Choosing a course of study and career in pharmacy—student attitudes and intentions across three years at a New Zealand School of Pharmacy

Abstract
Factors influencing undergraduates’ selection of Pharmacy as a course of study, career, study and professional perspectives were evaluated by survey over the years 2004–2006 at Otago University, New Zealand. Altruistic intent emerged as a powerful motivator for choosing pharmacy and entrepreneurial career intentions were prominent. A sizeable though declining number
of students selected pharmacy secondarily to medicine or dentistry. Gender differences were found between intended areas of practice.

Introduction
Graduates from the National School of Pharmacy
(NSP) atOtago University represent just over half of all
Pharmacy graduates educated in New Zealand. In the
year 2006, these students constituted 45% of additions
to the practising register, with other significant
additions being from Auckland University (23%) and
UK/Ireland (21%; Pharmacy Council of New Zealand,
2005a). The motivations, career aspirations and
choices ofNSP studentswill therefore have a significant
influence on the future practice and culture of
Pharmacy both in New Zealand and on the work
overseas that many will pursue. Indirectly, selection
criteria used to admit students to the BPharm course
will also play a role in shaping the next generation of
pharmacists.
Choosing pharmacy as a course of study—demographics
and motivations
The choice by students of any undergraduate degree
involves many factors, including but not limited
to: socioeconomic variables, gender and ethnicity,
academic ability and academic self-concept, career
ambitions, personality, and prior educational attainment
(Van de Werfhorst, Sullivan, & Cheung, 2003;
Reay, Davies, David, & Ball, 2001; Pike, 2006; Porter
& Umbach, 2006; Abowitz, 2006). Recent studies in
the UK have indicated that there are increasing
numbers of women studying pharmacy, with almost
twice as many women as men qualifying as pharmacists
in 2005 (Hassell & Eden, 2006) leading to
pharmacy now being described as a “female-dominated”
profession (Hassell, 2003). The ethnic mix of
pharmacists in the UK is also becoming more diverse,
with around 25% of newly qualified pharmacists now
recorded as being “Asian British” (Hassell & Eden,
2006)—that is to say Indian, Pakistani or Bangladeshi—
compared with 4% of the population (Census,
1991/2001). Black British and Chinese ethnic groups
are also growing in representation (Hassell & Eden,
2006), though there is huge variability in the makeup
of course cohorts around the country (Willis,
Shann, & Hassell, 2006d).
Race or ethnicity has in a different way been shown
to be strongly associated with the pursuit of a
pharmacy degree and career. A US investigation into
whether individuals who had initially expressed an
interest in pharmacy subsequently pursued this field,
found that Hispanic or “other” ethnic group students
were 12 times more likely than White students to
continue with their plans to become pharmacists
(Cline, Mott, & Schommer, 1999). This study found
that those with higher grade point averages and career
commitments were also more likely to apply to study
pharmacy, suggesting that “despite pharmacy’s
uncertain future, it is still able to attract academically
qualified students” (P399). The role of ethnicity,
attitudinal traits and academic factors have been
found to interplay in other ways, for example with
family influence in choice of pharmacy as a career
reported to be particularly strong for non-White
students (Willis, Shann, & Hassell, 2006a).
The strongest motivating factor to study pharmacy
in the UK has recently been found to relate to its being
a science-based course, with other extrinsic and
intrinsic motivators also featuring—namely career
status and prospects, and a desire to help people and
to work with patients (Willis et al., 2006d). In
Australia, extrinsic factors relating to self-employment
and salary, and intrinsic factors relating to a liking for
science, interpersonal aspects and a desire to be socially
useful have all been found to influence students’ choice
of pharmacy as a degree (Roller, 2004). At the graduate
entry level, future employment prospects and a desire
to make a contribution to healthcare feature most
highly as factors influencing decision to study
pharmacy (Davey, Evans, & Stupans, 2006). Consistency
in motivations to study pharmacy across time and
cultures is indicated when it is considered that similar
findings relating to science, salaries and a “desire to
help humanity” were obtained in the US from the
1950s through to the 1970s (Cline et al., 1999; Pratt,
1956; Smith, Gibson, & Mikeal, 1974).
Around 75% of UK pharmacy students initially
chose pharmacy as their first course of study, with white
females most likely to take pharmacy as a first choice
(84%;Willis et al., 2006a). Ethnicity also emerged as a
factor in first degree selection, with almost four times as
many non-White students reporting pharmacy was not
their first choice of degree, compared with White
students. At the NSP, it is said to be “inevitable” that a
portion of undergraduates will not have opted first for
pharmacy, as the majority of students take a common
health sciences first year and subsequently compete for
entry to pharmacy, medicine, dentistry and physiotherapy
courses, for all of which they may apply at the end
of this year (Shaw, 2000).
Selection criteria
Admission to pharmacy at NSP is mostly based on
students obtaining a minimum of an average B grade
(70%) in the common health sciences first year.
A smaller number of students are admitted from
second or subsequent year of study, usually at Otago,
or as “competitive” graduates (of a New Zealand
university within the previous 3 years). An “alternative
applicant” category brings in a few others: those who
may have graduated from a New Zealand university
more than 3 years previously; those who have obtained
degrees, usually in medicine or pharmacy, from an
overseas university; and those who have worked as an
allied health professional (most often a pharmacy
technician or nurse) for 5 years or more. All such
applicants are required to have passed the subjects of
Otago’s common health sciences first year course (or
the equivalents) and to have demonstrated competence
in English. A certain degree of positive
discrimination exists in that students who are Maori
or Pacific Islanders may be brought into the BPharm
programme even if they achieve only an average of
65% or more during their pre-admission year(s). Only
about 1–2 students are admitted in this way each year,
however. Very few applicants for admission are
interviewed—only those applying as “alternative”
candidates and for whom English is not their first
language.
In the UK, A-level grades have been found to show
a small but significant correlation with grades at
pharmacy undergraduate level and thus it has been
argued that both teachers’ estimates of A-level
performance and actual A-level scores remain useful
in selection and forecasting (Foy & Waller, 1987).
A-level biology scores may perhaps be a stronger
predictor of performance in a pharmacy degree, and
English ability at entry level is also important as an
indicator of student success (Sharif, Gifford, Morris,
& Barber, 2003). Given that pharmacy undergraduates
must have the capacity to acquire diverse
scientific knowledge and skills, as well as developing
the knowledge and interpersonal skills of pharmaceutical
care, it is also reasonable to ask whether there
might be other selection criteria also applicable to
undergraduate admissions. With respect to the
contemporary focus of pharmacy practice as one
centred on patient care (Strand, Cipolle, Morley, &
Frakes, 2004), it has been suggested that formal
assessments of self-reported empathy be used in the
admissions processes of pharmacy schools. Similarly,
with reference to the scientific demands of the course,
that critical thinking skills and mathematical ability
should be taken into account, in addition to a range of
other non-academic and affective qualities (Duncan-
Hewitt, 1996).
The use of a variety of aptitude tests for pharmacy
admissions is now commonplace in the US (Chesnut &
Phillips, 2000), for example the Pharmacy College
Admission Test (PCAT; Duncan-Hewitt, 1996;
Chesnut & Phillips, 2000), which incorporates
measures of communication skills, reasoning ability
and chemistry- and biology-specific knowledge (American
Association of Colleges of Pharmacy, 2006).
Currently, no equivalent pharmacy admissions test
exists at the NSP; however, students pursuing entry
into medicine or dentistry from the common health
sciences first year are admitted in part according to
their performance on the UMAT (Undergraduate
Medicine and Health Sciences Admissions Test).
Given the potential relevance of various factors which
may be used in admissions, ranging from interpersonal
relations to problem-solving skills to ethical awareness
(Chesnut & Phillips, 2000), the novel step was taken
in this study to ask students themselves, what they
consider to be important and relevant selection
criteria for the pharmacy degree.
Career aspirations—professional intentions and influences
In the US, a study of eight Pharmacy Schools
indicated that the majority of students (71%) have
career aspirations that are strongly oriented towards
“direct patient care”, although concern is expressed
that this may be at odds with the realities of drug
distribution-based pharmacy likely to be encountered
in the professional workplace (Siracuse, Schondelmeyer,
Hadsall, & Schommer, 2004). This study also
found evidence that the more career-committed of
students will also be those aspiring to work in direct
patient care. Others have found that the “professional
subculture” of students entering pharmacy is comparable
to nursing and medical students as regards
their emphasis on patient care (Horsburgh, Perkins,
Coyle, & Degeling, 2006).
Pharmacy students in the UK apparently possess a
strong expectation that they will work very hard no
matter what pharmacy job they acquire—95% believe
this to be the case—and 80% state they are very
ambitious about their pharmacy career (Willis et al.,
2006a). Diverse factors have been shown to affect the
choice made by students about specific career paths,
including previous work experience, the influence of
sections of the undergraduate syllabus directed
towards pharmacy practice (Siverthorne, Price, Hanning,
Scanlan, & Cantrill, 2003) and practical matters
such as salary and work location, a desire for personal
fulfilment and to help patients (Carvajal & Hardigan,
1999; Carter & Segal, 1989).
As recently as 2000, concern has been expressed
that hospital pharmacy in the UK is said at the
undergraduate level to have an “image problem”,
being considered elitist, badly paid, dull and repetitive
(Hatfield, Marriott, & Harper, 2000). In contrast to
this (or perhaps evidence of a shift in attitude and
intention of students), more UK students stated that
they were at least “certain” that “in 10 years time”
they wanted a career in hospital pharmacy (60%)
compared to any other career option, although
significant interest was shown in community practice
(proprietor, 33%; employed by multiple, 51%),
working abroad (43%) and primary care (37%; Willis
et al., 2006a). Given that more than one option was
permitted in this survey, students do appear to be
hedging their bets to an extent, but these figures at
least suggest an open-mindedness about the practice
sites available to them.
Of those intending to work in the community sector
in the UK, strong entrepreneurial intentions are
evident, with 44% of male students and 28% of female
students saying they are certain they want to own a
pharmacy (Willis et al., 2006a) and pharmacy
ownership reported as the top ambition for students
(Wilson, Jesson, Langley, Hatfield, & Clarke, 2006).
The proportion of these individuals who will attain
their ambitions, given the decline of the independent
pharmacy in Britain, remains to be seen, however.
Consequences of the “feminisation” of pharmacy relate
to the likelihood of women working part time once in
their 30s, and gravitating towards temporary community
work (Hassell, 2003). It has been suggested also
that this feminising shift may at least correlate with
pharmacy itself becoming a more attractive career for
women than men (Gidman & Hassell, 2005).
Attitudes and career intentions in pharmacy have
not been as clearly elucidated in New Zealand.
