Elsevier

Drug and Alcohol Dependence

Volume 168, 1 November 2016, Pages 69-75
Drug and Alcohol Dependence

Behavioral risk assessment for infectious diseases (BRAID): Self-report instrument to assess injection and noninjection risk behaviors in substance users

https://doi.org/10.1016/j.drugalcdep.2016.07.032Get rights and content

Highlights

  • Risk assessments for infectious disease in substance users do not include contemporary risks.

  • The Behavioral Risk Assessment for Infectious Diseases (BRAID) is a 14-item self-report, dichotomous measure of past 6 months risk behaviors.

  • The BRAID has been initially psychometrically validated in injection and noninjection users.

Abstract

Background

Infectious diseases such as Human Immunodeficiency Virus and Hepatitis C are a significant problem among substance abusers. Current risk behavior measures [e.g., HIV Risk Taking Behaviour Scale (HRBS) and Risk Assessment Battery (RAB)] were developed for injection drug users and do not include newly identified risks or noninjection drug use behaviors. This study developed and provided initial, internal validation of the Behavioral Risk Assessment for Infectious Diseases (BRAID) to assess infectious disease risk behaviors among alcohol and other drug users.

Methods

A self-report measure was developed from literature regarding risk behaviors. Participants (total N = 998) with alcohol/substance use disorder completed the measure in 2 phases to establish initial psychometric validity.

Results

Phase 1 (N = 270) completed 65 self-report questions; factor analysis revealed a 12-item solution with 5 factors (Unprotected Sex with Risky Partners, Injection Use, Sex on Cocaine/Crack, Condom Availability, and Intranasal Drug Use). Infectious disease history was positively associated with Injection Use (Sample 1) and Unprotected Sex with Risky Partners (Sample 2) and negatively associated with Intranasal Drug Use (Samples 1 and 2). Phase 2 (N = 728) added additional injection-related items and confirmed the factor structure of the existing BRAID.

Conclusions

The BRAID is a 5-factor, 14-item self-report measure of past 6 month risk behaviors that is composed of noninjection and injection risk behaviors and was psychometrically confirmed. Though additional external (convergent/divergent) validation is needed, this report provides preliminary support for the use of the BRAID to assess infectious disease risk in substance users.

Introduction

Infectious diseases, such as Human Immunodeficiency Virus (HIV), Hepatitis C (HCV), chlamydia, syphilis, and gonorrhea, are a significant problem among alcohol and other drug users. Between 2012 and 2013, more than 47,000 and 29,000 people were newly diagnosed with HIV and HCV in the United States, respectively (Centers for Disease Control and Prevention CDC, 2013a,b), and HIV and HCV account for more than 30,000 annual deaths (CDC, 2013a, CDC, 2013b). The incidence of chlamydia, syphilis, and gonorrhea has also recently increased in the US for the first time since 2006 (National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, 2015). Infectious diseases are generally blood-borne illnesses that can be transmitted through sexual behaviors and injection drug use (CDC, 2013a, CDC, 2013b, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, 2015), though a growing body of research has implicated noninjection drug use (such as prescription drug and noninjection stimulant use) as additional robust risk factors for disease acquisition (Strathdee and Sherman, 2003, Neaigus et al., 2007, Scheinmann et al., 2007, Cicero et al., 2007, Substance Abuse and Mental Health Services Association, 2014).

Research regarding the acquisition of infectious diseases among substance users has largely focused on HIV and the specific contribution that drug injection and drug-related sexual risk behaviors (e.g., the use of sex to procure drugs or money for drugs) have on transmission. Two risk assessments, the HIV Risk-taking Behaviour Scale (HRBS) (Darke et al., 1991) and the Risk Assessment Battery (RAB) (Navaline et al., 1994), were created in the early 1990’s to quantify the incidence and frequency of HIV risk behaviors among intravenous drug users. These scales helped to guide prevention, intervention, and research efforts, and continue to be the most widely-reported scales for measuring infectious disease risk behaviors among substance users. Yet they are limited by a lack of rigorous psychometric evaluation. For instance, the HRBS was originally developed (Darke et al., 1990) and validated (Darke et al., 1991) for injection drug users and its reliability has only been subsequently evaluated in a single study of 84 substance users (Petry, 2001). No published studies have psychometrically validated the RAB. In addition, the risky sexual behaviors assessed by the HRBS and RAB are not equated with unprotected sex. Thus, endorsement of sexual risk behaviors on these scales can represent condom-protected and unprotected sex, which incur substantially different levels of risk.

