =0.81, 0.75)

Control 0.80 0.64 3.80 1.07 4.20 1.02

Find out 0.86 0.77 3.81 1.11 4.06 1.12

Find meaning 0.54 0.50 3.57 1.12 3.75 1.19

Think of a way 0.57 0.45 3.59 1.08 3.86 1.09

Avoidant coping

( =0.65, 0.63)

Laugh it off 0.43 0.35 2.46 1.27 2.86 1.29

Put out of mind 0.35 0.52 3.02 1.18 3.12 1.30

Daydream 0.56 0.56 2.87 1.29 3.17 1.23

Sleep 0.55 0.56 2.76 1.20 3.04 1.31

Go away 0.54 0.44 2.50 1.25 2.86 1.31

TABLE 1. Factor loadings of final confirmatory factor analysis model,

summary statistics, and alpha coefficients for Latino

(n=691) and African-American women (n=714)
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TABLE 1. (continued)

Summary Statistics

AfricanFactor Loadings* Latinas Americans

Latent and Manifest African- Standard Standard

Variables Latinas Americans Mean Deviation Mean Deviation

General AIDS

risk behaviors

( =0.60, 0.59)

AIDS Risk 1 0.61 0.48 1.76 0.62 1.79 0.61

AIDS Risk 2 0.53 0.38 2.14 1.01 2.42 1.10

Less condom use 0.22 0.64 3.56 0.96 3.86 1.10

Number sex partners 0.52 0.71 0.37 0.35 0.57 0.54

Partner shoots drugs 0.52 0.55 1.22 0.37 1.15 0.31

Specific drug use

behaviors ( =0.66, 0.48)

Drug use 0.94 1.00 1.09 1.56 2.06 1.56

Injection drug use 0.71 0.45 0.34 0.75 0.17 0.55

Sharing 0.56 0.31 1.13 0.34 1.06 0.24

Acculturation – – 2.98 1.43 – –

*All factor loadings significant (p 0.001).

†Alpha coefficients for Latinas and African-American women, respectively.

KEY: CES-D=Center for Epidemiological Studies Depression Scale; SCL-90=Somatization Scale of

the Somatic Complaint List; POMS=Profile of Mood States.

Emotional Disturbance. A latent variable of emotional disturbance

during the previous 6 months was indicated by mean scores on three

multiple-item scales with five-point Likert responses: the Center for

Epidemiological Studies Depression Scale (CES-D) (Radloff 1977),

the Somatization Scale of the Somatic Complaint List (SCL-90-R)

(Derogatis and Cleary 1977), and the Profile of Mood States (McNair et

al. 1981). Two items were dropped from the original 20-item CES-D,

one that was highly confounded with social support and another that

greatly overlapped with self-esteem. In addition to the original 16-item

subscale of the SCL-90-R, four items were added: loss of appetite,

gastrointestinal problems, fatigue, and insomnia.

Threat Appraisal. A variable reflecting generalized threat appraisal

or perception was developed for this model. Twenty-two items in

the Inventory of Current Concerns (Weisman et al. 1980) and seven

items from the primary appraisal instrument of Folkman and colleagues

(1986) were factor analyzed. Eight items that involved broad personal

concerns of the women (not involving children or other family
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members) emerged as highly correlated with each other (e.g., upset

about being very lonely, losing hope in the future). These eight items

were summed randomly to create three generalized composite threat

indicators, Threat 1, Threat 2, and Threat 3.

Barriers to Condom Use. A list of 14 reasons for not using a condom

with her main sexual partner (not a client) was presented to the participants. Factor analysis indicated that there were three reliable factors.

(A fourth factor consisting of two items indicating desire for a child

by either the woman or her partner was not used in the barriers construct.) The first factor was dislike of condoms by either the woman or

her partner. These two responses were summed to create an indicator

called “don’t like.” The second factor consisted of three items indicating

denial of the need to use a condom (e.g., “you feel you can’t get AIDS

from your partner”). The three responses were summed to create an

indicator, “deny need.” The third factor included seven items that

suggested social and educational deficiencies and lifestyle difficulties

and hardships. For example, this factor included fear of getting beaten

up by the partner, not knowing how to use condoms, and inability to

discuss condoms with the partner. This factor was labeled “powerless.”