However, given that currently 2100 (82%) of
pharmacists work in the community sector and 300
pharmacists (10%) in the hospital sector (Pharmacy
Council of New Zealand, 2005b) it could be valuable
to assess students’ perceptions of these and other
career paths.
Aims of this study
This study evaluated factors influencing students’
decisions to study pharmacy and to work as health
professionals, aswell as the characteristics they consider
important for selection to the course and for practising
pharmacy. Also investigated were pharmacy students’
career aspirations and intentions, and the relative
importance and attraction of various professional
activities and incentives. NSP students across three
separate cohorts and years were surveyed to examine
for commonalities and trends in these areas.
Method
This study, approved by the University of Otago
Human Ethics Committee, was developed in December/
January 2002/2003 following a series of interviews
and focus group discussions with current and recently
graduated students. It was piloted in 2003 by a
group of student researchers on that year’s second year
intake, following which a number of minor adjustments
were made to ensure consistency and ease of
analysis. The questionnaire has since then been
administered routinely to each incoming second year
class at the start of their first lecture, in the School of
Pharmacy. This first lecture which introduces students
to the School and pharmacy profession, is attended by
most students, all of whom have just been admitted
into the BPharm programme. The results presented in
this paper relate to the second year students of 2004–
2006.
The (anonymous) questionnaires were distributed
around the lecture theatre before the start of the lecture.
Students were then given 15 min to complete the
surveys and were asked to do so in silence, without
reference to their neighbours. At the end of the allotted
time, class representatives collected the completed
questionnaires and handed them to the academic staff
member present (who was not one of the researchers).
The questionnaire consisted of 24 separate questions,
many of which were subdivided into further
categories of choice. Most questions were multiplechoice,
requiring respondents to rate statements on a
Likert-type scale of 1–5, with 1 being not at all
important/ not at all interested through to 5 as most
important/ very interested. Other questions asked
students to rate order of importance of factors (e.g.
order of priority of factors influencing decision to
study pharmacy) or to make selections from alternatives
(e.g. ethnicity).
The following areas from the survey questionnaire
were analysed for the period 2004–2006:
1. Why do you want to work as a health professional?
(rating scale 1–5, 17 statements)
2. Which three of these factors (statements from
Question 1) were the most important in your
decision? (Please list in order of priority)
3. What, in your opinion, are the most important
attributes that the School of Pharmacy should
consider when selecting people for the Bachelor of
Pharmacy programme? (rating scale 1–5, 12
statements)
4. When you applied for admission to the Health
Sciences, was Pharmacy your first preference?
(yes/no) If not, please state which programmes
were preferred.
5. At this stage in your BPharm programme, do you
want to become a pharmacist? (yes/no)
6. Community pharmacists are involved in many of
the following activities in their day to day work.
Which activities are of most interest to you? (rating
scale 1–5, 11 statements)
7. What aspects of being a pharmacist are most
important to you? (rating scale 1–5, 14 statements)
8. During my working life, I would like . . . (tick as
many phrases as you feel apply [12 statements])
9. If you had to choose a pharmacy career path today, in
what field would it be? (Please tick one [6 options])
Further questions were also asked about gender,
age, ethnicity, language spoken and residency status.
Data were collated and analysed for all student
responses over the 3 years (n = 351) and separately for
each year to examine for trends. Participants’
responses between questions were not linked for the
2005 data, so analyses linking responses from different
questions are only presented for 2004 and 2006.
In addition to reporting descriptive statistics,
participants were forced to rank only three factors in
Question 2. Thus ranking data in Figure 1 represent
the mean number of times participants ranked a factor
as primary importance (3), secondary importance (2),
and tertiary importance (1). A score of 3 would
indicate all participants said a factor was the most
important; conversely a score of 0 indicates a factor
was not ranked in the top 3 by any participant.
Using the two smallest cohorts (2004 and 2006), it
was estimated using G*Power 3 that with 80%power, a
two-tailed pairwise comparison would be able to detect
an effect of d ¼ 0.38. By convention, values of 0.2 and
0.5 are considered to be small and medium respectively,
meaning that where differences were not found,
any real differences are likely to be close to small in size.
Results
A total of 351 students completed the survey (2004,
n ¼ 103; 2005 n ¼ 125; 2006, n ¼ 123) representing
98% of the total of three cohorts. All students in 2005
and 2006 completed the survey; 103 of 110 students
did so in 2004. There was a small level of nonresponse
on some questions, but this appears to be a
student accidentally omitting a question rather than
systematically not responding.
Motivations to study pharmacy
The left-hand panel of Figure 1 shows a strong degree of
consistency between years as to the primary ranked
motivations of students to work as a health professional
(Question 2). By far, the most highly ranked motivation
was a desire to work in a job where they “care for/
help people”, which was twice as highly ranked as
the next highest motivation, an “interest in human
biology”. A job involving interaction with people, a high
salary, a desire to work in the community, a desire to
own a business and a number of other aspects also
featured as important motivators. University publicity,
friends studying in the health sciences, family tradition
and “having high grades but not knowing what else to
do” were the least reported reasons for wanting to work
as a health professional.
The right-hand panel of Figure 1 presents mean
rating data for the same factors. Few trends across the
surveyed years were evident in students’ motivations to
work as a health professional, with the exception of a
desire for a “career in research”. Over the 3 years,
there was an approximately 15% increase in the
importance placed on this factor. It would seem
therefore that students coming into the pharmacy
course are increasingly explicitly considering a research
career at an early stage. It is also interesting to note the
difference in responses between the ranking and rating
data. For example, students were clearly interested in
learning new technology, but it was not a top priority.
Admissions criteria
Figure 2 shows that students rated being a good
communicator with good English (language skills) as
the top attributes that they considered the School
should considerwhen selecting people for the pharmacy
programme. Highmarks in health sciences first year and
in science at schoolwere also highly-rated, aswas having
an “orderly/controlled mind”. Those attributes considered
least important fromthe options presented were
a previous tertiary qualification, being an older student
and high marks in arts subjects at school.
Study and career commitment
A large, but slightly decreasing number of students
opted first for medicine or dentistry on application
from health sciences, with those opting for pharmacy
as their first choice ranging between 38 and 50%.
2006 was the first year of the three that more
students selected pharmacy as their first preference
than did not (50% (CI: 42–59) in 2006, vs. 38%
(CI: 30–47) in 2005 and 46% (CI: 36–56) in 2004).
One notable trend is the decreasing numbers of
students opting for medicine as their first preference,
from 38% (CI: 29–48) of applicants in 2004 to 33%
(CI: 25–41) in 2005 and 24% (17–32) in 2006.
There appeared to be an increasing conviction
among students that they wished to become “a
pharmacist”. In 2004, 82% (CI: 75–90) of students
stated they “want to become a pharmacist”, in 2005
this rose to 89% (CI: 84–95) and 2006 to 98% (CI:
95–100). Of the 3 students in 2006 who said they
did not, one stated they would prefer to go into
research.
Matters of interest and importance in a pharmacy career
There appeared to be a sharp division in interest in
aspects of the role of the community pharmacist,
between the “generic” work of selling products,
arranging staff duties and administration, and health
care-specificwork such as offering health promotionand
compounding drugs. Students rated the eight health
care-specific activities presented as being of similar
interest (each receiving an average rating of around 4 out
of 5) and the three generic items at around 3 out of 5
(Figure 3). Out of the eleven activities presented for
rating, students rated “listening to patients” and
“interviewing people” most highly, suggesting a
particular enthusiasm for the interpersonal aspects of
pharmacy work.
“Reliable employment” and “steady job” were the
highest-rated aspects of being a pharmacist followed
closely by “ability to travel” (Figure 4). A number of
other factors were also rated, including professional
status, a good salary and working in the health sciences
and in the community. The least-rated aspect is
“working in a retail shop”.
Looking at trends evident in Figure 4, there was a
slight decrease in importance placed on the “ability to
travel with my qualification” as an important aspect of
being a pharmacist over the years (though it is still
rated highly), a similar decline in the importance
placed on salary, and a corresponding increase shown
in the importance of “owning my own pharmacy”.
Career aspirations
Looking to the future, an overwhelming majority of
students (87% averaged over 2004–2006) stated that,
during their working life they would like to be able to
live and work outside New Zealand (Figure 5). There
is some evidence of this declining in later years. A high
proportion of students (62%) would like to find work
in New Zealand, however, and only 11% say they want
to move away from New Zealand permanently.
Over two-thirds of students, stated they would like
to own a business at some point during their working
life. Furthermore, when asked separately to indicate
what pharmacy career path they would choose “if they
had to today” the majority chose “owner, community
pharmacy (urban)”. This choice has remained
relatively constant over the years (Figure 6). There
has been a decline in the number of students stating
they would choose a career in hospital pharmacy. Only
small numbers of students each year (around 4%)
indicated they would choose a career as a lecturer or in
public administration.
Undergraduate demographics
New Zealanders of European descent made up the
largest proportion of students at NSP at 39% with
sizeable other groups being ethnic Chinese (19%),
Korean (9%), Taiwanese (7%), Malay (6%), (Fijian)
Indian (6%) and Middle-Eastern (5%), though it is
worth noting that there are 25 separate ethnic
groups/nationalities listed in responses.
The male to female ratio of students studying
pharmacy has been consistent since the mid 1970s, at
about two-thirds female to one-third male students
(64–36%). This contrasts with the university student
profile as a whole, which is 55% female and 45% male.
The majority of students beginning the course are 18
or 19 years old (around 80%), with around 15% aged
20–22, and less than 5% aged 23 or over.
Gender and ethnic differences
Gender differences were found to exist in the career
aspirations of students (Figure 7). Only 2004 and 2006
datawere able to be analysed for effects, and across both
years female students were more likely than males to
indicate that they would choose hospital pharmacy “if
you had to choose a pharmacy career path today”
(females 37% versus males 20%; p = 0.006). There
were no significant differences between male and female
students in their preferences for an urban pharmacy or
rural pharmacy career. However, male students were
twice as likely as female students to opt for research as a
career path (females 13% versus males 31%,
p , 0.001). When asked whether during their working
life students wanted to own a business, 89% of male
students indicated this as a careerambition,with 81%of
females saying they did, though this difference was not
significant.
Students’ ethnicity appeared to be one determinant
of whether they studied pharmacy as a first choice, with
New Zealand/European students far more likely to have
done so than students from other ethnic groups (63%
NZ European versus 37% all “others”; p , 0.001). It
was not possible to separate out different ethnicities in a
fully satisfactory manner because of issues with data
collection (changing census classifications) over the
years of study. Of those students who identified
themselves as “Chinese” (n = 38) or “other” Asian
(n = 42), however, less than half had selected
pharmacy as a first choice (n = 27) and one of the
eleven Taiwanese students (all of whom are Chinese by
ethnicity if not by politics) had done so. Differences by
ethnicity were found in terms of influences of parents.
