Biomedical subjects

R de Graaf

Publications and source records attributed to R de Graaf.

At least 37 records · Page 2Linked to original sources

PubMed2001

The structure and stability of common mental disorders: the NEMESIS study.

BACKGROUND: We analyzed the underlying latent structure of 12-month DSM-III-R diagnoses of 9 common disorders for the general population in the Netherlands. In addition, we sought to establish (1) the stability of the latent structure underlying mental disorders across a 1-year period (structural stability) and (2) the stability of individual differences in mental disorders at the level of the latent dimensions (differential stability). METHODS: Data were obtained from the first and second measurement of the Netherlands Mental Health Survey and Incidence Study (NEMESIS) (response rate at baseline: 69.7%, n = 7076; 1 year later, 79.4%, n = 5618). Nine common DSM-III-R diagnoses were assessed twice with the Composite International Diagnostic Interview with a time lapse of 1 year. Using structural equation modeling, the number of latent dimensions underlying these diagnoses was determined, and the structural and differential stability were assessed. RESULTS: A 3-dimensional model was established as having the best fit: a first dimension underlying substance use disorders (alcohol dependence, drug dependence); a second dimension for mood disorders (major depression, dysthymia), including generalized anxiety disorder; and a third dimension underlying anxiety disorders (simple phobia, social phobia, agoraphobia, and panic disorder). The structural stability of this model during a 1-year period was substantial, and the differential stability of the 3 latent dimensions was considerable. CONCLUSIONS: Our results confirm the 3-dimensional model for 12-month prevalence of mental disorders. Results underline the argument for focusing on core psychopathological processes rather than on their manifestation as distinguished disorders in future population studies on common mental disorders.

Adult↗

PubMed2001

Expression of gp100, MART-1, tyrosinase, and S100 in paraffin-embedded primary melanomas and locoregional, lymph node, and visceral metastases: implications for diagnosis and immunotherapy. A study conducted by the EORTC Melanoma Cooperative Group.

With the recent availability of novel antibodies against melanoma antigens tyrosinase and MART-1, it is important to validate their usefulness in pathology practice and in screening patients for immunotherapy treatment. In the present study conducted by the Melanoma Cooperative Group of the European Organization for Research and Treatment of Cancer (EORTC-MCG), immunohistochemical staining for gp100 (antibodies NKI-beteb and HMB-45), MART-1 (A103), tyrosinase (T311), and S100 (S100) was compared on formalin-fixed and paraffin-embedded tumour lesions from 80 patients with 130 malignant melanoma lesions, comprising 44 primary tumours, 18 locoregional metastases, 41 lymph node metastases, and 27 visceral metastases from the lung, liver, and brain. A score between 0 and 5 was allocated to each immunohistochemically stained section. These scores were evaluated in a statistical analysis. S100 was by far the most sensitive marker in all four types of lesions tested. Apart from a significantly better performance for T311 in primary melanomas compared with HMB-45, no significant differences were observed between the four remaining antigens tested. Three settings were next investigated to determine whether the expression of melanoma antigens decreases with tumour progression. First, within the primary melanomas, only NKI-beteb and A103 staining showed a nearly significant negative correlation with Clark's level of invasion and a similar tendency was observed for these antibodies with Breslow thickness. Second, when comparing primary melanoma-metastasis pairs from the same patient, lymph node metastases showed less staining with NKI-beteb, HMB-45, A103, and T311, at a level near significance. This difference was not significant when comparing the primary tumour with visceral metastases, probably due to the lower numbers of pairs. Third, regarding tumour progression from primary melanoma to locoregional, to lymph node, to visceral metastasis, a significant decrease with progression was found only for T311. The apparently stable expression of most of the melanoma antigens, and the small contribution of decreased expression in melanoma tumour progression, supports the rationale for immunotherapy based on the melanoma immunogens gp100, MART-1, and tyrosinase.

Antigens, Neoplasm↗

PubMed2001

Predictors of incident care service utilisation for mental health problems in the Dutch general population.

