Health Protective Sexual Communication Scale

Abstract

The Health Protective Sexual Communication Scale (HPSC) is a standardized psychometric instrument developed by Joseph A. Catania and colleagues to assess the frequency with which individuals engage in verbal communication about sexual risk reduction, sexual history disclosure, and prophylactic practices with a new or first-time sexual partner. Distinguishing itself from measures of sexual communication focused on erotic enhancement or relational intimacy, the HPSC isolates conversational behaviors that have direct epidemiological and health-protective consequences. Originally introduced as a brief 3-item screening measure within large-scale epidemiologic studies—including the AIDS in Multi-Ethnic Neighborhoods (AMEN) Study—the instrument was subsequently expanded into a comprehensive 10-item self-report or interviewer-administered inventory utilized in the National AIDS Behavior Survey (NABS). Items are rated on a 4-point Likert-type frequency scale ranging from 1 (Never) to 4 (Always), with specialized administration guidelines for sexual minority populations. Exploratory factor analyses demonstrate an essentially unidimensional construct accounting for 37% of the total variance (dominant eigenvalue = 4.3), alongside a minor condom-specific secondary component (eigenvalue = 1.15; 6% of variance). Psychometric evaluations across diverse probability samples—comprising multi-ethnic heterosexual cohorts, high-risk urban communities, and adolescents—demonstrate robust internal consistency reliability (Cronbach’s alphas typically ranging from .82 to .90 across major demographic subsets). The scale exhibits criterion, convergent, and construct validity: elevated HPSC scores correlate strongly with actual condom use, prior HIV testing, sexual communication self-efficacy, and sexual assertiveness, while showing inverse associations with pre-coital alcohol consumption and perceived personal susceptibility to sexually transmitted infections (STIs). The HPSC serves as a foundational assessment tool in behavioral epidemiology, preventative medicine, and sex research.

Keywords

Health Protective Sexual Communication Scale, HPSC, sexual communication, condom negotiation, HIV prevention, AIDS Risk Reduction Model, sexual health behavior, STD prevention, psychometrics, sexual assertiveness

Authors

The primary developer of the Health Protective Sexual Communication Scale is Joseph A. Catania, Ph.D., Professor Emeritus in the College of Public Health and Human Sciences at Oregon State University, previously associated with the Center for AIDS Prevention Studies (CAPS) at the University of California, San Francisco (UCSF).

Collaborators and co-investigators who contributed to the empirical validation of the instrument across the AMEN and NABS cohort studies include:

• Thomas J. Coates, Ph.D. — University of California, San Francisco; later Director of the UCLA Center for World Health.
• Susan M. Kegeles, Ph.D. — Center for AIDS Prevention Studies, Department of Medicine, University of California, San Francisco.
• M. Margaret Dolcini, Ph.D. — College of Public Health and Human Sciences, Oregon State University; previously at UCSF CAPS.
• John L. Peterson, Ph.D. — Department of Psychology, Georgia State University; previously at UCSF CAPS.
• Mindy Thompson Fullilove, M.D. — Columbia University Mailman School of Public Health; New School for Social Research.

Institutional Correspondence: Joseph A. Catania, Ph.D., College of Public Health and Human Sciences, Oregon State University, Corvallis, OR 97331. E-mail: [email protected].

Purpose

The primary purpose of the Health Protective Sexual Communication Scale (HPSC) is to quantify interpersonal communication practices that directly mitigate the risk of acquiring or transmitting sexually transmitted infections (STIs), including Human Immunodeficiency Virus (HIV), as well as unintended pregnancy. In the field of human sexuality research, conversational interactions between prospective sexual partners encompass diverse functions, such as communicating sexual desire, expressing emotional intimacy, establishing erotic preferences, and negotiating risk-reduction strategies. The HPSC was purposefully constructed to disentangle risk-reduction dialogue from general sexual communication or pleasure-enhancement discourse, isolating conversational acts that have direct public health and clinical consequences.

Health protective sexual communication represents a complex interpersonal process. Prior to engaging in sexual intercourse with a new or non-primary partner, individuals must navigate interpersonal tension, social stigma, fear of rejection, and potential power differentials to elicit critical epidemiologic information and establish behavioral boundaries. The HPSC measures the regularity with which individuals initiate these discussions before intercourse takes place, specifically targeting interactions with first-time or new partners where baseline transmission risk is unknown and potentially highest.

