The Relationship between Religiosity and Drug Use ... - Springer Link

Journal of Religion and Health, Vol. 45, No. 1, Spring 2006 (Ó 2006) DOI: 10.1007/s10943-005-9005-6

The Relationship between Religiosity and Drug Use among ‘‘At Risk’’ Women HUGH KLEIN, KIRK W. ELIFSON, and CLAIRE E STERK ABSTRACT: This study focuses on the interplay between religiosity and drug use in a sample of 250 adult women from the Atlanta, Georgia metropolitan area who were interviewed between August 1997 and August 2000. The research addresses two principal questions: (1) Is there a relationship between the level of religiosity and the amount of illegal drug use reported? (2) If so, is this relationship maintained in multivariate analysis when the eects of other potentially relevant factors like demographic characteristics, childhood maltreatment experiences, psychosocial traits, and substance user-related measures are taken into account? We found that religiosity is related to the amount of drugs women used. Four variables were retained in the final multivariate drug use prediction model: religiosity, coping with everyday stresses, number of family members who are substance abusers, and amount of oral sex. Greater amounts of drugs were used by women who were less religious, less capable of coping with stress, had more drug-abusing family members, and reported having more oral sex. Together, these items explained nearly one-fifth of the variance in the dependent variable. The implications for substance abuse prevention and intervention eorts are discussed. KEY WORDS: religiosity; drug use; substance use; women.

Hugh Klein is a senior researcher working in the Rollins School of Public Health at Emory University and in the Department of Sociology at Georgia State University. His interests include substance use/abuse, HIV/AIDS, sexual behavior, and the mass media. His most recent research has focused on such topics as self-esteem and HIV risk, predictors of suicidal ideation, reasons why ‘‘at risk’’ women do not use condoms, and HIV risk behaviors among women who do not consider themselves to be at risk for contracting HIV. Claire E. Sterk is a professor in the Department of Behavioral Sciences and Health Education in the Rollins School of Public Health at Emory University. Her main interests include substance use/abuse, qualitative research methods, HIV/AIDS, and women’s health. Along with Kirk Elifson, she currently heads up a federally funded research study focusing on family relationships and drug use among young adults, and recently has worked on a few community-based projects targeting substance use/abuse and HIV risk behaviors in ‘‘at risk’’ women. Kirk W. Elifson is a professor in the Department of Sociology at Georgia State University. His main interests include substance use/abuse, quantitative research methods, and HIV/AIDS. Along with Claire Sterk, he currently heads up a federally funded research study focusing on family relationships and drug use among young adults, and recently worked on one research project targeting new users of heroin or methamphetamine and another research study focusing on users of the drug, ecstasy. Correspondence to Hugh Klein, 401 Schuyler Road, Silver Spring, MD, 20910, USA, E-mail: [email protected]. 40

Ó 2006 Blanton-Peale Institute

Hugh Klein, Kirk W. Elifson, and Claire E. Sterk

41

Introduction During the past decade, researchers have paid increasing attention to the impact that religious organizations can have upon a variety of health practices. Some, for example, have focused attention on the role that church-based programs can have upon reducing tobacco use and enhancing rates of smoking cessation. The results of these endeavors appear promising, suggesting that such programs are able to assist smokers who participate in church-based activities to stop using tobacco (Schorling et al., 1997; Stillman et al., 1993; Voorhees et al., 1996; Winett et al., 1999). Likewise, faith-based initiatives have been shown to be effective at helping people become involved in regular physical exercise (Kumanyika & Charleston, 1992; Sutherland, Hale, & Harris, 1995; Turner et al., 1995), enhance their nutrition (Kumanyika & Charleston, 1992; Turner et al., 1995), learn about and reduce their cholesterol levels (Flack & Wiist, 1991), reduce overall cardiovascular risk (Ferdinand, 1997; Oexmann et al., 2000), have mammographies (Derose et al., 2000; Fox et al., 1998), increase their knowledge about and have themselves screened for prostate cancer (Boehm et al., 1995), and reduce the perpetration of domestic violence (Strickland, Welshimer, & Sarvela, 1998). For the purposes of the present research, it is particularly noteworthy that many of these programs have targeted African Americans and achieved great success with members of this population. Despite research findings that religious and faith-based organizations can have a positive impact upon health behaviors, very little research has been done to examine their potential role in helping to educate people about substance use-related matters. In fact, much of the scholarly literature addressing the relationship of religiosity to drug use has focused on adolescents and the protective role that religiosity plays in their drug use. Most of these studies have found that adolescents who are not religious or who score lower on measures of religiosity typically report more substance use and substance abuse than adolescents who are more highly religious (Amey, Albrecht, & Miller, 1996; Cochran, Wood, & Arneklev, 1994; Hardert & Dowd, 1994; Kutter & McDermott, 1997; Miller, Davies, & Greenwald, 2000). Similar findings were also obtained by Free (1994) in his study of alcohol use among college students. Studies examining the nexus of religiosity and drug use/abuse among adults are fewer in number, but have derived analogous findings. For example, looking at drug use in the workplace, Lehman and colleagues (1995) discovered that the less frequently people attended church, the more they tended to use drugs at work. In their study of religiosity among female twins, Kendler, Gardner, and Prescott (1997) learned that greater personal devotion to religious beliefs corresponded with less alcohol use and a lowered lifetime risk for developing alcoholism. Based on their treatment-related outcomes research,