BACKGROUND: The determinants of first-time ('incident') use of primary care and mental health care services for mental health problems have not been previously investigated. Such information is needed to identify new client groups and to gain a better understanding of causal factors. METHOD: Data were derived from the Netherlands Mental Health Survey and Incidence Study, NEMESIS, a prospective general population study of adults. Potential predictors of care use (psychiatric disorders, burden of illness, sociodemographic characteristics) were recorded in the first wave of the study, and the utilisation of care services in the second wave. Psychiatric diagnoses were based on the Composite International Diagnostic Interview (CIDI) 1.1. RESULTS: Six of the ten indicators linked to the frequent utilisation of care were found not to be associated with incident use: higher age, lower income, living alone, paid employment, mood disorders and anxiety disorders. Four other indicators showed associations with both frequent and incident use: female gender, higher numbers of restricted activity days, poorer social functioning and unmet care needs. Two predictors of incident use only were lower educational attainment and being in treatment for a somatic disorder. CONCLUSION: New clients who come to primary health care or mental health care services with mental health problems are found in all age groups. They are more likely to be women, to have less education, to be in treatment for a somatic disorder and to have functional problems related to their mental health problems.

Acute Disease↗

PubMed2001

Care utilization and outcome of DSM-III-R major depression in the general population. Results from the Netherlands Mental Health Survey and Incidence Study (NEMESIS).

OBJECTIVE: To assess care utilization, individual characteristics and clinical and functional outcomes for various modalities of professional care in people with DSM-III-R major depression. METHOD: Psychiatric diagnoses were determined at baseline and 12-month follow-up in a representative sample (N = 7076) of the Dutch population, using the Composite International Diagnostic Interview (CIDI). RESULTS: A total of 45.3% of the 223 individuals with major depression received professional care in the 12 months between baseline and follow-up, and 42.6% of these were treated with antidepressant medication. Higher level of care was associated with clinical factors and functional limitations. Clinical outcomes were poorly correlated with functional outcomes. Mild to moderate effects in functional outcome were found for all care modalities. CONCLUSION: Outcome of antidepressant treatment can be improved and such treatment should focus on the more severe forms of depression. Functional outcome assessment is recommended in addition to clinical assessment.

Adolescent↗

PubMed2001

Determinants of poor 1-year outcome of DSM-III-R major depression in the general population: results of the Netherlands Mental Health Survey and Incidence Study (NEMESIS).

OBJECTIVE: To investigate risk factors of poor 1-year outcome of major depression in the general population and to compare the results with data from clinical populations. METHOD: Psychiatric diagnoses were determined in a representative sample (N = 7,076) of the Dutch general population, using the Composite International Diagnostic Interview (CIDI) at baseline and 12 months later. A broad range of potential risk factors were evaluated. RESULTS: Of the depressed people at baseline, 28.3% were depressed 12 months later. Younger age, severity of depression, longer duration of previous episodes, the presence of anhedonia and early awakening, external locus of control and multiple negative life events appear to be risk factors. CONCLUSION: Poor outcome of major depression is frequent in the general population. Largely the same risk factors are involved as in clinical populations.

Adolescent↗

PubMed2001

Decreased fertilization rate and embryo quality after ICSI in oligozoospermic men with microdeletions in the azoospermia factor c region of the Y chromosome.

Microdeletions of the azoospermia factor (AZF) region of the Y chromosome occur in between 1 and 29% of oligozoospermic and azoospermic men, and most deletions are found in the AZFc region. These men can father children when intracytoplasmic sperm injection (ICSI) is used, but the success rate is unclear. Thus, the success rate of 19 ICSI treatments in eight couples with a microdeletion in the AZFc region of the Y chromosome was analysed retrospectively. These were compared with a control group of 239 ICSI treatments in 107 couples undergoing ICSI treatment with ejaculated spermatozoa. The fertilization rate was significantly lower in the group of Y-deleted men (55%; 95% CI: 41-69%) compared with controls (71%; 95% CI: 67-74%; P < 0.01). The embryo quality was also significantly poorer among Y-deleted men (P<0.001). Pregnancy, implantation and take-home baby rates were not significantly lower in the Y-deleted group. This study shows that ICSI in oligozoospermic men with microdeletions in the AZFc region of the Y chromosome leads to a lower fertilization rate and poorer embryo quality.

Adult↗

PubMed2000

Psychiatric and sociodemographic predictors of attrition in a longitudinal study: The Netherlands Mental Health Survey and Incidence Study (NEMESIS).