None of the 2006 New Zealand European students
rated parental influence most highly in their decision to
become a health professional, indeed 70% gave it the
lowest possible rating. Parental influence on non-
European New Zealanders was more evenly spread
with 18% of students rating it as the most important
factor in their decision-making and only 33% rating it
as being least important.
Discussion
Motivations to study pharmacy
We have examined themotivation to study pharmacy in
a novel way, by asking students to rank which three
(of seventeen) factors had most influence upon their
choice, in addition to asking students to rate separately
the importance of the range of factors. This enables a
differentiation between factors that might appear at first
sight similarly salient (ratings), and those thatweremost
important in actually influencing a decision (factors
scored by rank). Using thismethod, themost important
motivation given by students in this study for choosing
pharmacyemerges as an intrinsic, altruisticone: that of a
desire to “care for/ help people”.
These findings are probably more pronounced than
those fromother research in this area but do correspond
with other studies of pharmacy students’ study choices.
These studies have consistently reported high prominence
of motivations to study broadly describable as
altruistic, such as “a desire to help humanity” (Pratt,
1956), aspiring to be “socially useful” (Ferguson,
Roller, & Wertheimer, 1986), a desire to make a
contribution to healthcare (Davey et al., 2006) and “a
desire to help people” (Willis et al., 2006a).
These and the current study’s results might seem to
imply that much of students’ motivation to study
pharmacy is in large part a deferred one, that is to say
directed towards their professional life after graduation;
however, other research has indicated that intrinsic
factors influencing the selection of a pharmacy degree
also relate to the course of study itself. Roller (1993)
found that the most important intrinsic or extrinsic
influences on Australian pharmacy students were that
the course was perceived to be “intellectually satisfying”;
however, students’ belief that pharmacy was
socially useful was also important. Willis et al. (2006d)
in the UK similarly identified the science-based nature
of pharmacy as the primary draw for students, but again
with the desire to help people also strong among
intrinsic factors. The current study did not ask directly
whether the course of study was inherently appealing,
although our finding that the second most important
reason why students selected the coursewas “an interest
in human biology” indirectly indicates this is likely to
have been relevant.
Extrinsic factors of most importance to students in
choosing to study pharmacy relate to a desire to earn a
high salary and to own their own business and, to a
lesser extent the status of the profession. Previous work
has also found that students are motivated to study
pharmacy for financial reward and the opportunity for
self-employment (Roller, 1993, 2004; Willis et al.,
2006d) with the most recent research in this area
claiming pharmacy ownership is the “top ambition for
students” (Wilson et al., 2006). Seston, Shann, Hassell
and Willis (2006) found that just under half of all UK
students report the prospect of ownership as having
some influence in their decision to study pharmacy,
with the effect particularly strong among male students
and ethnicminority students. Crucially, they also found
a strong link between the prospect of owning a
pharmacy as a reason for choosing pharmacy as a
degree, and career intentions after three years of study.
Career intentions and expected benefits
In the current study, there appeared to be an early
explicit intention expressed by students to pursue
a career in pharmacy: 121 of 123 respondents in
2006, stated that they want to become a pharmacist,
a proportion that has increased over the three
surveyed years. This result is striking for its being
obtained at a very early stage in students’ course of
study, where one might reasonably expect some
ambivalence towards the degree (though it should be
noted that students were not given the option of
expressing uncertainty). These high rates of commitment
to a career as a pharmacist may relate to other
findings which indicate pharmacy students are careercommitted
(Willis et al., 2006a) and the finding in this
study, that in 2006 for the first time more students
selected pharmacy than any other health profession as
their first choice of study. In 2004 and 2005, as many
of those surveyed had wished to study medicine as
pharmacy, whereas in 2006 over twice as many
students opted for pharmacy as medicine. Despite
this, large numbers (almost half) of NSP students
would have preferred to follow another profession,
usually dentistry or medicine, as has been noted
previously (Shaw, 2000). The tendency for European
New Zealand students to be more likely than ethnic
minority students to have chosen pharmacy as a first
choice is in keeping with other studies which have
found similar ethnic differences in application
priority. This result is curious though for its being
apparently robust across courses, countries and
cohorts (Ferguson et al., 1986; Willis et al., 2006a),
despite the very different actual mix of ethnicities
studying pharmacy between New Zealand, Australia,
Canada, the US and the UK. It may be of concern to
educators that ethnic minority, foreign-born or
overseas students appear to be those most likely to
be studying pharmacy as a second (or lower) choice,
particularly considering the high, and in many
instances increasing, proportion of these students on
pharmacy courses.
Since over two-thirds of students indicated that they
would like at some point in their working life to own
their own pharmacy, New Zealand students’ entrepreneurial
intentions seem as strong as their UK
counterparts (Seston et al., 2006). Interestingly, there
was a decline in the proportions selecting hospital
pharmacy as a desired career path over the years
surveyed.
With so many students wanting to own their own
pharmacy, the question should be asked to what extent
these ambitions are realisable. In theUK, they may well
not come to fruition “given the steady decline of
independent pharmacies through competition from
multiples over recent years and an economic climate
that is not favourable to small pharmacy business”
(Seston et al., 2006). The potential for proprietorship is
higher in New Zealand, which has a long tradition of
individual ownership. Recent changes in legislation,
however, have enabled pharmacists to have a share in
up to five pharmacies, with the consequence that
groups of pharmacists have banded together to form
some small chains of pharmacies, run by manager
pharmacists rather than owners. It will therefore be
important for educators in New Zealand and elsewhere
to be aware that students’ ambitions for individual
ownership may not remain viable.
That hospital pharmacy sector suffers an “image
problem” (Hatfield et al., 2000) is also not so much an
issue in New Zealand, where anecdotal evidence
suggests that pre-registration hospital placements are
more sought after than community internships. The
tendency for females to be significantly more interested
in hospital work than males found in this current
study is in keeping with UK findings (Willis et al.,
2006b) and findings spanning the US, Canada and
Australia (Ferguson et al., 1986). These findings seem
likely to be borne out by students’ career trajectories in
the UK, where three times as many women as men
work in hospitals (Hassell, 2003).
This well-documented gender difference may relate
to hospital pharmacy offering more flexible hours and
institutional benefits (Cockerill & Tanner, 2001), and
also be related to gender differences in entrepreneurial
ambitions, given the generally lower salaries pertaining
in the sector. Other research looking at UK
pharmacy students’ perceptions of hospital pharmacy
suggests that it is perceived by students to offer poor
salaries but more opportunities to interact with
patients and better career progression (Silverthorne
et al., 2003). However, Hassell (2003) identified
concerns among some UK pharmacists that a “glass
ceiling” exists for female hospital pharmacists,
resulting in them being under-represented in senior
positions in this field. This is not the situation in New
Zealand; however, where, in 2006, almost 70% of the
chief pharmacists working in the country’s main
hospitals were female.
As for student aspirations to pursue a career in
research, New Zealand differs from Europe or the US
in that it has only a small pharmaceutical research
industry and only two Schools of Pharmacy, which
may explain the relatively low numbers of NSP
students interested in this career pathway. Interest in a
research career, though still quite limited, is growing
and may increasingly be considered by students to be a
viable career option.
In the current study, students perceived from an
early stage the associated benefits of a pharmacy
career, foremost among these being reliable employment
and the ability to travel with their qualification.
Aspects such as being a professional, working in the
community and earning a good salary also feature as
important facets of being a pharmacist. These and
other factors—such as undergraduate practice and
work experiences (Silverthorne et al., 2003)—are
likely to play a part in influencing the particular career
trajectories of students. Perhaps contrary to expectations,
Carvajal and Hardigan (1999) have also
suggested that females are more likely than males to
experience job satisfaction from high salary and retail
work. This finding did not emerge in the current study
but would be worthy of future attention.
The diminishing importance given by students to an
ability to travel as pharmacists from 2004 to 2006 may
be a consequence of the recent ending of direct
reciprocal employment agreements between the UK
and New Zealand, which has traditionally been a
popular route for New Zealand pharmacists to engage
in their “overseas experience”. Despite this decline, it
should be noted that almost 90% of students still say
they would like to be able to live and work outside
New Zealand at some point in their lives. This finding
may be particular to New Zealand where it is
especially common for university graduates to travel
and live abroad for a few years, usually within the first
10 years post-registration.
Admissions criteria
When asked to consider what might constitute
appropriate admissions criteria for the BPharm
programme, students report that “being a good
communicator” was more important as a selection
criterion than any other of the hypothetical admissions
criteria presented to them, more so even than high
marks in the health sciences common first year
or school science subjects. Speaking English well was
rated highly, and this aligns with research that has
found English skills to correlate highly with final
pharmacy exam marks for non-native English speakers
(Sharif et al., 2003). Science marks and the critical
thinking/scientific capacity indicator “having an
orderly and controlled mind” also featured highly in
students’ opinion of appropriate admissions criteria.
These results regarding student appraisal of what
might be important admissions criteria taken together
are an interesting indicator of students’ own perceptions
about what constitutes a good pharmacist and a
capacity to do well in the degree course: a combination
of good communication skills and cognitive ability. It
has been argued in the pharmacy education literature
that empathic and other non-traditional measures
should be used in student selection (Duncan-Hewitt,
1996; Wright & Miederhoff, 1999). At the university
where this study was conducted such measures are not
currently used in student selection for pharmacy,
though they are in medicine and dentistry. Whether to
use such measures in pharmacy admissions is likely to
arouse continuing controversy, not least because it is
now possible for students to be coached in how to
perform well in these tests in such a way that may be
construed as “faking” their true attitudes.
Aspects of interest in pharmacy practice
Interpersonal/empathic aspects again emerged as
aspects of being a pharmacist of most interest to
students, with “listening to patients” and “interviewing
people” receiving the highest ratings. There appears
overall to be a pronounced division in opinions of the
two facets of professional pharmacy practice: students
perceive non-patient-centred aspects of work, such as
administration and selling products, to be less attractive
than the range of patient-centred work. This may be a
sign that students are already conceptualising pharmacy
work as comprising two different types of
activity—indirect and direct patient care—and that
they are inherently more interested in the latter. This
result is perhaps not surprising, and matches other
research indicating students aspire more to involvement
in direct patient care than indirect patient care, with the
latter described as being “product-focused” or involved
with “drug distribution” (Siracuse et al., 2004). Such
attitudes on the part of students would seem to be in
keeping with the altruistic, patient-centred motivations
expressed for studying pharmacy in the first place.
The current study’s results may in a positive way be
placed in the context of Davey et al.’s (2006) remark
that “as pharmacy practice continues to emphasise
patient interface it is encouraging to see that a
contribution to health care is of more significance (to
students) than the status of the degree”. A cautionary
note may also be added though, that in light of these
findings it will be important to consider in future
research the extent to which students’ expectations and
aspirations are matched by the realities of the workplace,
where “for many pharmacists, there is a clear
disconnect between what pharmacy leadership says
pharmacists should be doing and the reality faced by
practising pharmacists on a daily basis” (Siracuse et al.,
2004) especially in terms of the administrative and
bureaucratic demands of small business management.