Coping. A 30-item version of the Jalowiec Coping Scale (Jalowiec

and Powers 1981) assessed coping strategies used by the participant

to “get one’s life together” in the past 6 months rated on a five-point

Likert scale (“never” to “always”). Two of the five resultant factors

were hypothesized to reflect active coping and avoidant coping. Active

coping was indicated by four questionnaire items: “try to have some

control over the problem,” “find out more about the problem so you

can handle it better,” “try to find meaning in the problem,” and “think

of different ways to handle the problem.” Avoidant coping was indicated by five items: “laugh it off,” “try to put the problem out of your

mind,” “daydream,” “go to sleep,” and “go away.”

General AIDS Risk Behaviors. Five items associated with AIDS risk

were used as indicators of risky behavior. One item was an assessment

by the women of their chances of contracting the AIDS virus on a 1-to4 scale (AIDS Risk 1). A second was how often they think about the

possibility of becoming infected with the AIDS virus on a 1- to 4-scale

(AIDS Risk 2). Another indicator, less condom use, was a scaled

variable based on responses to three questions about sexual activity:

without a condom in the past 6 months, without a condom with a
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special partner, and without a condom with others. A fourth indicator

was the number of sexual partners the women had in the past 6 months.

Since the raw scores for this variable varied widely, and qualitatively

and psychologically there was a greater difference between zero and 10

than there would be between 90 and 100, the log of the response was

used for this item. The fifth item was whether, in the past 6 months,

her sexual partner(s) “shot” drugs (injection drug use).

Specific Drug Use Behaviors. Three indicators associated with the

woman’s drug use were used for this construct. One indicator, drug use,

was a sum of responses to use of nine categories of drugs: heroin or other

narcotics, cocaine, amphetamines, hallucinogens, other barbiturates,

nitrite or other inhalants, marijuana, “designer drugs,” and alcohol.

Another indicator, injection drug use, was the sum of responses to items

questioning injection (“mainlining”) of heroin, cocaine, amphetamines,

hallucinogens, and other drugs. The third indicator was the response

(yes or no) to whether she was sharing needles or other equipment with

others, including her partner.

Acculturation Level. For the Latinas, the mean value on a 12-item

acculturation scale reflecting language preference and country of origin

of most of her friends was used as an indicator of acculturation level

(Marin et al. 1987). Scores ranged from 1 to 5 (language questions:

1=Spanish only, 5=English only; friend questions: 1=all from my native

country, 5=all from this country); a higher mean score was interpreted

as greater acculturation.

Analyses

All latent variable analyses were performed using the EQS structural

equations modeling program (Bentler 1992). To specify a predictive

model with correlated cross-sectional data, the authors used the technique of covariance structure modeling with latent variables. This

technique allows one to evaluate “causal” hypotheses with correlational

nonexperimental data. The causal hypothesis can be rejected statistically, but it cannot be unequivocally proven. This is especially the case

with cross-sectional data because some alternate models might also be

plausible (MacCallum et al. 1993). However, to the extent that the

proposed model fits the empirical data and can be appropriately supported or justified theoretically, stronger conclusions can be drawn than
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can be considered in most nonexperimental research (Bentler and Stein

1992).

The closeness of the hypothetical model to the empirical data was

evaluated through goodness-of-fit indices, including chi-square/degrees

of freedom ratios and the Comparative Fit Index (CFI), which ranges

from zero to 1. A chi-square value of no more than twice the degrees of

freedom in the model generally indicates a plausible model. The CFI is

based on the improvement in fit of the hypothesized model over a model

of complete independence or uncorrelatedness among the measured

variables and adjusts for sample size (Bentler 1990, 1992). Values of

0.9 or higher are desirable and indicate that 90 percent or more of the

covariation in the data is able to be reproduced by the hypothesized

model (Bentler and Stein 1992).

