Sorting through chickens and eggs: a longitudinal examination of the associations between attitudes, norms, and sexual risk behavior.

OBJECTIVE Health behavior theories posit that health-relevant attitudes, beliefs, and behavioral skills drive subsequent actions people take to protect themselves from health threats. Within the realm of HIV-related sexual risk behavior, much of the research in support of this notion is cross-sectional, rather than longitudinal, particularly in studies of gay and bisexual men. Other psychological theories (e.g., self-perception or cognitive dissonance theories) suggest that the opposite could be true--that health-relevant attitudes and beliefs might change as a function of previous risk or precautionary behavior. Appreciating the complex nature of these associations is essential for modifying theory and developing appropriate interventions. DESIGN Using longitudinal data from gay and bisexual men (n = 1465), we used structural equation modeling to examine three possibilities--that perceived norms and attitudes about sexual risk would be (a) related to unprotected anal intercourse cross-sectionally, (b) related to unprotected anal intercourse at a subsequent time point, and/or (c) predicted from previous instances of unprotected anal intercourse. RESULTS Safe-sex norms and attitudes were related to unprotected anal intercourse cross-sectionally, but did not predict unprotected sex longitudinally. Rather, perceived norms and attitudes changed as a function of previous risk behavior. CONCLUSIONS These results raise the possibility that modified theoretical models might be necessary to adequately describe sexual risk behavior among gay and bisexual men.