Undergraduate demographics
The approximate 2:1 ratio of female:male students at
the NSP corresponds with what seems now almost to
be becoming an education standard for this increasingly
female-dominated profession (Hassell, 2003).
Whilst registers of practising pharmacists consist at
present of 53% females in the UK and New Zealand
(Hassell, 2003; Pharmacy Council of New Zealand,
2005b) this seems destined to change. There are
implications for workforce supply, as the current UK
register shows a far greater degree of part-time hours
worked by women in their 30s and 40s thanmen of the
same age group, which in part is due to family building
(Willis et al., 2006c). A similar trend towards
feminisation has been observed in other health
professions, including medicine and dentistry, in the
US, the UK and Australasia, where similar consequences
have been predicted as a result.
The student body at the NSP is noteworthy in that it
is very diverse and unique to this pharmacy school.
Whereas, well-represented ethnic minorities in pharmacy
in the UK are “Asian British”, that is to say
British students of Indian, Pakistani and Bangladeshi
origin, in New Zealand the ethnic origin of (mostly
New Zealand-resident) minority students are mostly
represented by Chinese, Taiwanese, Koreans and
Malaysians, with those from Arabic and other backgrounds
also rising in numbers. Given the high
diversity, there is likely to be consequent variability in
the learning behaviours of students that educators
may increasingly need to take into account (Miranda,
Bates, & Duggan, 2002).
Limitations and suggestions for future research
A social desirability effect on the self-report measures
in this study may be pronounced because the survey
asked about explicitly socially desirable factors such as
“desire to care for/help people”. A strength of this
study is the very high response rate (98%) obtained,
largely through our distribution of the survey during
compulsory course elements. Although the questionnaire
used in this study was based in part on surveys
used in previous research into pharmacy student
choices, its reliability and validity were not separately
tested. Indicators of reliability and validity however
include the emergence of dual factors from questions
pertaining to direct and indirect patient care and the
congruence of certain career- and study-related
motivators emerging in separate areas of the survey,
for example in the intention and aspiration to own a
business. It is the authors’ intention to use a followup
questionnaire in longitudinal research with the
cohort surveyed in 2004–2006, which may give
further indications of its validity and reliability.
A particular point for concern for this and similar
studies is the apparently limited extent to which
physicians have accurate retrospective recall of the
causes of their own behaviour in relation to career
choice (Pathman & Agnew, 1993).
Future work might focus on extending knowledge of
intrinsic and extrinsic factors in choice of profession by
placing the choice of pharmacy as a degree and career
against a wider social context. The extent to which
socioeconomic factors and family background influence
students’ decisions might be further considered, for
example. Large-scale work has indicated that “professional”
class background can have a particular
positive effect upon the choice of prestigious degrees
such as medicine and law (Van de Werfhorst et al.,
2003). These authors also presented evidence that
educational systems are institutionally biased towards
students who possess “cultural capital”, which makes it
difficult for working-class students to succeed in the
education system. Furthermore, because of differential
costs and benefits between class backgrounds, professional
career trajectories are less easily attainable for
working-class students. In the health sciences, differences
in career choice have been found between lowand
high income family backgrounds of medical students
(Cooter et al., 2004). It is not known whether such
influences are as important in New Zealand, where
social systems are perhapsmore fluid. Neither has there
been any examination of whether the cost of study—
which ranged in 2006 from US$3300 per annum for
physiotherapy toUS$3850 for pharmacy andUS$7400
for medicine/ dentistry—influences students’ choice of
career. Nevertheless, it is a matter for concern that the
proportion of BPharmstudents who identify asMaori is
well below the proportion of Maori in the general
population (1–2% compared with 12%).
A further limitation of this study is that it was
focussed to a large extent on students’ intentions,
which may vary over their course of study and may
also not manifest in reality. Edwards, Lambert,
Goldacre, & Parkhouse, (1997), for example, reported
that ten years after graduating only two-thirds of
medical students end up working in the field they
intended to during study. It will be of value in future
research therefore to ascertain the extent to which
students follow through with their intentions, which
will better inform the reliability and validity of this and
similar survey tools and, more importantly, to what
extent expectations and aspirations of pharmacy
students are realised in the workplace. This would
have significance for those promoting pharmacy
degrees and admitting students to their courses, as
to what character of advice is most appropriate and
honest to offer to these aspiring professionals.
Summary and conclusions
This study, as well as previous research across a range
of cohorts, courses and countries, offers a generally
consistent view of the motivations of students to study
pharmacy and work as a health professional. Whereas
other research has suggested that altruistic intent may
be similar in importance to other factors, this study’s
results point to a clear prominence for this particular
factor.
Scientific aspects inherent to pharmacy as a course
of study also act as attractors to the subject area and
pharmacy is perceived in favourable terms as offering
good employment prospects with considerable entrepreneurial
potential. A tendency still exists among
many first year pharmacy students to have selected
medicine or dentistry as a first choice, particularly
among ethnic minority students, a tendency which
may be declining but is likely to be to an extent
inevitable, particularly with a system in which all
students take the same first year curriculum. The
picture among the undergraduate cohort, nevertheless,
is of committed individuals who intend to
pursue a pharmacy career. Gender differences
were shown to emerge between aspirations to work
in the different sectors, and in pharmacy
ownership intentions. The perceived value of a
pharmacy “passport”, and intention to travel with it
is very high among NSP students and will see many
working overseas. Students perceived that good
communication and English skills are of greatest
importance when considering potential entrants to the
course, a belief borne out by the literature. Yet the
Pharmacy School’s admissions process does not place
a greater emphasis on this requirement (which is
currently assessed by means of a paper on Effective
Communication, provided by the University’s English
Department) than any of the other papers of the
compulsory health sciences first year course, despite
the fact that many of its students have English as a
second language.
There is some concern about the extent to which
students’ desire and intentions to own a pharmacy
will be realisable in the future and also the extent to
which students’ experience in community pharmacy
after registration will match their expectations and
preferences.
Future focus for research that elucidates the wider
range of factors likely to influence students’ pursuance
of pharmacy, such as that which relates to family, class
or cultural background is suggested. Also of importance
will be work that better investigates the link
between students’ education and ambitions and the
realities of their professional life.

Club Drug Use in Los Angeles Among Young Men Who Have SexWith Men

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Sex, Drugs, Intervention, and Research: From the Individual to the Social

Epidemiological estimates of the sexual risk behavior of drug users
have provided essential indicators to the current and future prevalence
of HIV transmission. An overview of recent research shows the majority
of drug injectors to be sexually active, low levels of reported
condom use, a significant minority of female injectors to be involved
in prostitution, relatively high levels of sexual mixing between drug
injectors and noninjectors, and only scant indications of sexual behavior
change. Epidemiological studies of risk, however, are unable to
yield the data required to understand the interaction between individual
risk behavior and social relationships. This is required if obstacles to
safer sex compliance and sexual behavior change are to be overcome,
and demands recognition of the influence and importance of social
context on the production of sexual risk behavior in future research
and intervention designs. In response, the paper explores the future
role of qualitative research in understanding the social relations of
“risk” and in contributing toward theoretical advancements in explanations
of risk perception and risk behavior. The paper concludes by
discussing the implications of this analysis for developing interventions
The advent of HIV infection and AIDS has encouraged public debate about
the most intimate of private behaviors. This debate has largely focused on the
sexual behavior and safer sex compliance of gay and bisexual men, women and
men involved in prostitution, and young people. In contrast, the primary focus
of research, intervention, and education targeting drug users has been injecting
behavior and-more specifically-the sharing of injecting equipment.
As mounting evidence indicates that drug injectors are changing their druginjecting
behavior in response to HIV and AIDS (Stimson, 1991), recent epidemiological
research has highlighted the importance of HIV-risk posed to
injecting drug users and their sexual partners through the sexual transmission
of HIV (Des Jarlais, 1992). In the United States, it is estimated that injecting
drug users are the source of HIV in at least three-quarters of heterosexually
transmitted cases of AIDS (Moss, 1987; Des Jarlais and Friedmaq1987). In
the United Kingdom, a drug-injecting partner is reported for over 60% of first
generation cases of heterosexual transmission (Evans et al., 1992). Concerns
predicting the “real heterosexual epidemic” to emanate from drug injectors
(Moss, 1987) have encouraged a “sexual re-awakening’’ for practitioners and
researchers working within the drug field. The recent British Governmenl
document and national health strategy Health of the Nation has fueled these
concerns by reaffirming the increasing significance of sexual transmission in
the future spread of HIV:
HIV is primarily sexually transmitted and prevention of infection depends
largely UPOR changes in sexual behaviour. (Department of
Health, 1992, p. 92)
This paper provides a brief overview of key research findings on the sexual
risk behavior of injecting drug users (IDUs) with the aim of discussing in
greater depth the role of future research and intervention in understanding and
responding to sexual risk behavior and sexual behavior change among drug
users and their sexual partners. It is argued first that there is a need for qualiiative
research to build upon current epidemiological understandings of sexual
risk so as to encompass understandings of the social relations and social context
of sexual behavior, and second that there is a concomitant need for interventions
to target social relationships (rather than simply individuals) so as to
overcome current obstacles to modifications in individual risk behavior and to
encourage wider social and community change.
DRUG TAKING AND SEXUAL RISK
Sexual Activity
Most studies of injecting drug use show the majority of IDUs to be sexually
active. One recent London study, for example, found 80% of drug injectors
to have had vaginal or anal sexual intercourse in the 6 months prior to interview,
and noted that two-thirds of IDUs had vaginal intercourse at least once
a week (Rhodes et al., 1994a). Despite the varying selection criteria and time
frames of measurement employed, other studies show similar proportions of
IDUs to be sexually active: 77% (Van den Hoek et al., 1990), 77% (Donoghoe
et al., 1989), 82% (Klee et al., 1990a), 86% (Coleman and Curtis, 1988).
Findings suggest that levels of reported penetrative sexual activity among
IDUs are comparable to those reported in the British adult population. One
recent study of heroin and cocaine users (IDU and non-IDU) found higher
levels of sexual activity than those in the adult population. In addition, the
average number of reported (noncommercial) sexual partners of IDUs in a 6-
month period (2.4 partners in London and 2.1 in Glasgow) have been found
to be slightly greater than comparative estimates in the British adult population
(Rhodes et al., 1993a).
Sexual behavior research among drug users prior to HIV infection and
AIDS focused primarily on the perceived pharmacological effects of drug use
on sexual activity. These studies suggested a reduction in sexual activity and
sexual interest to be associated with frequent opiate use (Mirin et al., 1980)
and an enhancement of sexual activity and interest to be associated with the use
of stimulants, such as amphetamines and cocaine (MacDonald et al., 1988).