Confirmatory Factor Analyses. Initial CFAs were performed with each

hypothesized latent construct predicting its manifest indicators. All

latent constructs were intercorrelated without any imputation of causality among them. This analysis tested the adequacy of the factor structure (measurement model) and assessed associations among the nine

latent variables. In the CFA for the Latinas, the manifest variable of

acculturation level was correlated with each latent variable. In addition,

the factor structure and relationships among the latent variables for the

two ethnic groups (excluding acculturation) were compared with

multiple group analyses.

Path Model. Once a well-fitting CFA model was developed for each

group, a predictive path model was explored in which self-esteem, social

resources, and emotional disturbance were intercorrelated background

factors that were hypothesized to predict threat appraisal, barriers to

condom use, active coping, avoidant coping, AIDS risk behavior, and

specific drug use behavior. In turn, threat appraisal was conceptualized

as a mediating variable that predicted barriers to condom use, active

and avoidant coping, and the AIDS and specific drug use behaviors.

In turn, barriers to condom use, active coping, and avoidant coping

were conceived as further predictors of the outcomes of AIDS risk and

specific drug use behaviors. For the Latinas, the manifest indicator of

acculturation level was a further covariate with the three predictor

constructs and another predictor of the mediating and outcome latent

variables. Nonsignificant paths and covariances were dropped gradually,

following the procedure of MacCallum (1986), until a final model
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emerged with all remaining paths having parameter estimate/standard

error ratios of at least 2:1, which corresponds to a z-score of 2.00. The

authors did not want to capitalize on marginally significant paths in

samples of such a large size. Modification indices from the Lagrange

Multiplier (LM) test (Chou and Bentler 1990) were examined to

determine whether any additional paths or covariances between error

residuals should be included. These were included only if they were

theoretically plausible.

RESULTS

Confirmatory Factor Analysis

Table 1 presents the factor loadings for the final CFA model for the

two ethnic groups. The factor loadings were similar across the groups

for most of the latent constructs, although multiple group analyses

revealed some substantive differences between the groups (see details

below), and the goodness-of-fit indices indicated that the hypothesized

factor structure was feasible for both groups. In addition, all manifest

variables loaded significantly (p<0.001) on their hypothesized latent

factors. Table 2 presents the correlations among the latent variables.

Latinas’ CFA. The initial CFA, with all covariances between constructs included, had the fit indices 2

 (483, n=691)=1,703.92,

CFI=0.88, indicating a fit not as good as desired. After the addition of

seven theoretically defensible covariances between error residuals and

one complex factor loading based on suggestions from the LM test, the

chi-square value decreased substantially, and the CFI improved considerably: 2

 (475, n=691)=1,080.46, CFI=0.94. The chi-square/degrees of

freedom ratio was very close to the 2:1 criterion, and the CFI was well

over 0.90. The complex factor loading allowed “less condom use” to

load on barriers to condom use as well as its initially hypothesized latent

factor of AIDS risk behavior.

African-American Women’s CFA. The initial CFA, performed with

the randomly selected set of African-American women, was the same

initial model that was hypothesized for the Latinas except that acculturation was not included as an additional covariate with the latent

factors. Results showed only a moderate fit: 2 (459, n=714)=1,325.96,

CFI=0.90. With the addition of six correlated error residuals and the

same complex factor loading that was added for the Latino women (“less
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TABLE 2. Correlations among latent variables for Latino (n=691) and