42

Journal of Religion and Health

Richard, Bell, and Carlson (2000) concluded that increasing church attendance led to reduced alcohol use and reduced cocaine use among people in their study. In the present study, we examine the relationship between the level of religiosity and the extent of drug use among adult urban women. The research addresses two principal questions: (1) Is there a relationship between the level of religiosity and the amount of illegal drug use reported? (2) If so, does this relationship ‘‘hold up’’ in multivariate analysis when the effects of other potentially relevant factors like demographic characteristics, childhood maltreatment experiences, psychosocial traits, relationship qualities, substance use-related measures, and sexual behaviors are taken into account? This study contributes to the existing body of literature in a number of ways. First, it examines the relationship between religiosity and substance use in a sample of adults, about whom, to date, little has been reported in the scientific literature on this particular topic. Second, the present study focuses on illegal drug use in general, rather than on one specific type of drug, as many of the previous studies have done. This enables us to examine the general interplay between religiosity and substance abuse rather than having to limit our findings to one specific type of drug or another. Third, this research utilizes a multivariate statistical analysis approach. Analytically, this technique is more sophisticated than most of the previously published studies examining religiosity and drug use, and it enables us to address the issue of whether or not religiosity influences women’s drug use even when the effects of other relevant variables are taken into account.

Methods Overview and sample The data for this study came from Project FAST, which was conducted between August 1997 and August 2000 in the Atlanta, Georgia metropolitan area. One of the principal goals of this 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 as experiencing any combination of a variety of life challenges, including, among others, the following seven characteristics. First, all of the women lived in areas known for having high rates of drug abuse (see below). Second, most (68%) were either active users of illegal drugs and/or had an immediate family member who was a substance abuser. Third, being impoverished was typical for women in this study. The median annual personal income was $4,200 and the median annual household income was approximately $9,600, both of which are well below the federally established poverty line. Fourth, a sizable proportion of Project FAST women lacked adequate medical care and/or related insurance. During the preceding year,


43

20% of the women reported not receiving needed medical care during the preceding year and 30% said that they were not covered by health insurance of any kind. Fifth, low education levels typified this sample, with 40% of the participants having not completed high school or its equivalent. Sixth, employment problems were common among women in Project FAST, such that 39% were unemployed and 9% were unable to work due to disability. Finally, many of these ‘‘at risk’’ women had a criminal history. Half had been arrested at least once before and more than half of the arrested women (57% of them) had been arrested two or more times. A sizable proportion of the women who had been arrested (36%) reported that their most recent arrest had taken place during the preceding year. As all of the preceding information indicates, the ‘‘at risk’’ women who took part in Project FAST tended to experience challenges and difficulties in a variety of domains in their lives. In all, 250 women participated in this study. Most (88%) were racial minority group members, predominantly African American. The median age was 35 (mean=35.3, s.d.=13.2, range=18–72). About half (53%) of the women were single and one-quarter (25%) were married or living as married at the time of their interview. Eligibility In order to participate in the study, several eligibility criteria had to be met. Each woman had to live in one of the study’s catchment areas. 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’’ 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