Recent behavioral research undertaken in the context of HIV transmission has
supported an association between stimulant use and increased sexual activity
(Kall and O h , 1991; Fullilove et al., 1990; Chaisson et al., 1989). These
trends, however, are by no means consistent, and there remains considerable
uncertainty about their causal determinants (MacDonald et al., 1988; Washton,
1989; Marx et al., 1991).
Safer Sex Compliance
Most studies of injecting drug use show reported levels of condom use to
be comparable with those in the heterosexual population as a whole. They also
indicate greater likelihood and greater frequency of condom use with casual
partners than with primary partners. Recent findings in London, for example,
show that in a 6-month period two-thirds (68%) of drug injectors never used
condoms with primary partners and over a third (34%) never used condoms
with casual partners (Rhodes et al., 1994a). Other reports indicate that 79%
of injectors in Glasgow (Rhodes et al., 1993a) and 75% of injectors in the
West Midlands (Klee et al., 1990a) never use condoms. Safer sex compliance
with primary partners has been shown to be statistically associated with an
awareness of HIV positive antibody status (Van den Hoek et al., 1992). although
studies also indicate relatively high levels of continued sexual risk
behavior among HIV-positive IDUs (Rhodes et al., 1993b). Surveys of anonymously
tested saliva samples in London also show that the majority of HIVpositive
IDUs are unaware of their positive status (Donoghoe et al., 1993;
Rhodes et a]., 1993b).
A combination of commonsense assumption and research evidence suggests
that drug use has a disinhibitory effect on decision-making about sexual safety
and on safer sex compliance (see Rhodes and Stimson, 1994). While there
remains little comparative or conclusive research in this area, recent research
has associated higher levels of sexual risk behavior with increased severity of
drug dependence (Gossop et al., 1993), frequent amphetamine use, temazepam
and polydrug use (Klee et al., 1990b), and cocaine or crack use (Chaisson et
al., 1991).
Most United Kingdom studies conclude that condom use remains at insufficient
levels to prevent the potential for further sexual transmission of HIV
between drug injectors and their sexual partners, particularly given average
rates of partner change and the significant minority of injectors who also continue
to share used equipment with people other than their sexual partners
(Rhodes et al., 1993a).
Prostitution
There is an established overlap between an involvement in injecting drug
use and an involvement in female prostitution, Estimates in London show 14%
of women prostitutes attending sexually transmitted disease (STD) clinics (Day
et al., 1988) and 33% contacted through street outreach (Rhodes et al., 1991)
to inject drugs. Estimates elsewhere range from 25% (Kinnell, 1989) to 59%
(McKeganey and Barnard, 1992). Studies of injecting drug use also indicate
a high proportion of female injectors to be involved in prostitution: recent
estimates suggest 14% in London and 22% in Glasgow (Rhodes et al., 1993a:i.
There is little evidence of injecting drug use among male prostitutes (Bloor et
al., 1992).
As is the case with female sex workers (Day et al., 1988), female IDUs
involved in sex work report higher levels of condom use with paying partners
than with nonpaying partners. In Glasgow, female IDUs involved in prostitution
report almost 100% condom use with paying partners compared with 9%
“always” condom use with nonpaying primary partners and 22 % “always”
with nonpaying casual partners. In London, female IDUs involved in prostitution
report 70% “always” condom use with paying partners (Rhodes et al.,
1994b).
Estimates of HIV prevalence among women prostitutes have found higher
rates of prevalence among prostitutes with a history of injecting drug use, and
in European and North American countries evidence associates HIV transmission
among prostitutes with an involvement in injecting drug use rather than
with an involvement with prostitution per se (Padian, 1988; Van den Hoek et
al., 1988; McKeganey et al., 1992). In the absence of controlled studies designed
to assess the relative risks of sharing used injecting equipment and
sexual transmission of HIV, it is difficult to determine the epidemiology of
epidemic spread among drug-using and nondrug-using prostitutes. A recent
prevalence survey in London found HIV infection to be no higher among female
IDUs involved in prostitution than among IDUs not involved in prostitution
(13% compared with 14%) (Rhodes et al., 199413). This adds further
support to emerging evidence which suggests that prostitution per se is not
independently associated with HIV prevalence or HIV risk behavior.
Sexual Partners
Studies show a relatively high degree of sexual mixing between injecting
and noninjecting drug users: approximately half of the sexual partners of injectors
are estimated to be noninjectors while approximately half of injectors
report noninjecting sexual partners (Rhodes et a]., 1993a). The vast majority
of these partners are women. This is in part an artifact of injecting drug use
being a predominantly male activity and in part because male injectors show
specific preferences for noninjecting female partners (McKeganey and Barnard,
1992). Such preferences may also be more likely with primary (i.e., more
important longer term) partners than with casual partners (Rhodes et al.,
1994a). This poses increased sexual risks to the noninjecting sexual partners
of injectors, and in particular to female primary partners, for whom contact
with an injecting drug user may be their only significant risk factor. It is within
primary relationships that condom use is most infrequent, while a significant
minority (between 16% and 19%, Rhodes et al., 1993a) of injectors report both
primary and casual partners in a 6-month period.
There are few studies which have explicitly involved the sexual partners
of drug users in research. North American qualitative research indicates the
difficulties female sexual partners of injectors have in initiating and negotiating
strategies of protection not only for themselves but also for their partners
both with regard to safer sex and needle safety (Wermuth et al., 1992; Kane,
1991).
There are few longitudinal or cohort studies of sexual behavior change
among drug injectors, and in comparison to studies of injecting and sharing
practices, only scant indications of change. Although some studies point tci
reductions in the number of sexual partners and sexual encounters and increased
levels of reported condom use (Skidmore et al., 1989), these have been
limited changes, and some studies report either no change or increased levels,
of sexual risk behavior over time (Des Jarlais et al., 1992; Calsyn et al.,
1992). The lack of notable sexual behavior changes relative to changes in drugtaking
behavior among drug users probably relates to a combination of factors.
These include injectors’ own assessments of sexual risk as relative to drugrelated
risks (Jain et al., 1991), the problems experienced in translating knowledge
about sexual risk into action, the primary focus of research, intervention
and education agencies on modifications in injecting behavior, and the associated
notions of identity and responsibility which this has created and reinforced
within drug-injecting communities about sharing and drug-using practices
(Rhodes and Quirk, 1996).
RESEARCH: EXPLAINING THE INDIVIDUAL AND SOCIAL
DYNAMICS OF “RISK’
Current Epidemiological Explanation: Some Possible
Improvements
Conventional epidemiology is concerned with the study of the distribution
and determinants of disease (Barker and Rose, 1984). In the case of the public
health response to the HIV epidemic, epidemiological research has provided
essential indicators of the distribution and determinants of HIV disease among
injecting drug users. This has provided baseline quantitative indicators on levels
of sexual activity and sexual risk behavior among drug users and their sexual
partners and has laid the foundation for the development of a range of HIV
prevention and safer sex health promotion initiatives targeting changes in individual
sexual lifestyles.
As HIV transmission routes among injecting drug users shift from parenteral
to sexual routes as safer injection becomes more commonly adopted
(Schoenbaum et al., 1989), it is important that future epidemiological studies
of sexual risk behavior both clarify and improve indicators of the distribution
and determinants of sexual activity and sexual risk behavior. Current epidemiological
explanations of sexual risk among drug injectors can be improved
in four main ways.
First, there remains a need for greater comparability between studies in
measures of sexual risk behavior. At minimum, indicators need to include
measures of the frequency, type, and number of sexual partners; frequency and
type of penetrative and nonpenetrative sexual encounters; and frequency of
condom use and safer sex. Most previous studies have employed partial indicators
of sexual risk, usually as a component of investigations primarily concerned
with drug-taking practices. Reliable epidemiological indicators of HIV
risk need to measure the interaction between the frequency and type of drugrelated
and sex-related risk behavior. It is fundamental also that studies remain
comparable in the time-frames of measurement (i.e., period of recall) and
categories of measurement (i .e., continuous or dichotomous) employed
(Samuels et al., 1992), as well as in the definition of key “risk” variables (e.g.,
“prostitution,” “safer sex”).
One possible methodological development in the measurement of drugtaking
and sexual risk behavior is the use of retrospective and prospective selfcompletion
diaries. Sexual diaries have provided an effective and reliable means
of data collection among gay and bisexual men, minimizing problems of recall
and providing a detailed and time-coded description of sexual encounters
(Coxon, 1988). The feasibility and reliability of using diaries as a method of
data collection among drug users is largely unknown. The use of diary methods
may provide more accurate assessments of the interaction between drug
taking and sexual risk, allowing examination of the causal dynamics of the
relationship between drug use and sexual activity by gathering time-coded
behavioral data within specific drug use and sexual encounters. Such analyses
may also provide opportunities for delineating the dynamics of the pharmacological
relationship between drug use and sexual risk and the influence of interpersonal,
situational, and social context on the perceived and experienced
effects of drug use on sexual behavior.
Second, improvements can be made to sampling designs. The majority of
studies of HIV prevalence and HIV risk behavior among drug users draw on
highly selective samples drawn primarily from drug user treatment and agencybased
populations (Samuels et al., 1992). The majority of drug users, however,
remain out of contact with treatment and helping services (Frischer, 1992), and
a number of studies have indicated higher levels of HIV prevalence and higher
levels of drug-related HIV risk behavior among nontreatment populations
(Lampinen et al., 1991; Donoghoe et al., 1993). Less is known about the
degree to which “hidden” populations of drug users also engage in sexual
transmission behaviors, and the influence (if any) of drug treatment on health
behavior changes not directly related to drug use such as sexual health is unclear.
The desire to change HIV transmission behavior, however, may be an
equally important determinant of changes in drug taking and sexual behavior
than the influence of drug treatment and helping services per se, while those
engaging in higher levels of risk related to drug use may also have a propensity
for higher levels of risk behavior as a whole. Future epidemiological research
needs to simultaneously recruit samples from a variety of drug user
treatment and nontreatment settings, with the aim of investigating the possibility
of bias in indicators of risk which rely primarily on clinic and agency-based
samples (Alcabes et al., 1992).
Third, improvements can be made to study design. The majority of studies
employ cross-sectional study designs with retrospective measures of risk, and
there are few longitudinal or cohort studies of sexual risk behavior and sexual
behavior change among drug users. While there are practical and methodological
difficulties inherent in cohort study designs among drug users (Vlahov and
Polk, 1988; Samuels et al., 1992), if future studies are to yield data on the
problems and possibilities of sexual behavior change, ideally these should simultaneously
include longitudinal as well as cross-sectional designs.