African-American women (n=714)*

Latent Variable 1 2 3 4 5 6 7 8 9

Self-esteem .29c –.78c –.51c –.30c.24c –.40c –.39c –.20c

Social resources .34c –.26c –.07a –.04c.23c –.08a –.11b –.10b

Emotional –.76c –.33c –.73c –.28c –.14b.51c –.44c –.13b

 disturbance

Threat appraisal –.58c –.21c.83c.31c.05 .41c.46c.11b

Barries to –.06c.12b.11a.23c –.08 .14b.74c.08a

 condom use

Active coping .19c.30c –.03 .09a.16c.05 –.20c –.15c

Avoidant coping –.30c.04 .41c.36c.05 .27 –.22c.02

General AIDS –.43c –.11b.52c.55c.39c –.02 .23c.20c

 risk behaviors

Specific drug –.23c.05 .29c.36c.13b.14b.29c.52c

 use behaviors

Acculturation† –.05 .24c.15c.14c.19c.31c.28c.31c.42c

*Latinas below diagonal, African-American women above diagonal.

†Latinas only.

ap<0.05

bp<0.01

cp<0.001

condom use” on barriers to condom use), the fit improved substantially:

2

 (452, n=714)=851.20, CFI=0.96. The CFI was quite high, and the

chi-square/degrees of freedom ratio was less than 2:1. The randomly

derived validation subsample (n=731) was also tested with the final

factor model to be sure that the authors were not capitalizing on chance

relationships in the data that generated the significant supplementary

correlated error residuals. The fit indices were also good for the validation subsample 2

 (452, n=731)=923.08, CFI=0.95; the supplementary

covariances and the complex factor loading added for the final model

were equally significant in the validation sample.

Multiple Group Comparisons. The initial factor structure (measurement model) of the two ethnic groups was compared with a multiple

group comparison analysis. The chi-square difference between a model

with the factor loadings constrained to equality between the groups and

a nonconstrained model was 270.91 with 33 degrees of freedom. This is

a significant difference and indicates that the factor structures were not

comparable in all respects across the groups. The LM test reported that

six factor loadings were contributing in particular to the significant

difference between the two factor structures. These included all three
379

indicators on the specific drug use behaviors factor (drug use, injection

drug use, and sharing needles), less condom use and number of sexual

partners on the general AIDS risk behaviors factor, and “try to have

control over the problem” on the active coping factor. When the constraints on these indicators were dropped, the chi-square/degrees

of freedom ratio for the chi-square difference improved considerably,

although it was still significant (90.75, degrees of freedom=27). It was

concluded that there were important behavioral differences between

the two groups, especially on the AIDS risk and drug use behavioral

measures. These results provided further justification for the separate

analyses by ethnic group.

Path Analysis

Latinas. The fit of the final path model for the Latinas was quite good:

2

 (492, n=691)=1,013.16, CFI=0.95. Figure 1 presents the final path

model with all significant paths and covariances included (for readability,

manifest indicators are not depicted).

In the model for the Latinas, self-esteem and social resources were

positively related, and both were negatively related to emotional disturbance. Threat appraisal was directly predicted solely by greater emotional

disturbance. Barriers to condom use were predicted by greater social

resources, greater threat appraisal, and greater acculturation. Active

coping was predicted by greater self-esteem, greater social resources,

greater threat appraisal, and higher acculturation. Avoidant coping

was predicted by greater social resources, greater emotional disturbance,

and higher acculturation.

General AIDS risk behavior among the Latinas was predicted by

greater barriers to condom use, less self-esteem, greater threat appraisal,

less active coping, and higher acculturation. Specific drug use behavior

was predicted by threat appraisal, avoidant coping, and higher acculturation. Specific drug use and general AIDS risk behaviors were positively

related.

African-American Women. The path model for the African-American

women is presented in figure 2. The fit of the model is also quite good,

with 2 (469, n=714)=859.08, CFI=0.96.

Self-esteem and social resources were positively correlated as expected; both of these resources were negatively correlated with emotional
380

disturbance. Threat appraisal was predicted by greater emotional disturbance. There was no significant predictive path between self-esteem

and threat appraisal, although they were highly correlated in the CFA.

That relationship was mediated by emotional disturbance.

Barriers to condom use were predicted by less self-esteem and greater

threat appraisal. Active coping was predicted by greater self-esteem,

greater social resources, and greater threat appraisal. Avoidant coping,

on the other hand, was significantly predicted only by greater emotional

disturbance.