44


her participation and offered referrals to local health/social service agencies, as appropriate. Measures used All of the data in Project FAST were based on self-reports. An interaction term measuring religiosity served as the principal independent variable in these analyses. This variable was created by multiplying scores on a worship service attendance question (a five-point ordinal measure of the frequency of attending worship services, with responses ranging from ‘‘not at all’’ to ‘‘weekly or more’’) by scores on a religious influence question (a four-point ordinal measure assessing how strongly women felt that their religious group’s beliefs affected their behaviors, with responses ranging from ‘‘not at all’’ to ‘‘strongly’’). Higher scores indicated greater overall religiosity. In addition to examining the relationship between religiosity and amount of drug use, we also looked at a number of other variables that might be associated with substance use. The items chosen for consideration were based on the findings of numerous published studies indicating the relevance of these factors to understanding differences in drug-using behaviors among women. Demographic and background variables used included age (coded as a continuous variable), race (coded as African American or other-than-African American), educational attainment (coded as less than high school graduate, high school graduate or equivalent, and at least some college education), marital status (coded as married or living as married versus other-thanmarried), and homelessness status (coded as homeless or domiciled). Childhood maltreatment variables examined included sexual abuse, physical abuse, emotional abuse, neglect,1 and one additional measure that indicated whether or not the person had been victimized in all four of these ways. Four psychosocial measures were also examined, including assessments of self-esteem (a continuous scale measure based on Rosenberg’s (1965) self-esteem scale)(Cronbach alpha = .84), depression (a continuous scale measure based on the Depression and Anxiety Stress Scale 42 [DASS 42] developed by Lovibond & Lovibond (1995))(Cronbach alpha = .86), optimism about the future (a continuous scale measure derived from five items)(Cronbach alpha = .64), and coping with everyday stresses (a continuous scale measure derived from the Ways of Coping Questionnaire (Folkman & Lazarus, 1988) (Cronbach alpha = .63). Two measures were used to examine women’s relationships and experiences with others. One assessed the overall closeness of the relationships the respondent had with close family members and friends (a scale measure derived from Armsden & Greenberg’s (1987) Inventory of Parent and Peer Attachment questionnaire)(Cronbach alpha = .81). The other assessed the openness of communications the person had with her dating/sexual partners (a scale measure comprised by responses to seven items)(Cronbach alpha = .81). Five substance abuse-related measures were also included in the analyses. Among these were variables examining the amount of alcohol use


45

reported during the 30 days prior to interview (a continuous measure), living with any person(s) who were substance users/abusers (coded yes/no), having two parents with substance abuse problems (coded yes/no), the number of family members with alcohol and/or other drug problems (a continuous measure), and the age of first drug use (a continuous measure). Finally, seven sexual behavior variables were examined.2 These included the amount of oral sex during the previous 90 days (regardless of the partner type(s) involved; a continuous measure), the amount of vaginal sex during the previous 90 days (regardless of the partner type(s) involved; a continuous measure), the number of times having sex with a main partner (regardless of the type(s) of sex involved; a continuous measure), number of times having sex with friends or acquaintances (regardless of the type(s) of sex involved; a continuous measure), the number of times having sex with paying partners (regardless of the type(s) of sex involved; a continuous measure), the total number of times having sex of any kind (regardless of sex type or partner type; a continuous measure), and the average frequency of engaging in risky sexual relations (a continuous scale measure based on responses to each of seven different types of risky sex) (Kuder–Richardson-20 = .79). The dependent measure used in these analyses assessed the total amount of illegal drug use reported during the 30 days prior to interview. Study participants were asked separate questions about their use of crack cocaine, powder cocaine, heroin, speedball, methadone, other opiates, amphetamine, marijuana, and a catch-all ‘‘other drugs’’ category. For each item, they indicated the number of days on which they used each drug during the preceding month and the average number of times per day they used each drug type. The frequency-of-use and times-per-day responses were multiplied for each drug type (to determine the number of times that each drug type was used during the month prior to interview), and then summed across all drug types (to determine the total amount of illegal drug use reported during the month prior to interview). This summative measure was the dependent variable used in these analyses. Values ranged from 0 (indicating no drug use during the previous month) to 910 (indicating an average of slightly more than 30 times using drugs per day) (mean = 39.3, SD = 116.1). Analysis A stepwise multiple regression approach was used to examine the relationship between the religiosity variable and women’s drug use. Initially, the religiosity variable was entered into a simple regression equation, to determine if it was a statistically significant predictor of the outcome measure. It was. Next, the bivariate relationships between the other predictor variables listed earlier were examined one by one, using Student’s t tests whenever the independent variable was dichotomous, analysis of variance whenever the independent variable was categorical or ordinal in nature with fewer than five response levels, and simple regression whenever the independent variable was ordinal

46


in nature with five or more response levels, or if it was continuous in nature. Items that were found to be marginally-significant (.15>p>.05) or statistically-significant (p < .05) predictors in these bivariate analyses were selected for entry into the multivariate equation. This was done one category at a time, until items from all of the categories of independent variables had been examined. The order in which they were entered into the multivariate equation was: religiosity, demographic, childhood maltreatment, psychosocial, relationships with others, substance abuse-related, and sexual behaviors, respectively.3 Results are reported as statistically significant whenever p < .05.

Results Religiosity As Table 1 shows, religiosity was found to be related to women’s drug use (p < .001). The more religious women were, the less illegal drug use they reported.