Since the development of the HRBS and RAB, several additional transmission and “proxy” risk behaviors have been identified within substance users that have been repeatedly associated with increased disease risk. These include noninjection risks such as sharing intranasal drug use equipment (Koblin et al., 2003) and binge drug use (Miller et al., 2006), and injection behaviors that incur heightened risk, such as transitioning between noninjection and injection drug use (Griffiths et al., 1992, Strang et al., 1992, Griffiths et al., 1994, Darke et al., 1994a, Darke et al., 1994b, Crofts et al., 1996, Irwin et al., 1996, Fuller et al., 2002, Abelson et al., 2006), assisting someone with injections or being a new intravenous drug user (Hagan et al., 2001, Vidal-Trecan et al., 2002, Wood et al., 2003, Roy et al., 2004, O'Connell et al., 2005, Fairbairn et al., 2006), and being a former but not current intravenous drug user (Friedman et al., 1995, Neaigus et al., 2001b). Additional sexual risk behaviors have also been identified, including the frequency of anal and vaginal sexual intercourse and whether the act was insertive or receptive (Benotsch et al., 1999, Hoffman et al., 2000), sex with other drug users (Neaigus et al., 2001a, Bravo et al., 2003, Roy et al., 2004, Purcell et al., 2006), having sex while under the influence of drugs (Celentano et al., 2006), having sex for an extended duration of time (Semple et al., 2009), having a lifetime history of a sexually transmitted disease (Hwang et al., 2000, Kalichman et al., 2005), and being sexually active following an HIV diagnosis (Campsmith et al., 2000, Aidala et al., 2006, Carrieri et al., 2006, Niccolai et al., 2006, Brewer et al., 2007). Finally, risks specific to the drug class being abused, including alcohol (Fitterling et al., 1993, Rasch et al., 2000, Stein et al., 2000, Rees et al., 2001, Kalichman et al., 2005, Raj et al., 2006), stimulants (Booth et al., 2000, Logan and Leukefeld, 2000, McCoy et al., 2004, Edwards et al., 2006, Volkow et al., 2007), and opioids (Sanchez et al., 2002, El-Bassel et al., 2003, Conrad et al., 2015) have also been associated with increased disease risk. Since all of these risks were identified after the development of the HRBS and RAB, they were not included in those assessments and are therefore not systematically queried or reliably used to determine infectious disease risk profiles for patients.

The current study aimed to develop and conduct initial validation studies on an updated measure of noninjection and injection risk behaviors for infectious disease among alcohol and other drug users. The Behavioral Risk Assessment for Infectious Diseases (BRAID) incorporates a broader and more up-to-date range of risk behaviors, including the aforementioned noninjection drug use and unprotected sexual risk factors, to permit a more thorough characterization of infectious disease risk behaviors, and was developed within the context of a large and diverse sample of alcohol and other drug users to increase overall generalizability.

Section snippets

Study phases

This study was conducted in two phases. Phase 1 consisted of initial scale development and Phase 2 consisted of scale extension and confirmation. Phase 1 and Phase 2 were conducted in independent and diverse samples of substance users (described below and meant to represent both alcohol and other drug users; Table 1). Collapsed across samples, participants (N = 998) reported regular abuse of alcohol (51.9% of participants); cocaine/crack (42.2%); prescription stimulants (31.0%), opioids (25.7%),

Results

This manuscript describes the initial development of the Behavioral Risk Assessment for Infectious Diseases (BRAID), a self-report measure of infectious disease risk behaviors in substance users. The BRAID has the potential to update and expand previous risk assessments like the HRBS and RAB by querying a broader and more contemporary array of risk behaviors, by explicitly defining risky sexual behavior as unprotected, and by deriving the items through sampling a large and diverse group of

Discussion

Strengths of this study include the reliance upon empirical literature to develop the questionnaire items, sampling from a large and diverse group of alcohol and other drug users, systematic psychometric evaluation of the subscales, inclusion of both injection and noninjection drug use behaviors, and an emphasis on unprotected sexual behaviors. Limitations include the fact that items were self-report and were not delivered via Audio-CASI, a well-known method for asking about HIV risk behaviors

Conflict of interest

The authors have no relevant conflicts of interest to declare.

Contributors

The study was designed by authors Dunn, Barrett, Herrmann, and Johnson. All authors contributed substantively to the data collection, interpretation, and manuscript development.

Role of funding

This study was supported by the grants from the National Institutes of Health: R01DA035246 (Dunn), R21DA035327 (Dunn), T32DA007209 (Bigelow), U01DA032629 (Plebani), R34DA037385 (Sigmon), R01DA032363 (Johnson), and R01DA035277 (Johnson). The funding source had no role in the data collection or interpretation.

Acknowledgement

The authors thank the staff members at the clinics from where Phase 1 data were sampled for their assistance with data collection.

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