General AIDS risk behavior was predicted by greater barriers to

condom use, greater threat appraisal, and less active coping. Avoidant

coping was not a significant predictor of general AIDS risk behavior

but did significantly predict more specific drug use behavior.

FIGURE 1. Final structural model and standardized estimates for

Latinas. Large circles designate latent variables; rectangle

represents single-indicator construct of acculturation;

small circles indicate residual variances. Path coefficients

are indicated with single-headed arrows; double-headed

arrows represent correlations between constructs.

*p<0.05

†p<0.01

‡p<0.001
381

The final model was also tested with the validation sample for the

African-American women. The fit indices were good, with 2 (469,

n=731)=948.23, CFI=0.95. One predictive path that was significant

for the original sample was not significant for the validation sample: the

predictive path of barriers to condom use on specific drug use behavior.

Considering the large number of parameters estimated in the model,

having one discrepancy is not unsatisfactory or unexpected.

DISCUSSION

The primary objective of this study was to evaluate the role of

personal and social resources, threat appraisal processes, coping styles,

and barriers to risk reduction as predictors of AIDS risk and drug use

behaviors in impoverished women at risk for AIDS. The theoretical

model of relationships among various psychosocial characteristics was

effective in predicting risky AIDS behaviors among two groups of women

at high risk for AIDS. As predicted by the hypothesized model, selfesteem was associated with social resources, and self-esteem and social

FIGURE 2. Final structural model and standardized estimates for

African-American women. Large circles designate latent

variables; small circles indicate residual variances. Path

coefficients are indicated with single-headed arrows;

double-headed arrows represent correlations between

constructs.

*p<0.01

†p<0.001
382

resources were inversely associated with emotional disturbance for both

African-American and Latino women. Greater self-esteem and social

resources also directly predicted active coping for both groups. Active

coping was, in turn, associated with fewer general AIDS risk behaviors

for both ethnic groups and less specific drug use behavior among the

African-American women. Among Latinas, self-esteem directly influenced general AIDS risk behaviors and also indirectly through active

coping. Social resources, on the other hand, influenced AIDS risk

behavior indirectly through barriers to condom use and active coping.

Social resources also influenced specific drug use behavior indirectly

through barriers to condom use and avoidant coping.

Neither self-esteem nor social resources significantly predicted

threat appraisal in the women. Certainly one implication of this is that

threat appraisal is more strongly associated with other more important

factors such as emotional disturbance, which also had strong and independent effects on risk behavior. Although causal implications are not

possible because of the cross-sectional nature of the data, results may

indicate that health care practitioners and social scientists should assist

in reducing the emotional-disturbance level of impoverished women.

Lowered emotional disturbance may subsequently lessen threat appraisal

and its association with adverse behaviors. Further research is warranted

on this relationship.

The fact that lower self-esteem predicted barriers to condom use

among African-American women, whereas social resources predicted

barriers to condom use among Latinas, points to important cultural

differences that should guide the educational and outreach efforts of

practitioners and social scientists. These findings suggest the importance of a theoretical distinction between personal and social resource

variables. These resources differed in function from each other and

between the two ethnic groups. For instance, self-esteem enhancement

to increase condom use may be an important intervention for impoverished African-American women. However, the evidence suggests that

social resources inhibit risky behaviors among African-American women

but predict more barriers to condom use among Latinas. This relationship may be understood from the traditional sociocultural and religious

norms among Hispanics, which forbid or strongly discourage use of

condoms (Marin 1989; Marin and Marin 1992). Thus, culturally

specific interventionists might consider including direct attention to
383

reducing barriers to condom use among African-American women

through self-esteem enhancement. Although there is little empirical

research on impoverished women with which to compare these findings,

Tashakkori and Thompson (1992) reported that self-esteem was associated with intentions to take precautions against contracting AIDS

among young African-American men in college. However, for Latinas,

family and community education may be necessary to encourage reduction of barriers to condom use. Moreover, because barriers to condom

use were predicted by greater threat appraisal and higher acculturation

among Latinas, support is provided for interventions, directed at more

acculturated women, that target cognitive appraisal processes and

enhance socially approved self-efficacy skills in risk reduction, rather

than employing threat appeals (Jemmott et al. 1992; Rippletoe and

Rogers 1987).