Demographic variables None of the demographic variables examined was related to the amount of drugs women used. Educational attainment and marital status were marginally significant (p < .15), though. The indication in the data was that more drug use was reported by women who were less well educated compared to those who had more years of schooling, and by those who were married or living as married compared to those who were not. These variables were entered into the multivariate equation along with the religiosity item. In the multivariate model, marital status remained a marginal contributor and was retained. Educational attainment was not significant in the multivariate equation and, therefore, was dropped from the model and excluded from further consideration. Childhood maltreatment Drug use was not related to any of the measures examined here. As a result, none of them was entered into the multivariate equation. Psychosocial measures Self-esteem was related to the amount of drug use reported (p < .01) such that women with higher levels of self-esteem reported less drug use. Likewise, having a greater ability to cope with everyday stresses corresponded with less drug use (p < .001). Both depression and optimism levels were associated weakly with drug use (p < .15 for both) such that somewhat more drug use

.064

)6.58 *** ()0.25)

p < .15, *p < .05, **p < .01, ***p < .001.

Closeness of Relationships Living with a Substance Abuser # of Drug-Using Family Members Amount of Oral Sex Frequency of Having Risky Sex R-squared

Optimism about the Future Coping with Stress

Depression

Self-Esteem

Educational Attainment Marital Status

Religiosity

Variable Entered

Religiosity b (b)

.078

)6.19 *** ()0.24) )23.33 ()0.09) 25.43 (0.09)

Demographic Variables b (b)

.108

–

22.64 (0.08) )2.14 ()0.02) 1.00 (0.01) )27.89 ()0.05) )35.87 ** ()0.20)

.122

22.11 (0.08) 1.17 (0.12) 1.39 *** (0.24) 14.76 (0.10) .192

27.11 (0.11) 1.15 * (0.12)

.094

)22.22 ()0.12) –

)27.70 * ()0.16) –

)32.00 ** ()0.19) )0.42 ()0.00)

–

–

–

–

)3.82 ()0.13) –

Sexual Behaviors b (b)

–

–

–

–

)4.93 ** ()0.18) –

Substance Use-Related b (b)

–

–

–

)4.92 ** ()0.19) –

Relationships with Others b (b)

)4.97 ** ()0.19) –

Psychosocial Measures b (b)

Developing a Multivariate Model Predicting Amount of Drug Use

TABLE 1

.181

1.22 * (0.13) 1.59 *** (0.28) –

–

)23.31 * ()0.14) –

–

–

–

–

)3.92 * ()0.15) –

Final model b (b)

Hugh Klein, Kirk W. Elifson, and Claire E. Sterk 47

48


was reported by women who were more depressed and those who were more optimistic about the future. All four of these measures were entered into the multivariate equation (see Table 1). Only one of them—coping—contributed significantly to the model. The other psychosocial variables were dropped from further consideration. Also, the addition of the coping measure to the equation rendered marital status nonsignificant and, consequently, that variable was excluded at this stage as well. Relationships with others Although the openness of women’s communications with their partners was not found to relate to the amount of drugs they used, their closeness of relationships with others did predict their drug usage (p < .05). The closer their relationships tended to be, the less drug use they reported. This item was entered into the multivariate equation. It did not contribute to the model’s explanatory power and, therefore, was dropped from further consideration. Substance use-related measures Two of the substance use-related measures were related to the amount of drug use reported. Women who lived with substance abusers reported about three times as much illegal drug use as those who said that they did not live with any substance abusers (p < .01). Also, the more family members women had who were drug abusers, the more drugs that they themselves tended to use (p < .05). These two measures were entered into the multivariate equation (see Table 1). The number of drug-abusing family members contributed significantly to the model and the ‘‘living with substance abusers’’ measure was a marginal contributor. As a result, both items were retained. Sexual behaviors All of the sexual behavior variables were found to be associated with the amount of drug use women reported. In all instances, more drug use was reported by women who reported greater involvement in the sexual behavior in question. Because some of the sexual behavior measures partially overlapped with one another,4 a separate stepwise multiple regression equation was conducted exclusively with these items before entering any of them into the multivariate model predicting women’s drug use. By relying upon the results of this stepwise procedure for the sexual behavior variables, only those that were the most consequential to developing an understanding of women’s drug use were considered. The results of this intermediate step in the analysis showed that the amount of oral sex was the best predictor (p < .001); the frequency of engaging in risky sex was the next best predictor (p < .15); and all


49

of the other sexual behavior variables were nonsignificant when examined in this multivariate fashion. Based on these findings, the oral sex and frequency of risky sex measures were entered into the multivariate equation along with the religiosity, coping with stress, living with substance abusers, and number of drug-using family members measures retained in the previous step in the multivariate model (see Table 1). The addition of these items into the model rendered some of the items previously entered into the model nonsignificant. Nonsignificant items were removed in a stepwise fashion, to derive the final, best-fit model, which is shown in the last column in Table 1. As a result of the stepwise elimination procedure, the ‘‘living with substance abusers’’ and ‘‘frequency of having risky sex’’ measures were removed from the model. All remaining items contributed significantly. Together, the four retained items explained 18.1% of the variance in women’s reported drug use. The final predictors included religiosity, coping with everyday stresses, number of drug-abusing family members, and amount of oral sex.