This article discusses the effects of sociodemographics and the presence of psychiatric disorders diagnosed in the 12 months before the first interview by using the Diagnostic and Statistical Manual of Mental Disorders: DSM-III-R, third edition, revised, on three types of attrition (failure to locate, refusal to participate, morbidity/mortality) in the second wave (1997-1998) of the Netherlands Mental Health Survey and Incidence Study, a longitudinal, general population survey of psychopathology among 7,076 subjects aged 18-64 years. Compared with those reinterviewed successfully, persons not located at the 1-year follow-up (n = 219) were more often younger, poorly educated, urban, not cohabiting with a steady partner, and born outside the Netherlands. Refusers (n = 923) had a lower educational level. Morbidity/mortality (n = 72) was associated with higher age, lower educational level, not being employed, and somatic disorders. After adjustment for sociodemographics, none of the disorders was positively associated with refusal. Failure to locate was linked to agoraphobia, alcohol abuse, and the categories of mood, substance use, and eating disorders. Morbidity/mortality was linked to dysthymia, agoraphobia, simple phobia, obsessive-compulsive disorder, and the category of anxiety disorders. Overall attrition was only slightly higher among respondents with one or more disorders (odds ratio = 1.20, 95% confidence interval: 1.04, 1.38). Thus, psychopathology has only weak-to-moderate effects on attrition and is mainly related to failure to locate and morbidity/mortality but not to refusal.

Adolescent↗

PubMed2000

Functional properties of the saphenous vein harvested by minimally invasive techniques.

BACKGROUND: Since surgical techniques affect the functional properties of the vessel wall, the present study investigated the influence of minimally invasive harvesting techniques on the vascular reactivity of the saphenous vein. METHODS: Saphenous vein remnants were obtained after aortocoronary bypass operation from patients subjected to conventional (n = 6), mediastinoscope-assisted (n = 4), or endoscope-assisted venectomy (n = 5). After preservation in University of Wisconsin solution (UW), ring preparations were mounted in a standard organ bath setup and concentration-response curves were constructed for phenylephrine, sodium nitroprusside, and acetylcholine. RESULTS: Saphenous vein reactivity was not altered after preservation in UW. For the vein preparations harvested by means of the three venectomy methods, no differences were demonstrated for responses to KCl, phenylephrine, or sodium nitroprusside. The maximal endothelium-dependent acetylcholine-induced dilation of precontracted vein rings varied between 5% and 12%, independent of the surgical technique applied. CONCLUSIONS: It was demonstrated that minimally invasive surgical techniques for harvesting the saphenous vein, which are developed to reduce postoperative complications at the site of explantation, did not affect the vascular reactivity in a different manner than the conventional method.

Aged↗

PubMed2000

Radiological and clinical results of longterm treatment of rheumatoid arthritis with methotrexate and azathioprine.

OBJECTIVE: To study whether the reported superior effect of methotrexate (MTX) compared to azathioprine (AZA) in retarding radiologic progression after one year in rheumatoid arthritis was sustained at 2 and 4 years. METHODS: All 64 patients enrolled in the original randomized double blind study were invited for an open extension of followup to 4 years including 4-monthly clinical and laboratory assessments and radiographs of hands, wrists, and feet at 2 and 4 years. RESULTS: After 4 years, 18 patients (58%) from the MTX group and 7 patients (21%) from the AZA group continued the initial study drug. During followup more patients (n = 21) switched from AZA to MTX than vice versa (n = 5). In an intention-to-treat analysis improvement of clinical and laboratory variables at 4 years was more pronounced in the MTX group. Mean radiologic scores increased in both treatment groups during followup. According to an intention-to-treat analysis increase in erosion score at one and 2 years in the MTX group was significantly lower than in the AZA group: after one year MTX group 1.8 versus AZA group 5.3 (p = 0.002); after 2 years MTX 3.5 versus AZA 6.5 (p = 0.05). After 4 years there was a trend toward less progression in the MTX group: MTX 6.8 versus AZA 10.8 (p = 0.09). For the total score, progression in the MTX group was less after one and 2 years. After 4 years marked radiologic progression was observed more often in the AZA group. CONCLUSION: Drug continuation after 4 years of followup was better for MTX than for AZA. In an intention-to-treat analysis the beneficial effect of MTX on radiologic progression compared with AZA was sustained after 2 years of followup. Thereafter differences between treatment groups leveled off, probably mainly due to the greater number of switches from AZA to MTX than vice versa.

Anti-Inflammatory Agents, Non-Steroidal↗

PubMed1999

Broader vaccination of expatriates against HBV infection: do we reach those at highest risk?