Moreover, the sexual partner’s support for condom use was significantly related to increased condom use intentions. Longitudinal studies

are now warranted to study the impact of such interventions on actual

condom use, particularly with objective measures such as new incidence

of STDs, pregnancy, and HIV seropositivity.

The two types of coping styles also function quite differently from

each other and relatively differently in the two groups. For Latinas,

more background factors, such as acculturation and emotional disturbance, predicted more avoidant coping than for African-Americans;

active coping predicted less general AIDS risk behavior; and avoidant

coping predicted more specific drug use behavior. For the AfricanAmerican women, an active coping style predicted less general AIDS

risk and specific drug use behaviors, and an avoidant style predicted

more specific drug use behavior. A previous intervention directed at

coping enhancement has demonstrated improved coping responses

(Nyamathi et al. 1993c); designing culturally sensitive coping enhancement training may prove worthwhile.

The finding that drug use behavior was predicted by high threat

appraisal and avoidant coping for both groups is supported by other

researchers who report that impoverished women cope with stresses

by using drugs (Hser et al. 1987; Reed and Moise 1987, pp. 114-128).

However, higher acculturation was also a predictor for specific drug use

and general AIDS risk behaviors among Latinas. Higher acculturation

may be a “mixed blessing” for Latino women who may not yet have
384

replaced traditional standards and values with those equal to what they

have given up to become more Americanized. As these analyses suggest,

higher acculturation, although positively associated with more active

coping and greater social resources, is also associated with more specific

drug use and more general AIDS risk behaviors. Less acculturated

Latinas may be more responsive to their societal proscriptions against

the use of drugs and promiscuous behavior, particularly during the

childbearing and childrearing phases of their lives. Thus, the impoverished and yet more acculturated Latino and African-American women

may be the ones to target for educational outreach about negative

consequences of drug addiction on fetal and neonatal development

(Madden et al. 1986), parenting dysfunction, and loss of custody of

their children (Miller and Downs 1993).

NOTE

1. Source: Nyamathi et al. 1995. Copyright © 1995 by the American

Psychological Association (Washington, DC). Adapted with permission.

REFERENCES

Bentler, P.M. Comparative fit indexes in structural models. Psychol Bull

107:238-246, 1990.

Bentler, P.M. EQS Structural Equations Program Manual. Los Angeles: BMDP

Statistical Software, 1992.

Bentler, P.M., and Stein, J.A. Structural equation modeling in medical research.

Stat Meth Med Res 1:159-181, 1992.

Bentler, P.M., and Wu, E.J.C. EQS/Windows User’s Guide. Los Angeles: BMDP

Statistical Software, 1993.

Centers for Disease Control and Prevention. HIV/AIDS Surveillance Rep 5(1),

April 1993.

Centers for Disease Control and Prevention. HIV/AIDS Surveillance Rep 7(2),

1995.

Centers for Disease Control and Prevention. Update: Mortality attributable

to HIV infection among persons aged 25-44 years, United States, 1994.

MMWR Morb Mortal Wkly Rep 45:121-125, 1996.

Chou, C.P., and Bentler, P. Model modification in covariance structure

modeling: A comparison among likelihood ratio, Lagrange Multiplier,

and Wald tests. Multivariate Behav Res 25:115-136, 1990.
385

Coopersmith, S. The Antecedents of Self-Esteem. San Francisco: W.H. Freeman,

1967.

Derogatis, L., and Cleary, P. Confirmation of the dimensional structure of the

SCL-90: A study in construct validation. J Clin Psychol 33:981-989, 1977.