Discussion The principal research issue we wanted to address in this work was whether or not religiosity influenced women’s drug usage, particularly when other relevant factors were taken into account. Our analyses showed that religiosity is, indeed, related to drug use, such that women who were more religious tended to use drugs less than their counterparts who were less religious. Figure 1 depicts this quite well. This finding complements those obtained by other researchers, who have also reported an inverse relationship between various measures of religiosity and substance use/abuse (Free, 1994; Kendler, Gardner, & Prescott, 1997; Lehman et al., 1995; Trinkoff et al., 2000). Moreover, this relationship was strong enough that it held up even when the effects of other influential variables like demographic characteristics, childhood maltreatment experiences, psychosocial factors, relationship qualities, and other substance use-related factors were taken into account. The primary implication of this finding is that it might be beneficial to incorporate spirituality-enhancing or religiosity-boosting components into drug abuse prevention programs. Community-based program leaders may wish to consider collaborating with local clergy to try to find ways to get people—particularly those who are already members of a religious organization—to attend worship services more often and become more involved in religious organization-affiliated social and community activities. Such involvements, if successful, would increase the role that religiosity plays in people’s lives and, that, in turn, our research suggests, has a good chance of resulting in reduced drug usage among these persons. Such an approach has a considerable amount of support in the scientific literature. Richard, Bell, and

50


FIGURE 1 Level of Religiosity* and Amount of Drug Use (p < .0001)

*This is based on recoded values of the religiosity variable. The groups presented represent scores of 0 (very low/zero), 1–5 (low) 6–10 (moderate), and 11+ (high)

Carlson (2000) found that, when people increased their frequency of church attendance, concomitant reductions in their use of alcohol and cocaine resulted. Similarly, church-based programs have been successful at helping smokers to stop using tobacco (Schorling et al., 1997; Stillman et al., 1993; Winett et al., 1999). These results are very encouraging and suggest that a substance abuse prevention/intervention/educational approach availing itself of religious and spiritual community groups/leaders has promise. This conclusion is supported by the National Institute on Drug Abuse in its summary document, Lessons from Prevention Research (NIDA, 2001). There, the agency noted that Prevention programs should be designed to enhance ‘‘protective factors’’ and move toward reversing or reducing known ‘‘risk factors.’’ . . . Protective factors include strong and positive bonds within a prosocial family; parental monitoring; clear rules of conduct that are consistently enforced within the family; involvement of parents in the lives of their children; success in school performance; strong bonds with other prosocial institutions, such as school and religious organizations; and adoption of conventional norms about drug use (emphasis added).


51

In addition to our principal finding regarding religiosity, we would also like to discuss some of the other results derived by the present research, starting with our findings pertaining to coping. In this study, women who had better coping skills reported less drug use than those whose coping skills were less adaptive. The implication of this finding is clear: Programs designed to avert or reduce substance abuse and attendant problems would be wise to incorporate skills-building components into their overall approaches so that people can develop more adaptive ways of handling day-to-day stresses. Typically, researchers have found that programs that were successful in improving coping skills were also successful in improving drug abuse and/or abstinence rates. This has been found to be true for alcohol-related outcomes (Conrod et al., 2000; Walton, Blow, & Booth, 2000), cocaine abuse (Monti et al., 1997), and drug-related outcomes in general (Conrod et al., 2000; Miller, Meyers, & Hiller-Sturmhoefel, 1999; Moggi et al., 1999). We also discovered that the more family members that women had who were substance abusers, the more drug use they themselves tended to report. Learning that drug use runs in families is by no means a novel finding, since it has been documented on many occasions in the scientific literature (see, for example, Johnson & Leff, 1999; Kumpfer, 1999, and Luthar et al., 1992, among many others). What is most noteworthy, though, is that this finding indicates a need for substance abuse prevention programs to continue to view relatives of drug abusers as persons who are at high risk for developing drug problems themselves. It also suggests that a Control Theory-guided prevention approach would be wise, particularly if it targeted some of its efforts at women’s drug-using family members. If these individuals can be helped by such a program, there is good reason to believe that additional benefits might be derived by drug-using women themselves. That is, since drug abuse among family members corresponds with one’s own drug usage, if the former can be reduced, the latter probably will demonstrate subsequent decreases as well. Several programs that have implemented family intervention approaches in an effort to reduce the harms associated with a family member’s drug abuse have been discussed in the scientific literature. Generally speaking, these programs appear to have been successful at assisting affected family members and the drug abusers themselves to develop improved coping strategies, better health habits, stronger interpersonal interaction skills, and reduced drug usage (Catalano et al., 1999; Copello et al., 2000; Kirby et al., 1999). Finally, the present study found a strong, direct association between the number of times women had oral sex and the amount of drugs they used. To some extent, this relationship reflects the tendency for more seriously druginvolved women to engage in higher rates of sex-trading activities, which typically involve performing oral sex for their paying partners. Although this explanation applies to the present study sample, it fails to account for the relationship between drug use and oral sex for a substantial number of women in Project FAST. For example, among women who reported no drug use during