In clinical, public health, and research contexts, the HPSC fulfills several applications:

• Epidemiological Surveillance and Behavioral Risk Profiling: The scale enables population-level surveillance of protective communication competencies, identifying sub-populations (stratified by gender, race/ethnicity, age, or education) that experience communication barriers during sexual encounters.
• Intervention Efficacy Evaluation: Public health interventions designed to curb STI/HIV transmission frequently target communication skills, behavioral self-efficacy, and sexual assertiveness. The HPSC provides a standardized outcome measure to assess changes in protective communication before and after behavioral interventions.
• Clinical Risk Assessment and Counseling: In family planning clinics, primary care settings, and sexual health clinics, clinicians can utilize the brief or expanded HPSC to identify patients who struggle to negotiate barrier methods or discuss STI status, allowing for tailored sexual counseling.
• Testing Behavioral Etiological Models: The instrument facilitates empirical evaluations of theoretical models of health behavior change, such as the Health Belief Model, Social Cognitive Theory, and the AIDS Risk Reduction Model.

Psychological Construct

The construct assessed by the HPSC is Health Protective Sexual Communication, defined as the proactive, verbal exchange of information and boundaries between prospective sexual partners aimed at identifying, reducing, or neutralizing the transmission of sexually transmitted pathogens and preventing unwanted conception. This construct is multidimensional in behavioral content yet functionally unified by its protective objective. The scale measures several distinct domains of health dialogue:

1. Barrier Negotiation and Condom Mandating

A central dimension of the construct is the explicit discussion and enforcement of barrier methods. Rather than evaluating passive consent or silent compliance, the HPSC assesses active inquiry into partner attitudes regarding condom use (e.g., asking how a partner feels about using condoms) and assertive behavioral conditioning (e.g., explicitly stating that intercourse will not occur unless a condom is utilized). This reflects communicative assertiveness and the ability to maintain health boundaries in emotionally charged or erotically salient situations.

2. Mutual Sexual History and Exposure Disclosure

The scale measures reciprocal transparency regarding past sexual exposure. This involves two symmetrical conversational behaviors: eliciting information regarding a partner’s past number of sexual partners and disclosing one’s own sexual history. Engaging in mutual disclosure requires interpersonal trust, vulnerability, and communication self-efficacy, enabling both individuals to approximate the network-level transmission risks present in the encounter.

3. Biological Status and Disease Verification

This dimension focuses on direct inquiry regarding past or current infections, specifically querying whether a prospective partner has ever had classic venereal diseases (such as syphilis, gonorrhea, herpes, or chlamydia). It also extends to discussions regarding pre-coital biological testing, such as negotiating mutual HIV antibody testing before initiating a sexual relationship.

4. Transmission Risk Factor Inquiries

Recognizing the epidemiological synergy between substance use, behavioral networks, and STI transmission, the construct encompasses discussions targeting non-coital risk practices. This includes asking whether a partner has ever engaged in intravenous drug use (e.g., injecting heroin, cocaine, or amphetamines) and, within heterosexual encounters, discussing past bisexual or same-sex behaviors that could alter risk profiles.

5. Temporal Delay of Coitus

The construct captures behavioral pacing, specifically verbal negotiations aimed at delaying sexual intercourse until the partners have established greater interpersonal familiarity and trust. This pacing serves as a protective mechanism, allowing time for testing, emotional grounding, and the assessment of personal safety.

6. Reproductive and Contraceptive Planning

For heterosexual dyads, health-protective communication includes discussing contraception and birth control before coitus occurs, mitigating the risk of unintended pregnancy alongside disease prevention efforts.

Theoretical Framework

The conceptual architecture of the Health Protective Sexual Communication Scale is grounded in the AIDS Risk Reduction Model (ARRM), formulated by Catania, Kegeles, and Coates (1990). The ARRM is an integrative, stage-based behavioral framework synthesizing principles from the Health Belief Model, Social Cognitive Theory (Bandura), and Janis and Mann’s decision-making conflict theory to explain how individuals alter high-risk sexual practices in response to epidemics.