Fawzy, F.I.; Cousins, N.; Fawzy, N.W.; Kemeny, M.E.; Elashoff, R.; and Morton,

D. A structured psychiatric intervention for cancer patients: Changes over

time in methods of coping and effective disturbance. Arch Gen Psychiatry

47:720-725, 1990.

Folkman, S.; Lazarus, R.S.; Dunkel-Schetter, C.; De Longis, A.; and Gruen, R.

Dynamics of a stressful encounter: Cognitive appraisal, coping, and

encounter outcomes. J Pers Soc Psychol 50:992-1003, 1986.

Gass, K., and Chang, A. Appraisals of bereavement, coping, resources, and

psychosocial health dysfunction in widows and widowers. Nurs Res 38:31-

36, 1989.

Gutierres, S., and Reich, J. Attributional analysis of drug abuse and gender:

Effects of treatment and relationship to rehabilitation. J Soc Clin Psychol

7:176-191, 1988.

Hobfoll, S. Stress resistance in times of illness: Further applications of the

models of ecological congruence and conservation of resources. In: Hobfoll,

S., ed. The Ecology of Stress. New York: Hemisphere, 1988.

Hser, J.I.; Anglin, M.D.; and McGothlin, W. Sex differences in addict career. I.

Initiation of use. Am J Drug Alcohol Abuse 13(1&2):33-57, 1987.

Ickovics, J., and Rodin, J. Women and AIDS in the United States:

Epidemiology, natural history, and mediating mechanisms. Health Psychol

11:1-16, 1992.

Jalowiec, A., and Powers, M.J. Stress and coping in hypertensive and emergency

room patients. Nurs Res 30:10-15, 1981.

Jemmott, J.B.; Jemmott, L.S.; and Fong, G.T. Reductions in HIV risk-associated

sexual behavior among black male adolescents: Effects of an AIDS

prevention intervention. Am J Public Health 82:372-377, 1992.

Kobasa, S.C.; Maddi, S.R.; Puccetti, M.C.; and Zola, M. Effectiveness of

hardiness, exercise, and social support as resources against illness.

J Psychosom Res 29:525-533, 1985.

La Gory, M.; Ritchey, F.; and Mullis, I. Depression among the homeless.

J Health Soc Behav 31:87-101, 1990.

Lazarus, R.S., and Folkman, S. Stress, Appraisal, and Coping. New York:

Springer, 1984.

MacCallum, R. Specification searches in covariance structure modeling.

Psychol Bull 100:107-120, 1986.
386

MacCallum, R.C.; Wegener, D.T.; Uchino, B.N.; and Fabrigar, L.R. The

problem of equivalent models in applications of covariance structure

analysis. Psychol Bull 114:185-199, 1993.

Madden, J.D.; Payne, T.F.; and Miller, S. Maternal cocaine abuse and effects

on the newborn. Pediatrics 77:209-211, 1986.

Marin, B.V., and Marin, G. Predictors of condom accessibility among Hispanics

in San Francisco. Am J Public Health 82(4):592-595, 1992.

Marin, G. AIDS prevention among Hispanics: Needs, risk behaviors, and

cultural values. Public Health Rep 104(5):411-415, 1989.

Marin, G.; Sabogal, R.; Marin, B.; Otero-Sabogal, R.; and Perez-Stable, E.

Development of a short acculturation scale for Hispanics. Hispanic J Behav

Sci 9:183-205, 1987.

McNair, D.; Lorr, M.; and Droppleman, L. Profile of States. San Diego, CA:

Educational and Industrial Testing Service, 1981.

Miller, B.A., and Downs, W.R. The impact of family violence on the use of

alcohol by women. Alcohol Health Res World 17(2):137-143, 1993.

Mondanaro, J. Strategies for AIDS prevention: Motivating health behavior in

drug dependent women. J Psychoactive Drugs 19(2):143-149, 1987.

Muhlenkamp, A.F., and Sayles, J.A. Self-esteem, social support, and positive

health practices. Nurs Res 35:334-338, 1986.