52


the prior month, 7.1% reported any sex trading activities during the previous year. For women who reported using drugs an average of no more than three times per day, sex trading was reported by 15.8% of the women. Among those using drugs three or more times per day, on average, the sex-trading rate was 27.0%. Clearly, although sex-trading activities may account for some of the observed relationship between oral sex and drug use among the women in this sample, other factors must also be operating here. Regardless of what accounts for the relationship, the finding itself has implications for intervention projects. It suggests that, for some women, drug use underlies their oral sex (and perhaps also their sex-trading) activities, and thus, people wishing to reduce HIV-related risks among such women need to address their drug use needs. Our finding of an association between oral sex and drug use also indicates that it is imperative to identify and target the underlying causes of women’s propensity to engage in both of these behaviors if we wish to reduce their overall levels of risk. Skills-building activities to teach women how to reduce their risky behaviors and psychoeducational components designed to improve psychological functioning (e.g., reduce depression, bolster self-esteem, improve coping skills, etc.) are likely to be effective ways of accomplishing this. Published research findings support this contention (Basen-Engquist, 1992; Ferreira-Pinto & Ramos, 1995; Folkman et al., 1992). Potential Limitations of This Research We would like to acknowledge three potential limitations of this research. First, the data collected as part of Project FAST were all 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 numerous authors have noted that persons in their research studies (which, like the present study, have included fairly large numbers of substance abusers) have provided accurate information about their behaviors (Anglin, Hser, & Chou, 1993; Higgins et al., 1995; Jackson et al., 2004; Nurco, 1985). A second possible limitation pertains to recall bias. Respondents were asked to report about their beliefs, attitudes, and behaviors during the past 30 days, the past 90 days, and the past 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 that 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, Georgia metropolitan


53

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,5 and there may be inherent biases in who was/not identified as potential study participants in Project FAST.

Acknowledgments This research was supported by a grant from the National Institute on Drug Abuse (R01-DA09819).

Notes 1. All four of these measures were based on experiences prior to age 18 and were coded as ‘‘happened’’ or ‘‘did not happen.’’ These constructs were assessed using items from Bernstein et al.’s (1994) Childhood Trauma Questionnaire. 2. These measures were included based upon research studies that have shown that many women substance abusers engage in higher rates of risky behaviors to obtain drugs or money in order to support their drug habits. The sexual behavior measures were entered into the multivariate equation last so that readers who prefer to focus on influences on women’s drug use without considering the impact of these behaviors could see what the model looked like immediately before these items were entered and what the model looked like after they were entered. 3. To ensure that the order in which items were considered for inclusion in the development of the final multivariate equation was not influencing the results obtained, the analyses were conducted using a stepwise procedure, a forward selection procedure, and a backward selection procedure. The same results were obtained in the final model regardless of which approach was adopted. 4. For example, the variable representing the number of times women had oral sex was computed by summing the number of times they had oral sex with their main partner, the number of times they had oral sex with a friend or acquaintance, and the number of times they had oral sex with a paying partner. The number of times women reported having sex with their main partner was calculated by adding the number of times they had oral sex with their main partner, the number of times they had vaginal sex with their main partner, and the number of times they had anal sex with their main partner. In this manner, many of the sexual behavior variables used had at least some overlap with one another. 5. 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.

References Amey, C. H., Albrecht, S. L., and Miller, M. K. (1996). Racial differences in adolescent drug use: The impact of religion. Substance Use and Misuse, 31, 1311–1332. Anglin, M. D., Hser, Y., and Chou, C. (1993). Reliability and validity of retrospective behavioral self-report by narcotics addicts. Evaluation Review, 17, 91–103.