Fourth, improvement can be made to current epidemiological measurements
of “risk behavior.” Current studies invariably take the individual as the
unit of analysis. Because HIV infection is a behavioral disease, its progression
is not random or uniform but subject to much variation and change. Reliable
epidemiological indicators of the distribution of HIV risk and HIV spread require
a measure not just of the frequency and type of risk behavior in individuals
but also a measure of the interaction and epidemiological efficiency of
mixing patterns between individuals (Vlahov et al., 1990; Samuels et al.,
1992).
In addition to the individual, it is equally important that future epidemiological
study takes as its unit of analysis “social units” of drug injectors, defined
in terms of the social and epidemiological ties and connections between
individuals which are relevant for investigating HIV transmission. These social
units range from particular relationships between individuals as in the case
of friendship or sexual dyads to wider social relationships of individuals as with
drug dealing and friendship networks. Since it is the interaction between individuals
which determines HIV transmission, shifting the unit of analysis toward
“social units” to determine the epidemiological efficiency of these inter -
actions enables greater reliability in assessments of risk and in estimates of
cpidemic spread.
One priority for future research in this area includes an assessment of the
assortative and disassortative* sexual mixing patterns among drug injectors and
the sexual partners of drug injectors. While current research has highlighted
an increased risk of HIV infection to the noninjecting sexual partners of injec-
tors, there are difficulties in estimating the associated risks of sexual transmission
to noninjecting heterosexual populations without concomitant knowledge
of the sexual mixing patterns of both injectors and their sexual partners.
Theorizing Risk: The Limits of Individualism
Conventional epidemiology remains locked into a conception of risk which
is restricted to the individual (Tannahill, 1992). As noted above, most epidemiological
study takes the individual as its unit of analysis and most explanation
and prediction is based entirely on measures of individual risk behavior
(see Table 1). Such explanations are limited because they remain blind to a
variety of other social and cultural processes which influence the ways in which
individuals behave, and thus also the ways in which epidemics spread. As
recently suggested, the social impact and significance of HIV-risk can only be
understood and explained by “filling-in and questioning the empty categories
of epidemiological prediction” (Kane, 1991, p. 1037).
It is in this context that it is important to note that epidemiology and epidemiological
approaches have largely framed the focus and parameters of lay
and professional understanding about HIV infection and AIDS (Herdt and
Lindenbaum, 1992). As noted by Berridge, epidemiologists have played the
lead part in defining and ordering the disease and in giving it a name
(Berridge, 1992). It is important to recognize that it is epidemiological understandings
and categories of “risk behavior” and of “risk groups” that have
informed and defined the boundaries of psychosocial behavioral research investigating
the determinants of individual risk behavior and lifestyle.
Psychosocial models of research and health behavior based upon individualistic
lifestyle notions of risk are often inadequate to address the complex
social realities of risk acceptability, risk perception, risk assessment, and behavior
change (see Table 1). These models, which emphasize the “health beliefs”
(Becker, 1974), “self-efficacy’’ (Bandura, 1977), and motivations and
skills (Joseph et al., 1988) of individuals to behave in certain ways, recognize
a cognitive decision-making process in risk perception and risk behavior but
fail to adequately capture either their social dimensions or their complexity.
While providing pointers to behavioral intention, this is often devoid of social
and cultural explanation or understanding (Romer and Hornik, 1992; Ingham
et al., 1992). Such research has been found to have a limited capacity and
utility in either predicting or explaining health beliefs about sexual risk and
sexual behavior change (Rosenstock et al., 1988; Bloor et al., 1992; Montgomery
et al., 1989).
Current epidemiological and psychosocial theorizing on risk perception and
behavior is based on the assumption of individual rationality (Rhodes, 1995).
Dominant theoretical approaches to understanding health behavior-such as
derivatives of the theories of Reasoned Action, Planned Behavior, and the
Health Belief Model (see; Ingham et al., 1992; Becker, 1974; Fishbein and
Azjen, 1975; Azjen, 1988)-view “risk-taking” as the result of an individual’s
rational decision-making based on the perceived costs and benefits of risk action.
At their crudest, such models of explanation assume a single rationality
of choice-making about risk (Rhodes, 1995). Choices to avoid risk, which are
frequently spoken of in health promotion discourses as the “healthy choices, ”
are seen as “reasoned” choices, as exemplars of rational rather than irrational
behavior. This often demeans explanations of continued risk behavior among
IDUs to the rather dubious scientific categories of “unreasoned” behavior and
cognitive malfunction.
Recent attempts to move beyond “single rationality” theories of risk perception
toward theories of “situated rationality” overcome some of these limitations
but clearly remain inadequate (Bloor, 1995; Rhodes, 1995). These theories
recognise that rationality is inextricably linked to the specific situations and
contexts in which choices about risk are made. They go as far as to allow a
plurality of rationalities and thus move beyond a one-dimensional matrix of
“cost and benefit” where cost is synonymous with risky actions and benefit is
synonymous with their avoidance. “Situated rationality” theories of risk behavior
may help explain, for example, why condom use by IDUs with casual
partners has increased over time while condom use with primary partners has
remained relatively constant. Our current qualitative work on sexual negotiation
indicates that in some cases HIV-negative IDUs may continue to have
unprotected penetrative sex with their HIV-positive partners, despite knowledge
and understanding of the proximity and susceptability of risk (Rhodes and
Quirk, 1996). “Situated rationality” theories would posit that these decisions
about risk are reasoned by individuals on the basis of costs and benefits which
are situation and context dependent (e.g., where loss of trust or intimacy may
be perceived to be of greater cost than the risk of HIV).
But as we noted above, “situated rationality” theories remain inadequate
to explain the social realities of risk behavior. As with other derivatives of
theories of “reasoned action,” they assume that decisions about risk action are
calculated. While in some instances this may be the case, this does not recognize
the habituation of risk behavior (Bloor, 1995). Many of the behaviors
in which IDUs routinely engage, whether deemed “risky” by themselves or by
social scientists, are everyday behaviors which occur in a mundane or unspectacular
fashion, often without individual “decisions,” “choices,” or “calculations”
having to be made. Because such theories are ostensibly theories of
individual cognition, they are unable to recognize that individual rationalities
and perceptions are socially organized:
If a group of individuals ignore some manifest risks, it must be because
their social network encourages them to do so. Their social
interaction presumably does a large part of the perceptual coding on
risks. (Douglas, 1986, p. 67)
The individualism of current theories of risk provide limited understandings
of risk behavior. “Risk” is neither perceived nor understood by individuals
as a neutral category but is socially and culturally organized and acted upon
(Douglas, 1986, 1992; Douglas and Wildavsky, 1983; Bloor, 1995, Rhodes,
1995; Hart and Boulton, 1995). This means that epidemiological understandings
and measures of risk-particularly when applied in survey-based research-
often lack social and cultural specificity and appropriateness. They fail
to account for the ways in which risk is socially and culturally defined and the
ways in which individual understandings of risk are socially and culturally
mediated (see Table 1). Because individual rationalities are based on wider
socially organized boundaries of explanation and meaning, “risks” are not simply
or only “calculated” by individuals and neither is risk action necessarily
individually “chosen” or “decided” upon. It is for this reason that the notion
of risk taking is both inaccurate and misleading. The “choices” which current
psychosocial research paradigms assume to be “taken” by individuals are COMcomitantly
determined by a combination of social, cultural, and economic factors.
What social scientists often view and measure as being individual volktion
may sometimes not be “choice” at all (e.g., cases of sexual persuasion,
“negotiation,” and coercion, or unsafe sex for money). Contemporary explanations
of HIV and sexual risk behavior provide little notion or measure of
“the social.” Parrallels can be made with anthropological critiques of how
theorizing on risk has tended toward the “deculturing” of individuals:
Expert risk analysis takes as its decision-making unit the individual
agent, excluding from the choice any moral or political feedback that
he may be receiving from his surrounding society. The rational agent
of theory is decultured. (Douglas, 1986, p. 67)
Rather than focusing exclusively on the psychological determinants of individuals
in risk-related encounters, there is a need for future research to recognize
how individual perceptions of risk and individual capabilities to control
risk-related encounters are relative, both to wider peer-group, social, and community
norms and to situational and structural context (see Table 1). The fundamental
aim of such research is to focus on the pattern of interaction between
risk behavior and social relationships and less on individual decision-making
and the risk behavior patterns themselves (McKeganey and Barnard, 1992).
Investigating the relationship between individual risk perception and social
context encourages an understanding of the obstacles to individual behavior
change. This demands a shift in direction toward a more qualitative action
oriented research paradigm suited to investigating the social contexts and social
relations of drug use and sexual activity (Rhodes and Stimson, 1994).
This new paradigm of HIV risk research aims to build upon current epidemiological
and sociological understanding of sexual risk behavior among
drug users in an attempt to provide pragmatic support to developments in health
promotion and intervention. It is our contention that it is timely and important
that a new paradigm of sexual risk research requires more than evidence of risk
behavior and of behavior change: it also needs to investigate and influence the
process of change.
Understanding the Social Processes of Risk
We have suggested that epidemiological research is of incontestable importance
in mapping the future determinants of epidemic spread, and that this
contribution is best invested in an understanding the interactive nature of risk
and risk behavior. While epidemiological and psychosocial study is suited to
mapping the determinants and distribution of individual risk perception and
behavior cross-sectionally and longitudinally, it currently lacks the descriptive
capabilities to understand the social processes which determine the ways in
which perceptions and behaviors are produced. It is unable to appreciate the
subjective nature of the objects of study.
What is needed is a move toward an interactive paradigm of research
which is inclusive of sociological and anthropological methodology and explanation.
At the outset this demands a shift from conventional epidemiological
approaches toward a “social epidemiology” which aims to classify the determinants
of disease and illness on the basis of their social and economic origins
(Paterson, 1981; Scott-Samuel, 1989; Tannahill, 1992). The role of sociological
and anthropological research in this context is twofold.
First, it aims to describe the personal and social meanings attached by
individuals and by groups of individuals to specific behaviors categorized as
“risky” by the epidemiologist. This means describing behavior in the context
of the meanings participants themselves have ascribed to their behavior. Behaviors
attributed “risky” by the epidemiologist are thus to the qualitative sociologist
part of a wider structure or culture of behaviors and associated meanings,
which to participants themselves are often viewed and experienced as “normal,”
rational, even mundane (Schwartz and Jacobs, 1979). This means understanding
risk behavior in the context of drug users’ everyday lives:
For the IV drug using subculture in particular, the risks associated
with AIDS transmission overlap with a constellation of risks about
which we know little. The concept of risk-taking as a common and
meaningful dimension of the lives of IV drug users has so far been
hidden behind an externally-constructed pastiche of risk behaviours
specific only to AIDS. (Connors, 1992, p. 591)
Second, it aims to understand the processes by which individuals come to
attach meaning to “risk behaviors” and the ways in which individuals interact
with wider systems or structures of knowledge and influence about HIV, risk,
and health. This means investigating the social and cultural production of
knowledge about HIV-related risk (of which epidemiology and dominant scientific
discourse is a part) in the light of other situational and environmental
factors which influence health behavior. Overall, the aim is to understand the
“reciprocal effects of social settings upon individuals and of individuals upon
social settings” (Schwartz and Jacobs, 1979, p. 9) with the objective of determining
the problems and possibilities of reducing drug and sex-related harm.