BACKGROUND: The effects of the implementation of a new Dutch hepatitis B virus (HBV) vaccination strategy (1991) for expatriates on HBV vaccination status and HBV infection prevalence were evaluated in a group of 864 expatriates returning from HBV-endemic areas. METHODS: During a routine medical examination at the participating medical centres Dutch expatriates were asked to complete a questionnaire and to donate a serum sample for HBV testing. Blood was tested for antibodies against the hepatitis B core (anti-HBc) and surface antigens (anti-HBs). The serological data were related to information gathered on aspects of residence, sexual risk behaviour and occupational risks. RESULTS: A significantly higher percentage of expatriates (37%) were vaccinated compared to a previous study in 1987-1989 (14%). However, the percentage of expatriates with HBV infection markers (5%) had not decreased significantly. Moreover, the risk for HBV infection, as determined with a questionnaire, was still affected by well-known risk factors such as homosexual contacts (odds ratio [OR] = 6.6, 95% CI: 1.7-26), more than five casual local partners (OR = 3.6, 95% CI: 1.2-11) and more than five occupational accidents in the last 3 years (OR = 20, 95% CI: 2-187). Detailed analysis of the vaccination status indicated that especially young female expatriates with low risk behaviour (65%) were protected, while older male expatriates with high risk behaviour were less protected (20%). CONCLUSION: We conclude that the new vaccination strategy has resulted in a higher percentage of expatriates protected. However, only a small proportion was reached of those at highest risk for HBV infection.

Adult↗

PubMed1998

[Prevalence and relevant background characteristics of deafness and severe hearing loss in the Netherlands].

OBJECTIVE: To determine the prevalence of deafness and severe hardness of hearing among the Dutch population and of some relevant background characteristics. DESIGN: Study of documents. SETTING: Dutch schools for deaf and hard-of-hearing children. METHOD: The number of deaf and severely hard-of-hearing children of 6-12 years who received education or ambulatory supervision at schools for deaf and hard-of-hearing children was counted in the period November 1996-April 1997, and a number of relevant background characteristics were collected. By means of consultation with experts, this number was corrected for children who could not be retrieved by means of the inventory at these schools. To estimate the total number of deaf and severely hard-of-hearing people in the Dutch population, this adjusted number was extrapolated to older and younger year cohorts. RESULTS: The number of deaf and hard-of-hearing children of 6-12 years, after correction for missing groups, was 0.74 (95% confidence interval (95% CI): 0.69-0.78) per 1000 persons. In 9% the age of onset of the handicap was postlingual; they more often received ambulatory supervision and more often received education at a school for hard-of-hearing children than those with a prelingual auditive handicap. Of the children 29% had a non-Western origin; they less often received ambulatory supervision, and more often received education from a school for deaf children than indigenous pupils. Among the total Dutch population, the number of deaf and hard-of-hearing persons in 1996 was estimated to be 11,400 persons (95% CI: 10,690-12,110). CONCLUSION: The prevalence of deafness and severe hardness of hearing in the Netherlands (15,490,000 inhabitants in 1996) was 11,400 persons (95% CI: 10,690-12,110).

Adolescent↗

PubMed1998

Neonatal risk factors and risk scores including auditory evoked responses.

UNLABELLED: In a prospective study, 81 preterm infants and 25 healthy term infants were neurologically and neurophysiologically evaluated in the neonatal period. At 5-7 years of age the neurodevelopmental outcome was assessed. The validity and predictive value of the Neonatal Neurological Inventory (NNI) and the Neurobiological Risk Score (NBRS), including an additional gestational age factor (GAF) and an auditory evoked response factor (AERF) were assessed. Three of the 53 surviving preterm infants showed major neurological abnormalities at 5-7 years. Five infants showed neuropsychological abnormalities and 12 infants showed both neurological and neuropsychological abnormalities. An important subgroup of preterm infants could be identified as high-risk using the NNI and NBRS. The low sensitivity and negative predictive value resulted in a number of false-negative results. Logistic regression showed that intraventricular haemorrhage (IVH) and bilirubin levels contributed highly to the prediction of neurological outcome. For neuropsychological outcome these factors were IVH and assisted ventilation. Addition of the GAF and AERF as separate items to the NBRS did not affect the predictive power. Combined addition of the GAF and AERF showed improvement of both validity and predictive value. CONCLUSION: This study shows that IVH, bilirubin and assisted ventilation contribute most to the validity and predictive value of the NBRS. Furthermore, regarding neurological outcome addition of a GAF in combination with an AERF resulted in a substantial improvement of the validity and predictive value. The shortcomings of the current neonatal risk scores require a careful interpretation of clinical perinatal data regarding the prediction of neurodevelopmental outcome in preterm infants.