The ARRM conceptualizes risk reduction as a dynamic progression across three sequential stages:

1. Stage 1: Labeling. The individual must perceive their personal sexual behaviors as potentially problematic or hazardous. This requires accurate knowledge of transmission routes, perceived personal susceptibility to infection, and an emotional acknowledgment that one’s sexual practices present genuine vulnerability.
2. Stage 2: Commitment. The individual makes an explicit, firm cognitive commitment to reduce sexual risk and adopt preventative practices. This stage is governed by a decisional balance analysis weighing the perceived costs and benefits of safer sex, perceived peer and social norms, and personal self-efficacy.
3. Stage 3: Enactment (Action). The individual executes the specific behavioral actions required to achieve risk reduction. Enactment involves two distinct sub-phases: seeking relevant information/services and actively negotiating protective strategies with sexual partners.

Within the ARRM framework, health-protective sexual communication constitutes the central interpersonal mechanism of Stage 3 (Enactment). Even when an individual successfully labels their risk (Stage 1) and forms an internal commitment to practice safer sex (Stage 2), protective outcomes fail if the individual lacks the verbal negotiation skills, self-efficacy, or interpersonal assertiveness required to enact these strategies within a dyadic encounter. In social contexts where gender roles, socio-cultural scripts, or intoxication introduce friction into sexual negotiation, communicating about condoms, STIs, and partner histories serves as the behavioral bridge converting internal cognitive intent into tangible interpersonal protection.

Furthermore, the scale draws upon Bandura’s construct of communication self-efficacy—the perceived confidence an individual possesses in their capacity to execute specific conversational maneuvers despite anticipated social friction, potential partner anger, or fear of abandonment. Catania and colleagues posited that health-protective communication operates as a proximal determinant of condom use, functioning either as an immediate precursor to barrier application or as an assertive gatekeeping mechanism that prevents intercourse if safety criteria are unmet.

Validity

The validity of the HPSC has been established across large, diverse population cohorts, notably the multi-wave AIDS in Multi-Ethnic Neighborhoods (AMEN) Study in San Francisco (Catania et al., 1992, 1994) and the National AIDS Behavior Survey (NABS) (Catania, 1995; Dolcini et al., 1995).

Criterion and Predictive Validity

The primary criterion against which the HPSC was evaluated is the frequency and consistency of barrier contraceptive (condom) use. In an early examination of the AMEN longitudinal cohort (Catania et al., 1992, 1994), researchers investigated whether the association between HPSC scores and condom use followed a strictly linear trajectory across the entire continuum of scores or operated via a threshold model. Empirical analyses revealed a non-linear threshold dynamic: significant elevations in consistent condom use were concentrated among individuals scoring in the upper one-third (highest tertile) of the HPSC distribution.

Individuals who communicated consistently about sexual risk across multiple partners exhibited significantly higher odds of consistent condom use compared to those in the lower two-thirds of the scale. When dichotomized to capture this upper-tertile threshold, high protective communication emerged as a robust independent predictor of condom use after adjusting for sociodemographic factors, perceived risk, and partner relationship type.

In a subsequent analysis of the AMEN cohort evaluating individuals with multiple sexual partners (Dolcini et al., 1995), predictive validity was demonstrated regarding sexual network dynamics. Among respondents who maintained a primary partnership while acquiring a new secondary sexual partner within the past year (n = 201), lower levels of health protective communication significantly predicted engagement in multi-partner sex (odds ratio [OR] = 1.3 per unit decrease in protective communication; 95% Confidence Interval [CI] = 1.05, 1.50). Individuals unable or unwilling to initiate protective dialogue were more prone to uncoordinated, multi-partner sexual trajectories lacking prophylactic safeguards.

Convergent and Discriminant Validity

Multiple regression analyses conducted on the expanded 10-item NABS probability sample (Catania, 1995) established convergent validity across related cognitive and behavioral constructs. Higher HPSC scores were significantly associated with:

• Sexual and Condom Negotiation Skills: Strong positive correlations with validated indices assessing direct behavioral negotiation capacity and interpersonal communication comfort.
• Sexual Assertiveness: Significant positive associations with measures capturing the general propensity to advocate for one’s bodily autonomy and sexual preferences.
• Condom Use Commitment and History: Increased likelihood of having ever used a condom and higher stated commitment to future condom use.
• Preventative Health Utilization: Significantly higher rates of voluntary HIV antibody testing.