The move toward such a research paradigm demands fundamental shifts
in contemporary thinking about social problems. As noted above, conventional
epidemiology has played the key role in identifying and defining HIV risk and
in influencing how policy and health interventions should best respond. The
need to view HIV infection and HIV risk as socially constructed problems requires
untangling the processes which have been key to “inventing” HIV and
AIDS (Patton, 1990). One of the challenges of the second decade of AIDS is
to bring about fundamental shifts in how research aims to reconstruct the social
realities of health behavior and everyday life among populations affected
by HIV transmission. As has been observed in the field of risk perception:
A very significant body of work views risk perception as an individual
and not as a social phenomenon. . . . It seems that the neglect of culture
is so systematic and so entrenched that nothing less than a large
upheaval in the social sciences would bring about a change. (Douglas,
1986, p. 1)
Understanding Drug Taking and Sexual Risk
A closer inspection of current research explanations of the relationship
between drug taking and sexual risk demonstrates the importance of viewing
sexual risk behavior as a socially organized interaction. Here we use the example
of crack and cocaine use (see Rhodes and Stimson, 1994, for a full
discussion).
There is mounting epidemiological evidence which shows there to be an
association between the use of crack and cocaine and increased levels of reported
sexual activity and sexual risk behavior (Wolfe et al., 1990; Fullilove
et al., 1990; Chitwood and Comerford, 1990; Chaisson et al., 1989, 1991).
This reflects contemporary concerns that stimulant drugs (and in particular,
cocaine and crack) have disinhibiting effects on safer sex compliance:
The danger of crack lies in its potential to promote high-risk sexual
behavior through which AIDS can be contracted [italics added].
(Bowser, 1989, p. 539)
More than a cursory glance of the epidemiological literature reveals that
there are many studies which show no such associations or which show such
associations to be complicated by an interaction of social, situational, and
material factors (Hartgers et al., 1991; Wolfe et al., 1990, 1992; Inciardi,
1989). While studies show associations between cocaine and crack use and HIV
positivity, there are few studies of sexual transmission and few which show
these to be causal associations in people without a history of injecting drug use
(Marx et al., 1991; Chaisson et al., 1991).
While the current epidemiological picture remains blurred (see Marx et al.,
1991, for a review), it is becoming increasingly clear that sexual risk behavior
among crack and cocaine users is determined by a range of social, situational,
and cultural factors which often remain peripheral to the vision of
epidemiology. Two examples help to demonstrate this.
First, ethnographic research has shown the importance of social and group
norms in influencing individuals’ perceptions, expectations, and accounts of the
effects of crack on sexual behavior and performance (Inciardi, 1989; Carlson
and Siegal, 1991). This means that there is often a subcultural “mythology”
attached to crack and sexuality which informs individual and group expectations
and understandings of the effects of crack and cocaine on sex-related
behavior. While sexual behavior in crack-related encounters may vary depending
on an interaction of social, situational, and material factors (see below),
individuals often make sense of such experiences in a limited number of ways
in the light of shared knowledge about what is legitimate (i.e., “normal”)
behavior. It is important to study both the processes by which knowledge is
socially organized and the ways in which individuals interact with this body
of knowledge to make sense of their own behavior:
We may make more sense of people’s explanations, especially when
given in social contexts, if we . . . acknowledge that, as accounts,
common-sense explanations often serve to excuse and justify, and not
merely to explain. (Hewstone, 1989, p. 37)
Second, ethnographic research has shown that in some crack-related settings
it is normal and legitimate for the drug to be exchanged for (often unsafe)
“sexual favors” which are often initiated and performed by men as “degradation
rituals” (Carlson and Siegal, 1991). These encounters are often not
viewed or understood as “prostitution” by the participants concerned but are
seen as a necessary or usual component of the drug deal and of the crack-related
encounter. While this may be documented as being of epidemiological importance
given the increased sexual risks associated with crack use, this cannot
fully explain the processes which determine such events. Such sexual
encounters are determined not simply by an interaction between pharmacology
and individual psychology but by a complex interaction between the individual
and the social which determines both the economics and currency of drug and
sex exchanges.
Future research which aims to investigate and influence sexual behavior
change among drug users requires an understanding of the social, cultural, and
material exchange “value” of behavior and the ways in which such values and
meanings limit the predictive and explanatory effectiveness of rational and
decision-making models of individual behavior.
INTERVENTION: FROM INDIVIDUAL TO SOCIAL CHANGE
HIV Prevention and the Limits of Individual Change
While ethnographic research points to indications of large-scale and community
changes in drug-injecting behavior (Burt and Stimson, 1993), HIV
prevention programs targeting drug users have found greater difficulty in promoting
and achieving sexual behavior change (Table 2). In recognizing the
inadequacy of interventions based on biomedical notions of individual lifestyle
and sexual behavior change (Ehrhardt, 1992), the challenge for safer sex health
promotion is to both create and nurture a collective and social responsibility
about sexual behavior and sexual health.
The recent advocation and adoption of community-based HIV prevention
strategies targeting harder-to-reach drug users may provide the foundation and
stimulus for such a response (Rhodes, 1993, 1994a, 1994b). Current UK interventions
are predominantly focused toward the individual client and toward
achieving individual behavior change. These initiatives attempt to contact drug
users, the majority of whom are out of contact with existing health services,
with the aim of enabling them with the means to make safe choices about drugtaking
and sexual behavior.
The effectiveness and efficiency of current UK models of community-based
HIV prevention have recently come under critical review. Recent evaluation
has raised important questions about the limitations of community-based interventions
which work within a mode of health education dominated by an individualistic
focus. Evaluation of the UK syringe exchange schemes, for example,
has indicated the inherent limitations of the approach in encouraging and
sustaining behavior change among drug injectors in the community and in
social environments where risk behavior is actually produced (Stimson et al.,
1991; Stimson and Donoghoe, 1996). Despite the availability of injecting
equipment though syringe exchanges, “choices” about whether to share such
equipment are also influenced by particular social relationship dynamics (e.g.,
between sexual partners), social desirability, and social acceptability. Qualitative
research in Glasgow, for example, notes differences in patterns of sharing
among women and men where sharing was found to be a “socially embedded
behaviour which [was] responsive to the many rights and obligations” within
social relationships (Barnard, 1993).
While outreach and extra-agency work enables education in situ-within
the social environments where risk behaviors are produced-this also largely
remains targeted toward individuals with the aim of encouraging “self-empowerment”
on a client-centred basis (see Table 2). Evaluation of street-based
outreach questions the utility of such an approach, pointing to wider social and
material factors (e.g., peer group norms, housing and welfare needs) which can
impede the effective promotion and adoption of changes in individual lifestyle
and sexual risk behavior (Rhodes and Holland, 1992).
This confirms ethnographic and behavioral research which shows the importance
of social and peer group norms and of situational and social setting
in shaping behavior change (Rhodes and Hartnoll, 1996). If intervention is to
build effectively on the findings of recent research, greater emphasis must be
placed on the targeting of networks and communities as objects and as agents
of change rather than individuals and individual risk behavior alone (Friedman
et al., 1992, 1994; Rhodes, 1993, 1994b; Stimson et al., 1994). This is necessary
as a first step to creating the social relations in which individuals can
exercise “choices” about their health behavior.
Toward Social Network and Community Change
There are few UK interventions which explicitly attempt to encourage
collective or community change among drug users, and there remains considerable
inexperience in using the appropriate intervention methods to achieve
these aims. UK interventions have much to learn from their international counterparts
(largely US and Australian) reportedly effective in encouraging community
change (Wiebel, 1988; Friedman et al., 1992; Friedman et al., 1994;
Trotter et al., 1993) and much to learn from studies of community participation
and organization in health promotion as a whole (Rogers and Shoemaker,
1971; Rogers, 1983; Bracht, 1990; Tones et al., 1990; Freire, 1972).
In understanding the possibilities for initiating and reinforcing change in
social networks or communities of drug users, it is useful to draw on the established
theories and practices of community development and, in particular,
communication and diffusion of innovations (Rogers and Shoemaker, 197 1 ;
Rogers, 1983). Communication of innovations theory provides important guiding
principles which govern the conditions necessary for change and the likelihood
of change being adopted. There are essentially four principles (Tones
et al., 1990): the characteristics of communities govern the need and desire for
change; the ownership of, and identification with, an innovation (or intervention)
by a community governs the likelihood of adopting and sustaining change;
the process of change is governed by the homophily* existing between community
leaders and change agents; and the process of change is governed by
the characteristics and perceived consequences of change.
To move beyond the limitations of interventions targeting individuals as
agents of change, interventions first require knowledge of the characteristics
and structure of drug-using social networks. This is necessary so as to understand
and monitor the possibilities for diffusion, of the “processes by which an
innovation is communicated through certain channels over time among the
members of a social system” (Rogers, 1983, p. 5). Analysis of social network
structure thus requires epidemiological and sociological mapping of the nature
and structure of social relationships within social networks. As noted by Scott
on the subject and method of social network analysis:
Relations are not the properties of agents, but of systems of agents;
these relations connect pairs of agents into larger relational systems.
(Scott, 1991, p. 3)
This means describing the “contacts, ties, and connections” between individuals
within a network with the aim of delineating the channels of communication
and influence for targeted innovations. It is for this reason that the
role of outreach worker or peer educator often overlaps with the role of community
ethnographer and that many outreach programs in the United States
have developed simultaneously in the light of ongoing ethnographic intervention-
based research (Wiebel, 1988, 1996; Feldman and Aldrich, 1990; Grund
et al., 1996). An ethnographic description of drug-using special networks thus
consists of “a body of qualitative measures of network structure” (Scott, 1991,
p. 3) delineating the “specific type of relation linking a defined set of persons”
(Knoke and Kuklinski, 1982, p. 12).
