In this study, we identified the determinants of the intention to get tested for STI/HIV in the coming six months among the Surinamese and Dutch-Antillean communities in the Netherlands, and assessed which determinants need to be addressed when promoting STI/HIV testing among these communities. Results showed that the variables health motivation, cues to action, subjective norms, risk behavior, test history, open communication, and marital status were important predictors (univariately) of the intention to get tested for STI/HIV for both the Surinamese and Dutch-Antillean respondents. Subjective norms (whether a respondent thinks his social environment finds it important to get tested frequently) was the most salient predictor of intention to get tested, and explained 10% and 13% of variance for the Surinamese and Dutch-Antilleans respectively. The Surinamese respondents showed higher intention to get tested in the coming six months when they were surrounded with people who find frequent testing important, when they were previously tested for an STI or HIV, and when they found it normal to openly communicate with their family. The Dutch-Antillean respondents showed higher intention to get tested when they felt motivated despite of possible barriers, when they knew people who were tested for an STI, when they were surrounded with people whom find frequent testing important, when they were aware of their risk behavior, when they were previously tested for an STI or HIV, and when they found it normal to openly communicate with their friends about sexuality.
When interpreting the results some limitations must be considered. First of all, the respondents were recruited in two different ways. The majority was recruited through Dutch Internet panels, and a total of 93 Surinamese and Dutch-Antillean respondents were recruited through group activities in which they filled in a paper version of the online questionnaire. Combining the respondents from the different sampling waves could have influenced the results found in the study (Table
1). For the Surinamese, the pen-and-paper questionnaire (PPQ) group is only 3% of the total, and thus its influence on the analyses can be neglected. For the Dutch-Antilleans, when only looking at the variables of the multivariate model, we find that differences between the online PPQ group were found for all variables in the model except for health motivation and open communication. It is possible that the higher perceived severity, higher motivation, and lower mean age of the PPQ group led to a higher mean intention of this group as they are more likely to perform sexual health behavior. However, it is also possible that the higher education of the online panel led to a more realistic perception regarding the threat of STIs, resulting in lower intention. Although the underlying mechanism remains unclear, we should take the possibility of bias into account
. A second limitation is that both the Surinamese and Dutch-Antillean communities consist of multiple smaller ethnic communities. For example, the Surinamese community includes Hindustani, Chinese, Creoles, and many other smaller ethnic communities. During the study, the respondents were asked to fill in the country of birth, which made it impossible to discriminate between the smaller ethnic communities during the research. Therefore, the results of the study may not be applicable to these smaller ethnic communities in the Surinamese and Dutch-Antillean community.
Another point of consideration is that we measured a proxy of sexual risk behavior rather than the actual sexual risk behavior, because we felt that questioning the respondents directly on this intimate subject might have led to a dropout of respondents. We believe that the constructed variable is a reasonable proxy for risk behavior, because most respondents would only be afraid of being infected, or afraid of the test results, if they actually had had unsafe sex. However, the constructed variable of sexual risk behavior may have included respondents who perceive themselves as having been at risk while their actual risk was minimal, also known as the ‘worried well’
. Lastly, social desirability bias should be taken into account. Social desirability bias refers to the tendency of respondents to answer questions with responses they believe are socially desired, rather than answering questions by responses which reflect their actual thoughts or feelings
. This phenomenon is not uncommon in social studies regarding widely accepted social norms or attitudes, and often occurs when the respondents feel that their answers could be linked back to them. Within the Afro-Caribbean community, it is still perceived as a taboo to talk about sexuality. Although we used an (internet) survey method, which should increase the perceived feeling of privacy among the respondents and therefore lower the social desirability bias, it is still possible that the respondents answered the questionnaire as they felt it should be answered. Also, the perceived prejudices of this community about their sexual behavior could have prevented them to truthfully fill in the questionnaire in order to prevent meeting the beliefs of the social environment. Despite these limitations, we feel that our study provides insight into the determinants related to the intention to get tested among the Surinamese and Dutch-Antilleans, and contributes to the identification of determinants that should be targeted in an intervention.