Child↗

PubMed1998

Underlying reasons for sexual conduct and condom use among expatriates posted in AIDS endemic areas.

Among people who work abroad, sexual activity and therefore the risk of HIV infection appear to be relatively high. Little is known about the factors that influence sexual conduct when staying abroad, separated from their usual social environment. This is why 55 expatriates who had been sexually active in AIDS endemic areas were selected for an in-depth interview from the original sample of 864 Dutch expatriates participating in a study on sexual behaviour and HIV infection. The social and cultural context in which the sexual contacts took place was addressed in these interviews. Qualitative analysis of the data led to the identification of four styles with regard to the meaning of and motivations for having sex abroad: 'the unprepared', 'the fanatical', 'the unaffected' and 'the slightly accessible'. These styles are described separately and attention is paid to the association of these styles with protection behavior.

Acquired Immunodeficiency Syndrome↗

PubMed1998

Occupational risk of HIV infection among western health care professionals posted in AIDS endemic areas.

In this study on occupational risks of HIV infection among 99 Dutch medics working in AIDS endemic areas, 61% reported percutaneous exposures during an average stay of 21 months. The mean number of injuries was lower among physicians (2.0 versus 3.9 per year) and higher among nurses (1.9 versus 1.2) than in previous research conducted in 1987-1990 among Dutch medics returning from Africa. But the reduction of exposures among physicians might be explained by the fact that the number of procedures they carried out was less in the later study. Also among nurses a shift of tasks was seen. On the basis of an estimated HIV prevalence in the patient population of 19%, a chance of transmission per accident of 0.3%, and 1.9 percutaneous exposures per year, the mean occupational risk of HIV infection per year can be estimated at 0.11% per person. Besides length of stay and number of activities, characteristics of the work setting were associated with the frequency of different kinds of injuries. From the analysis of 109 extensive descriptions of recent accidents, it appeared that the majority of the injuries occurred during routine activities and were self-inflicted. Injuries with hollow needles usually occurred after the actual medical act (e.g. during recapping). Carelessness (e.g. due to fatigue) or being in a hurry (e.g. because of an emergency) were also often the cause of percutaneous injuries, as were the poor quality of the equipment, lack of professional skills, or a combination of these factors. Prevention activities are still important to reduce the frequency of occupational exposures. But they will not eliminate them totally; from the descriptions of recent exposures it was clear that some of the injuries occurred in spite of precautions.

Acquired Immunodeficiency Syndrome↗

PubMed1997

Sexual risk of HIV infection among expatriates posted in AIDS endemic areas.

OBJECTIVE: To assess the prevalence of HIV infection and related risk factors among Dutch expatriates returning from assignment in sub-Saharan Africa, Latin America, and South and South-east Asia. METHODS: From July 1994 to January 1996, a questionnaire on the risks of sexual exposure was completed by 864 respondents, and blood samples were taken. RESULTS: Of the 634 men, 41% reported having sex with casual or steady local partners and 11% with casual or steady expatriate partners, during an average stay of 26 months in the previous 3 years. Of the 230 women, these figures were 31 and 24%, respectively. Of the men with local casual partners (29%), 59% paid for sex at least once. For men as well as women, having sexual contacts abroad was associated with younger age, positive intention prior to departure to have sex abroad, being single at departure, and, only for the men, working for a commercial organization, and feelings of loneliness and boredom. Among men, consistent condom use with casual local partners was 69%, and with casual expatriate partners 63%. Among women, these figures were 64 and 48%, respectively. Consistent condom use with steady local or expatriate partners was much lower. Among men, non-consistent condom use with casual partners was more prevalent if they had been abroad for a longer time, condoms were not taken along from The Netherlands, the country where they were posted was Asian, and the estimated HIV prevalence among the local population was lower. Among the women, non-consistent condom use was more prevalent if condoms were not taken along, and if they did not have the intention before departure to have sex abroad. Of the persons from whom blood could be obtained, one man was HIV-positive. Another man who refused to participate in the study indicated that he was HIV-positive. CONCLUSIONS: Although 23% of the expatriates had unprotected sex with partners from endemic areas, very few HIV infections were found. In comparison with a previous study among this population carried out in 1987-1989, which found five out of 1968 expatriates to be HIV-infected, consistent condom use with casual local partners did increase considerably (from 21 to 67%). However, health education is needed to reduce the risk of HIV infection, which should emphasize the sociocultural differences in sexual practices.