More particularly, it is important to gauge the extent to which specific
networks or communities of drug users are homogeneous. The extent as well
as the specific nature of connections within networks clearly influences the
feasibility for diffusion of communications. Each individual drug user can be
seen to have a multitude of ties into a number of overlapping ego-centered
networks: it is the job of ethnography to determine which particular ties into
which particular networks are relevant for targeting as potential channels of
diffusion into group-centred networks. The potential that drug-dealing networks
hold for communication of innovations, for example, may differ from the
potential that drug-using, friendship, or sexual networks have. The heterogeneity
within as well as across social networks and communities of drug users
across time and space must be considered the first obstacle to targeting social
networks as a way of instrumenting “community change” (Rhodes, 1993). In
contrast to a greater developed sense of collective social and political identity
among communities of gay men, for example, identities, “ties and connections”
within social networks of drug users may be more functional than ideological,
and perhaps more imagined than real (Rhodes, 1994a). Interventions encouraging
community change within drug-using networks thus need to build upon
existing social ties, norms, and values by first identifying perceived needs for
change and second by creating and nurturing a sense of collective identity and
shared responsibility about innovation and change in individual and collective
health behavior.
Available evidence points to the effectiveness of interventions targeting
peer influence as a method of facilitating collective action and community
change. Among gay men, research has demonstrated the importance of collective
action in first creating the social and cultural conditions necessary for
sexual behavior change and second in influencing and reinforcing the validity
and efficacy of continued changes in sexual behavior (Ehrhardt, 1992; Hart and
Boulton, 1995). A number of studies show greater sexual risk reduction
changes among gay men who are socially integrated into existing gay social
networks than among gay men who are not (Kippax et al., 1992; Freeman et
al., 1992). Studies also show that greater sexual risk reduction changes are
reported among gay men who receive social and peer support when attempting
changes in their sexual behavior and condom use (Kelly et al., 1990,
1992). Crucially, controlled comparative evaluation shows greater sexual risk
reduction to be achieved among those targeted by peer group organizing within
preexisting social networks than by conventional individually-targeted health
education alone (Kelly et al., 1992).
While drug-using subcultures are often characterized by social relationships
which appear unconducive to the creation and reinforcement of collective social
responsibilities (Friedman et al., 1990), recent research has demonstrated
both the normative importance of sharing in drug users’ social and material
relationships (McKeganey and Barnard, 1992) and of peer support in influencing
behavioral norms and behavior change (Friedman et al., 1992). Friedman
et al. (1992), for example, note the importance of peer support from the drugusing
and nondrug-using friends and relatives in changing drug users’ sexual
behavior (Abdul-Quader et al., 1989) and condom use (Sotheran et al., 1989),
while condom use among female sexual partners of drug users (Tross et al.,
1992) and among women enrolled in methadone treatment programs (Ramos
et al., 1992) have also been found to be associated with peer support and
endorsement.
It is well established that longer-term more experienced drug users often
initiate and “educate” new recruits into appropriate drug-taking behavior (Des
Jarlais et al., 1989). Future interventions might begin by targeting such individuals
within specified social networks with the aim of encouraging them to
impart health recommendations to new recruits into drug use and to individuals
new to their social networks and social circles.
Examples of Social Network and Community Change
Since 1987, the US National Institute of Drug Abuse (NIDA) has funded
a number of demonstration outreach projects targeting drug injectors and their
sexual partners. Of key importance has been the development of “Peer Driven”
and “Indigenous Leader Models” of outreach (Wiebel, 1988, 1996; Broadhead
and Heckathorn, 1994; Koester, 1992) and recent moves toward social network
interventions (Trotter et al., 1993). One of the best established demonstration
projects targeting community changes among injecting drug users is the Chicago
AIDS Community Outreach Intervention Project (Wiebel, 1988, 1996).
Developed initially as a method to intervene and control community outbreaks
of heroin use, it combines epidemiological indicators of risk behavior with
community-based ethnography as a way of designing and implementing appropriate
intervention in the community. The project employs a sequence of strategies
to identify and execute appropriate intervention targets with the overall
aim of facilitating collective change (Wiebel, 1988).
First, the use of qualitative and ethnographic methods and of ethnographers
are outreach workers helps identify community norms and values attached to
health behaviors. Second, the use of former and current drug users as outreach
workers and ethnographers facilitates access to target populations and communication
with target drug users. Third, the repeating of outreach contacts using
a series of complementary risk reduction messages at different locations
maximizes health recommendation exposure and reinforces its content. Fourth,
and most significantly, the targeting of key individuals and their subsequent recruitment
as AIDS Prevention Advocates to enhance and impart health recommendations
to their friends and peers helps encourage socially responsible
beliefs and opinions about health behavior, and, over time, generates a collective
response to behavior change.
The Chicago outreach project can be seen to embody many of the classic
heath promotion strategies developed in communications of innovations theory
(Rogers and Shoemaker, 1971; Rogers, 1983). It is based on sound epidemiological
and ethnographic assessment of the structure and shared norms of identified
social networks, and it employs ideas of homophily in the use of indigenous
outreach workers/ethnographers and key community leaders as peer
educators. This gives indication of the likelihood of change being adopted and
of the possibilities for reinforcing and sustaining the process of change overtime.
The project has been effective in encouraging risk reduction changes over
time and recently has been associated with a declining incidence of new HIV
infections among target populations (Wiebel et al., 1994).
The Chicago project can be seen as a model intervention where ethnographic
observation informs intervention strategy and response (Wiebel, 1996).
One other model intervention, recently developed in Connecticut, provides an
example of a social network intervention where the preexisting structure of
social networks is defined less by a priori ethnographic research than by IDUs
and their peers themselves (Broadhead and Heckathorn, 1994; Grund et al,
1996). The East Connecticut Outreach Project (ECHO) employs ethnography
to make initial contact with IDUs and to develop and implement appropriate
intervention messages, but thereafter encourages IDUs, by a coupon system of
peer-referral, to contact and educate their peers (see Grund et al., 1996, for
a description of intervention methods). All IDUs receiving education from their
peers are encouraged to do likewise and educate peer contacts of their own and
to make contact with the core outreach team for assessments of peer education
given and received. Whereas the Chicago project builds up a picture of the
structure and connections within drug-using social networks by ongoing ethnographic
observations, the ECHO project begins to identify the structure of
preexisting networks by the connections which are made between peers involved
in the outreach intervention.
This means that no a priori assumptions are made as to what a network
is or of how it best operates with regard to the communication of health interventions.
While the Chicago project operates within the paradigm of “Indigenous
Leader Models” of intervention aiming to identify which IDUs within
a network have “leadership” status or potential, the ECHO project operates
within a paradigm of “Peer Driven Models” of intervention which aim to identify
and exploit preexisting channels of communication and influence as they
“naturally occur” within social networks (Broadhead and Heckathorn, 1994;
Grund et al., 1996). The Chicago project aims to diffuse communication within
networks by identifying which individuals appear to have most influence in
maintaining or “policing” network norms, while the ECHO project aims to
diffuse communication by a cue-system based on preexisting power and organi
zational structures (peer to peer rather than “peer educator” to peer). Without
altering the dynamics and nature of communication flow within networks, the
ECHO project aims to encourage a system of “group mediated social control”
where groups or networks of people “police” themselves (see Heckathorn,
1990, for a theoretical outline of Group-Mediated Social Control, and Broadhead
and Heckathorn, 1994, for a description of its application to HIV outreach).
While the ECHO project remains in its developmental stages (6 months
implementation at the time of writing), preliminary findings from process evaluation
suggest that it is well received by IDUs (Grund et al., 1996).
Social network interventions may also be planned and developed on the
basis of systematic social network analysis. Work undertaken by Trotter and
colleagues points to the pragmatic value of an intimate and synergistic linkage
between social network analysis and intervention (Trotter et al., 1993). Such
research has shown how ethnographic research undertaken among key target
populations may lead to a realization that there exists a luck of cohesion within
and across bounded groups of drug users. Exploration of the interplay between
such groups produced a closer understanding of the extent and nature of connections
within different “types” of drug-using networks, which ranged from
“closed networks” displaying an absence of social interaction between members
to “open networks” where membership was based on acquaintance and
acquiescence (Trotter et al., 1993). Social network interventions require an understanding
not simply of whether connections between drug-using individuals
and groups exist but of the nature and suitability of these connections for
the feasibility and diffusion of interventions.
At the time of writing there are few published evaluations of “peer education”
or social network interventions encouraging group-mediated change
among drug users. Ethnographic field research has shown the value of understanding
preexisting channels of communication and influence within drug-using
social networks when targeting key individuals as peer educators or health
advocates. As well as drug dealers and drug users, key individuals selected as
peer educators have included local shopkeepers, bar workers, and managers of
shooting galleries (Oeullet et al., 1991; Murphy and Waldorf, 1991). The
comparative value of peer or “indigenous leader” interventions against those
which tend to be “peer-driven” remains unknown. It is clear, however, that
future HIV prevention interventions need to make fundamental shifts toward
encouraging group rather than individually-mediated change within social networks
of drug users (Rhodes and Hartnoll, 1996).
While little is known about the scope, feasibility, and effectiveness of peer
interventions among drug users, preliminary research findings suggest that
interventions targeting the changing of community norms may do more to
change risk behavior than interventions targeting changes restricted to individuals.
Friedman et al. (1992) reported on the preliminary findings from a community
organizing initiative emphasizing collective identity and participation
among drug injectors in Brooklyn, which they show achieved greater levels of
risk reduction in sexual and drug-taking behavior than street-based individually-
focused outreach (see also Jose et al., 1996).
Evaluation of syringe exchange in Rotterdam shows a higher return rate
of equipment, a higher retention rate of attendance, and higher levels of risk
reduction from an intervention recommending collective change and encouraging
drug users to take care of their friends and peers than from a similar intervention
recommending individual change (Grund et al., 1992). Similar findings
are reported from peer-based syringe exchange projects in South Australia,
which shows that peer-based programs were more effective in distributing
equipment and in reaching new injectors than nonpeer-based programs (Herkt.
1993).
Peer education and peer endorsement may be particularly important in the
context of behaviors most private and subject to most social and public policing,
such as sexual behavior (Ehrhardt, 1992). The targeting of peer influence
as a method of initiating and reinforcing change in drug users’ social and
sexual relationships can be viewed as a first step toward encouraging a process
of community and collective change. It also may be considered the first
step toward providing the foundation for community mobilization and organization
among drug users in defining and controlling collective norms and values
about health behavior and in confronting the social constraints which marginalize
equity to public health.
CONCLUSION
An understanding of the obstacles to individual behavior change requires
an understanding of the social context of risk behavior. Without confronting
the obstacles to behavior change it is unlikely that opportunities for change will
be created. This demands an approach to research and intervention which recognizes
both an epidemiology and a sociology of risk behavior. It is timely for
a shift in the direction and emphasis of most research and intervention designs
toward a conception of risk behavior and behavior change which encompasses
and combines a vision of the social as well as the individual. If intervention
is to be effective in changing individual risk behavior, then it must also be
effective in changing the social context of risk behavior. It is timely for research
and intervention to consider the problem of the social and of social
change. This is one of the challenges of the second decade of AIDS. When
facing this challenge, drug users themselves may prove to be the most helpful
advocates of innovation and change.