54


Armsden, G. C. and Greenberg, M. T. (1987). The Inventory of Parent and Peer Attachment: Relationships to well-being in adolescence. Journal of Youth and Adolescence, 16, 427–454. Basen-Engquist, K. (1992). Psychosocial predictors of ‘‘safer sex’’ behaviors in young adults. AIDS Education and Prevention, 4, 120–134. Bernstein, D. P., Fink, L., Handelsman, L., Foote, J., Lovejoy, M., Wenzel, K., Sapareto, E., and Ruggiero, J. (1994). Initial reliability and validity of a new retrospective measure of child abuse and neglect. American Journal of Psychiatry, 151, 1132–1136. Boehm, S., Coleman-Burns, P., Schlenk, E. A., Funnell, M. M., Parzuchowski, J., and Powell, I. J. (1995). Prostate cancer in African American men: Increasing knowledge and self efficacy. Journal of Community Health Nursing, 12, 161–169. Catalano, R. F., Gainey, R. R., Fleming, C. B., Haggerty, K. P., and Johnson, N. O. (1999). An experimental intervention with families of substance abusers: One-year follow-up on the Focus on Families project. Addiction, 94, 241–254. Cochran, J. K., Wood, P. B., and Arneklev, B. J. (1994). Is the religiosity/delinquency relationship spurious? Social control theories. Journal of Research in Crime and Delinquency, 31, 92–123. Conrod, P. J., Stewart, S. H., Pihl, R. O., Cote, S., Fontaine, V., and Dongier, M. (2000). Efficacy of brief coping skills interventions that match different personality profiles of female substance abusers. Psychology of Addictive Behaviors, 14, 231–242. Copello, A., Orford, J., Velleman, R., Templeton, L., and Krishnan, M. (2000). Methods for reducing alcohol and drug-related family harm in non-specialist settings. Journal of Mental Health, 9, 329–343. Derose, K. P., Hawes-Dawson, J., Fox, S. A., Maldonado, N., Tatum, A., and Kington, R. (2000). Dealing with diversity: Recruiting churches and women for a randomized trial of mammography promotion. Health Education and Behavior, 27, 632–648. Ferdinand, K. C. (1997). Lessons learned from the Healthy Heart Community Prevention Project in reaching the African American population. Journal of Health Care for the Poor and Underserved, 8, 366–371. Ferreira-Pinto, J. B. and Ramos, R. (1995). HIV/AIDS prevention among female sexual partners of injection drug users in Ciudad Juarez, Mexico. AIDS Care, 7, 477–488. Flack, J. M. and Wiist, W. H. (1991). Cardiovascular risk factor prevalence in African-American adult screenees for a church-based cholesterol education program: The Northeast Oklahoma City Cholesterol Education Program. Ethnicity and Disease, 1, 78–90. Folkman, S., Chesney, M. A., Pollack, L., and Phillips, C. (1992). Stress, coping, and high-risk sexual behavior. Health Psychology, 11, 218–222. Folkman, S. and Lazarus, R. S. (1988). Ways of Coping Questionnaire: Research Edition . Palo Alto, CA: Consulting Psychologists Press. Fox, S. A., Stein, J. A., Gonzalez, R. E., Farrenkopf, M., and Dellinger, A. (1998). A trial to increase mammography utilization among Los Angeles Hispanic women. Journal of Health Care for the Poor and Underserved, 9, 302–321. Free, M. D. (1994). Religiosity, religious conservatism, bonds to school, and juvenile delinquency among three categories of drug users. Deviant Behavior, 15, 151–170. Hardert, R. A. and Dowd, T. J. (1994). Alcohol and marijuana use among high school and college students in Phoenix, Arizona: A test of Kandel’s socialization theory. International Journal of the Addictions, 29, 887–912. Heckathorn, D. D. (1997). Respondent-driven sampling: A new approach to the study of hidden populations. Social Problems, 44, 174–199. Higgins, S. T., Budney, A. J., Bickel, W. K., Badger, G. J., Foerg, F. E. et al. (1995). Outpatient behavioral treatment for cocaine dependence: One-year outcome. Experimental and Clinical Psychopharmacology, 3, 205–212. Jaccard, J. and Wan, C. K. (1995). A paradigm for studying the accuracy of self-reports of risk behavior relevant to AIDS: Empirical perspectives on stability, recall bias, and transitory influences. Journal of Applied Social Psychology, 25, 1831–1858. Jackson, C. T., Covell, N. H., Frisman, L. K., and Essock, S. M. (2004). Validity of self-reported drug use among people with co-occurring mental health and substance use disorders. Journal of Dual Diagnosis, 1, 49–63. Johnson, J. L. and Leff, M. (1999). Children of substance abusers: Overview of research findings. Pediatrics, 103, 1085–1099.