Namir, S.; Wolcott, D.; Fawzy, F.; and Alumbaugh, M. Coping with AIDS:

Psychological and health implications. J Appl Soc Psychol 17:309-328, 1987.

Nyamathi, A. Comprehensive health seeking and coping paradigm. J Adv Nurs

14(4):281-290, 1989.

Nyamathi, A. Relationship of resources to emotional distress, somatic

complaints, and high-risk behaviors in drug recovery and homeless

minority women. Res Nurs Health 14(4):269-277, 1991.

Nyamathi, A. A comparative study of factors relating to HIV risk level of black

homeless women. J Acquir Immune Defic Syndr 5:222-228, 1992.

Nyamathi, A.; Bennett, C.; Leake, B.; Lewis, C.; and Flaskerud, J. AIDS-related

knowledge, perceptions, and behaviors among impoverished minority

women. Am J Public Health 83:65-71, 1993c.

Nyamathi, A.; Leake, B.; Flaskerud, J.; Lewis, C.; and Bennett, C. Outcomes of

specialized and traditional AIDS counseling programs for impoverished

women of color. Res Nurs Health 16:11-21, 1993b.

Nyamathi, A.; Stein, J.A.; and Brecht, M.L. Psychosocial predictors of AIDS

risk behavior and drug use behavior in homeless and drug-addicted women

of color. Health Psychol 14(3):265-273, 1995.

Nyamathi, A.; Wayment, H.; and Dunkel-Schetter, C. Psychosocial correlates

of emotional distress and risk behavior in African-American women at risk

for HIV infection. Anxiety Stress Coping 6:133-148, 1993a.
387

Radloff, S. The CES-D scale: A self-report depression scale for research in the

general population. Appl Psychol Meas 1:385-401, 1977.

Reed, B., and Moise, R. Implications for treatment and future research. In:

Addicted Women: Family Dynamics, Self Perceptions, and Support Systems.

DHEW Publication No. (ADM)80-762. Washington, DC: Supt. of Docs.

U.S. Govt. Print. Off., 1987.

Rippletoe, P.A., and Rogers, R.W. Effects of components of protectionmotivation theory on adaptive and maladaptive coping with a health

threat. J Personal Soc Psychol 52:596-604, 1987.

Rosenstock, I.; Strecher, V.; and Becker, M. Social learning theory and the

health belief model. Health Educ Q 15:175-183, 1988.

Schlotfeldt, R. Nursing in the future. Nurs Outlook 29:295-301, 1981.

Tashakkori, A., and Thompson, V.D. Predictors of intention to take precautions

against AIDS among black college students. J Appl Soc Psychol 22(9):736-

753, 1992.

Tucker, B.M. Social support and coping: Applications for the study of female

drug abuse. J Soc Issues 38:117-137, 1982.

Weisman, A.; Worden, J.; and Sobel, H. Psychosocial Screening and Intervention

With Cancer Patients: Research Report. Cambridge, MA: Shea Bros., 1980.

Wofsy, C.B. Human immunodeficiency virus infection in women. JAMA

257:2074-2076, 1987.

ACKNOWLEDGMENT

This research was supported by National Institute on Drug Abuse

grants DA-05565-05 and DA-01070.

AUTHORS

Adeline Nyamathi, R.N., Ph.D., F.A.A.N.

Associate Professor

School of Nursing

University of California, Los Angeles

(310) 825-8405 (Tel)

(310) 206-7433 (Fax)

anyamathi@sonnet.ucla.edu (E-mail)
388

Judith A. Stein, Ph.D.

Research Psychologist

University of California, Los Angeles

Department of Psychology

(310) 825-1396 (Tel)

(310) 206-4315 (Fax)

jastein@ucla.edu (E-mail)

Mary-Lynn Brecht, Ph.D.

Principal Statistician

School of Nursing

University of California, Los Angeles

(310) 825-5114 (Tel)

(310) 206-7433 (Fax)

lbrecht@sonnet.ucla.edu (E-mail)

10833 Le Conte Avenue

Los Angeles, CA 90024-6918