We found that adding subjective norms to the multivariate regression analysis increased the explained variance for the Surinamese and Dutch-Antilleans with respectively 10% and 13%. This indicates that the intention to get tested for STI/HIV is primarily driven by the approval of the social environment regarding frequent testing, making the subjective norms important predictors. These findings are in contradiction with the meta-analysis of Armitage et al., who found that the subjective norms were the weakest predictor of intention to condom use
. However, in the same study it is stated that multiple-item measures of social norms and normative beliefs, like we used in our study, had significant higher correlations with intention than the other measures
Our study also shows that for the Surinamese self-efficacy is negatively correlated with the intention to get tested in the coming six months; the more people perceive themselves as being capable to get tested, the less intention these people show; the same was found for perceived severity. We found some evidence in the data that could help explain the negative correlations found. We found that most (63%) of the Surinamese and Dutch-Antillean respondents with a high intention and low self-efficacy, perceived higher barriers regarding testing than their peers with a low intention and high self efficacy. This finding indicates that we are probably dealing with ‘temporal construal’
; the respondents with a high intention are thinking the behavior through in more detail, because getting tested is relevant for them. However, because these people are analyzing the behavior in detail, they perceive more barriers and show low self efficacy
. People who showed high self-efficacy and low intention could be people for whom getting tested is not that relevant. These people could then perceive getting tested as easy, because it does not apply to them. In this case, the negative correlation between self-efficacy and the intention to get tested is caused by the intention, and not by self-efficacy. Therefore, it would be inappropriate to enclose self-efficacy in the model with variables which do predict (i.e. cause) the intention. Secondly, bivariate analysis showed that people with high self-efficacy also perceived higher severity. The people with higher severity perceived higher barriers, and higher emotional outcomes when being infected after testing. These barriers and emotional outcomes could lead to a decrease of their capability to perform the behavior, which could increase denial and defensive reaction towards testing, causing a low intention
. The results of the bivariate analysis also indicate that people are afraid of gossiping, and consequently stigmatization, when getting tested. It also indicates that people are afraid of getting a positive test result when getting tested. The consequences of being infected, and therefore stigmatized, could be a reason for a decrease in the intention to get tested. This is similar to the results found in a qualitative study regarding the fear of stigmatization as a barrier to HIV voluntary counseling and testing among South Africans
For the Dutch-Antillean high intenders, almost twice the number of respondents reported to know someone in their direct social environment who got tested for an STI as compared to the low intenders. The Surinamese and Dutch-Antillean high intenders also found themselves more often in a social environment that perceived it as normal to openly discuss sexuality, and among people who found that frequent testing is important. These findings suggest that it is important to focus on these determinants when stimulating STI/HIV testing among the Surinamese and the Dutch-Antilleans. It is expected that when people would discuss sexuality more openly, more people would know others who got tested, which could increase their own intention to also get a test. However, in order to achieve this, both personal norms and subjective norms should be targeted. A possible solution could be found in interventions based on the social norms approach (SNA)
. This theory assumes that our behavior is influenced by the perceptions of the social environment on how to behave, and was used in the promotion of safer drinking
, the prevention of sexual assault
, safe driving, and smoking behavior
. SNA distinguishes three target audiences for an intervention: a whole community including those who are not at-risk (universal), members of a group at-risk (selective), and individuals at-risk. In terms of our study, it could be a good idea to start focusing on the universal audience. By inviting the whole Surinamese and Dutch-Antillean community in the Netherlands to get an STI/HIV test, for example yearly, stigmatization will be lower because no one can see whether or not you have had unprotected sex. People could simply state that they take up the invitation that they received from the testing facility. A similar invitation was sent to youngsters for the participation in a chlamydia screening project in the Netherland regardless whether these youngsters were sexually active or not
[2, 30]. Over time, testing will become a social norm. Secondly, the individuals at-risk should be targeted by providing them with accurate information on the importance of testing, normative feedback, and coping strategies to promote the desired behavior. By targeting these points-of-entry, targeting both the personal perceptions of individuals and the (social) environmental factors, a future intervention is more likely to effectively promote testing behavior.