55

Kendler, K. S., Gardner, C. O., and Prescott, C. A. (1997). Religion, psychopathology, and substance use and abuse: A multimeasure, genetic-epidemiologic study. American Journal of Psychiatry, 154, 322–329. Kirby, K. C., Marlowe, D. B., Festinger, D. S., Garvey, K. A., and LaMonaca, V. (1999). Community reinforcement training for family and significant others of drug abusers: A unilateral intervention to increase treatment entry of drug users. Drug and Alcohol Dependence, 56, 85–96. Kumanyika, S. K. and Charleston, J. B. (1992). Lose Weight and Win: A church-based weight loss program for blood pressure control among Black women. Patient Education and Counseling, 19, 19–32. Kumpfer, K. L. (1999). Outcome measures of interventions in the study of substance-abusing parents. Pediatrics, 103, 1128–1144. Kutter, C. J. and McDermott, D. S. (1997). The role of the church in adolescent drug education. Journal of Drug Education, 27, 293–305. Lehman, W. E. K., Farrabee, D. J., Holcom, M. L., and Simpson, D. D. (1995). Prediction of substance use in the workplace: Unique contributions of personal background and work environment variables. Journal of Drug Issues, 25, 253–274. Lovibond, S. H. and Lovibond, P. F. (1995). Manual for the depression anxiety stress scales (2nd ed.). Sydney, Australia: Psychology Foundation. Luthar, S. S., Anton, S. F., Merikangas, K. R., and Rounsaville, B. J. (1992). Vulnerability to drug abuse among opioid addicts’ siblings: Individual, familial, and peer influences. Comprehensive Psychiatry, 33, 190–196. Miller, L., Davies, M., and Greenwald, S. (2000). Religiosity and substance use and abuse among adolescents in the National Comorbidity Survey. Journal of the American Academy of Child and Adolescent Psychiatry, 39, 1190–1197. Miller, W. R., Meyers, R. J., and Hiller-Sturmhoefel, S. (1999). The community-reinforcement approach. Alcohol Research and Health, 23, 116–120. Moggi, F., Ouimete, P. C., Moos, R. H., and Finney, J. W. (1999). Dual diagnosis patients in substance abuse treatment: Relationship of general coping and substance-specific coping to oneyear outcomes. Addiction, 94, 1805–1816. Monti, P. M., Rohsenow, D. J., Michalec, E., Martin, R. A., and Abrams, D. B. (1997). Brief coping skills treatment for cocaine abuse: Substance use outcomes at three months. Addiction, 92, 1717–1728. National Institute on Drug Abuse (2001). Lessons from prevention research. Infofax document 13563. Rockville, MD: National Institute on Drug Abuse. Nurco, D. N. (1985). A discussion of validity: Self-report methods of estimating drug use (pp. 4–11). NIDA Research Monograph #57. Washington, DC: U.S. Government Printing Office. Oexmann, M. J., Thomas, J. C., Taylor, K. B., O’Neil, P. M., Garvey, W. T., Lackland, D. T., and Egan, B. M. (2000). Short-term impact of a church-based approach to lifestyle change on cardiovascular risk in African Americans. Ethnicity and Disease, 10, 17–23. Richard, A. J., Bell, D. C., and Carlson, J. W. (2000). Individual religiosity, moral community and drug user treatment. Journal for the Scientific Study of Religion, 39, 240–246. Rosenberg, M. (1965). Society and the adolescent self-image . Princeton, NJ: Princeton University Press. Schorling, J. B., Roach, J., Siegel, M., Baturka, N., Hunt, D. E., Guterbock, T. M., and Stewart, H. L. (1997). A trial of church-based smoking cessation interventions for rural African Americans. Preventive Medicine, 26, 92–101. Sterk, C. (1999). Building bridges: Community involvement in HIV and substance abuse research. Drugs and Society, 14, 107–121. Stillman, F. A., Bone, L. R., Rand, C., and Levine, D. M. et al. (1993). Heart, body, and soul: A church-based smoking-cessation program for urban African Americans. Preventive Medicine, 22, 335–349. Strickland, G. A., Welshimer, K. J., and Sarvela, P. D. (1998). Clergy perspectives and practices regarding intimate violence: A rural view. Journal of Rural Health, 14, 305–311. Sutherland, M., Hale, C. D., and Harris, G. J. (1995). Community health promotion: The church as partner. Journal of Primary Prevention, 16, 201–216. Trinkoff, A. M., Zhou, Q., Storr, C. L., and Soeken, K. L. (2000). Workplace access, negative proscriptions, job strain, and substance use in registered nurses. Nursing Research, 49, 83–90.

56


Turner, L. W., Sutherland, M., Harris, G. J., and Barber, M. (1995). Cardiovascular health promotion in north Florida African-American churches. Health Values, 19, 3–9. Voorhees, C. C., Stillman, F. A., Swank, R. T., Heagerty, P. J., Levine, D. M., and Becker, D. M. (1996). Heart, body, and soul: Impact of church-based smoking cessation interventions on readiness to quit. Preventive Medicine, 25, 277–285. Walton, M. A., Blow, F. C., and Booth, B. M. (2000). A comparison of substance abuse patients’ and counselors’ perceptions of relapse risk: Relationship to actual relapse. Journal of Substance Abuse Treatment, 19, 161–169. Watters, J. and Biernacki, P. (1989). Targeted sampling: Options for the study of hidden populations. Social Problems, 36, 416–430. Winett, R. A., Anderson, E. S., Whiteley, J. A., Wojcik, J. R., Rovniak, L. S., Graves, K. D., Galper, D. I., and Winett, S. G. (1999). Church-based health behavior programs: Using social cognitive theory to formulate interventions for at-risk populations. Applied and Preventive Psychology, 8, 129–142.