Adult↗

PubMed1997

Diagnostic and predictive value of auditory evoked responses in preterm infants: I. Patient characteristics and long-term neurodevelopmental outcome.

The diagnostic and predictive value of brainstem, middle latency, and cortical auditory evoked responses, obtained in the neonatal period, in 81 preterm infants was assessed in relation to neurodevelopmental outcome. Eighteen healthy term infants served as a control group. In this report the patient characteristics and neurodevelopmental outcome are presented. The preterm infants were neonatally classified according to risk category and gestational age. At 5 y of age the neurodevelopmental outcome was assessed based on neurologic and neuropsychologic evaluations. The neuropsychologic test results showed the highest IQ scores in term infants, intermediate IQ scores in low risk preterm infants, and lowest IQ scores in high risk preterm infants. The intermediate IQ scores in the low risk preterm group were due to significantly lower test scores in a small subgroup of low risk preterm infants. In a post hoc analysis 12 low risk preterm infants with an unfavorable outcome could be identified. The neuropsychologic test results of the remaining low risk infants showed no clear differences compared with the term infants. The results suggest that the unfavorable outcome of the low risk preterm group as a whole is due to moderate to severe impairment of the few, rather than slight impairment of the majority.

Evoked Potentials, Auditory↗

PubMed1997

Diagnostic and predictive value of auditory evoked responses in preterm infants: II. Auditory evoked responses.

In this study, the diagnostic and predictive value of brainstem, middle latency, and cortical auditory evoked responses (BMC-AERs) obtained in the neonatal period in 81 preterm infants was assessed in relation to neurodevelopmental outcome. The preterm infants were neonatally classified according to risk category and gestational age. The BMC-AERs were analyzed with respect to detectability, latencies, and amplitudes as well as derived latency and amplitude measures. At 5 y of age the neurodevelopmental outcome was assessed from neurologic and neuropsychologic evaluations. The results showed that BMC-AER differences mainly correlated with risk category (low risk/high risk) and to some extent with degree of prematurity. In view of these findings the degree of prematurity and the effect of risk category have to be taken into account, when BMC-AERs are applied in the preterm period to predict neurodevelopmental outcome. In this study the BMC-AERs for infants with abnormal neurodevelopmental outcome were scarcely distinguishable from the BMC-AERs for infants with normal neurodevelopmental outcome. Thus far, this and previous reports have indicated that BMC-AERs in preterm infants are useful in maturational studies and with infants showing symptoms related to lesions or dysfunction of the peripheral and/or central auditory system. For predicting neurodevelopmental outcome in preterm infants, BMC-AERs are of limited clinical value.

Evoked Potentials, Auditory↗

PubMed1997

Condom use by Dutch men with commercial heterosexual contacts: determinants and considerations.

We report responses from 559 clients of female prostitutes, with a view to determining to what extent previously identified factors play a part in condom use. To increase the response rate to advertisements in daily and weekly newspapers, interviews were held by phone. This procedure had the advantage of ensuring the anonymity many clients demanded. Of those clients having vaginal or anal contact (91%), 14% had not always used condoms in the previous year. Compared with consistent condom users, these men were less highly educated, had twice as many commercial contacts, and had more contacts with "steady" prostitutes. They were either more emotionally motivated to visit prostitutes than were consistent condom users or exhibited a stronger need for sexual variation. They showed a more compulsive attitude toward visiting prostitutes, had a more negative attitude toward prostitution in general, evaluated condoms more negatively, had a higher personal efficacy to achieve unsafe contacts, and had a higher general risk assessment, commensurate with their behavior. Men with only safe contacts had either an intrinsic or an extrinsic motivation for condom use. Among extrinsically motivated men, their behavior change was more recent and had not yet taken root: They still envisioned unsafe commercial sex to be possible in the future. Education aimed at the small group of men practicing unsafe contacts will not easily and directly lead to behavior change. But these educational activities may support prostitutes to persist in (consistent) condom use, regardless of clients' pressure to do otherwise.

Adult↗