Evidence for discriminant and divergent validity was demonstrated through negative associations with risk-conferring practices and perceived vulnerability. Individuals with high HPSC scores were significantly less likely to report consuming alcohol prior to sexual encounters, corroborating the hypothesis that chemical intoxication compromises conversational engagement. Furthermore, high communicators reported lower perceived susceptibility to STIs, reflecting the objective protective reality conferred by their active screening and negotiation practices.

Demographic Interactions and Cultural Validity

Validation studies revealed meaningful demographic variations. In the NABS dataset, women were nearly three times more likely than men to score as high communicators, consistent with societal expectations regarding female responsibility for reproductive and relational boundary management. Analyses examining intersections of race and gender revealed nuanced patterns: among Hispanic women, an inverse association was observed between sexual guilt and HPSC scores, whereas Hispanic men who reported higher levels of sexual guilt exhibited higher HPSC scores. Across racial cohorts, African American respondents demonstrated marginally higher communication scores relative to Hispanic respondents.

Reliability

The internal consistency reliability of the HPSC has been evaluated across varied clinical, community, and national urban probability samples:

Brief 3-Item Version

The initial 3-item screening version (focusing on condom inquiries, partner history, and refusal of unprotected sex) demonstrated acceptable reliability given its brief length:

• Adolescent Clinical Cohort: In a sample of 114 sexually active adolescent females (aged 12–18; 92% White, 4% Hispanic, 4% other) recruited from a California family planning clinic, the 3-item brief scale demonstrated a Cronbach’s alpha of .67 (Catania et al., 1990).
• AMEN Longitudinal Cohort (Wave 2): In a probability sample of 320 unmarried, sexually active heterosexual adults (aged 20–44) exhibiting HIV risk markers, the brief scale demonstrated a Cronbach’s alpha of .84. Reliability across ethnic subgroups in this cohort remained strong: White participants (n = 146, α = .86), Black participants (n = 72, α = .83), and Hispanic participants (n = 85, α = .84). Men demonstrated an alpha of .84, and women demonstrated an alpha of .83.
• Sub-sample with Multiple Partners: When evaluated specifically among individuals reporting two or more sexual partners within the preceding year, the brief scale yielded a lower Cronbach’s alpha of .50 (Dolcini et al., 1995), reflecting greater behavioral variability and situational instability across multiple transient relationships.

Expanded 10-Item Version

The 10-item expanded scale evaluated in Wave 2 of the National AIDS Behavior Survey (NABS) demonstrated strong psychometric reliability across diverse demographic strata:

• Total Heterosexual Cohort: In the pooled national probability sample of heterosexual adults aged 18–49 who had at least one sexual partner in the past 12 months, overall internal consistency was α = .85.
• National Sample vs. High-Risk Urban Sample: The national sample (n = 155) yielded an alpha of .88 (Mean = 23.82, SD = 8.21, Range = 30.0, Median = 24.0). The high-risk urban sample of 23 cities (n = 810) yielded an alpha of .84 (Mean = 22.93, SD = 7.32, Range = 30.0, Median = 22.0).
• Reliability by Ethnicity:
  • White: National α = .88 (n = 101); High-Risk Cities α = .83 (n = 342).
  • Black: National α = .87 (n = 47); High-Risk Cities α = .83 (n = 329).
  • Hispanic: National α = .60 (n = 8, small sample constraint); High-Risk Cities α = .87 (n = 125).
• Reliability by Gender:
  • Male: National α = .90 (n = 81); High-Risk Cities α = .64 (n = 414).
  • Female: National α = .84 (n = 68); High-Risk Cities α = .82 (n = 379).
• Reliability by Educational Attainment:
  • < 12 Years of Education: National α = .76 (n = 14); High-Risk Cities α = .55 (n = 97).
  • 12 Years of Education (High School Graduate): National α = .88 (n = 49); High-Risk Cities α = .85 (n = 196).
  • > 12 Years of Education (Some College or Higher): National α = .88 (n = 91); High-Risk Cities α = .83 (n = 517).

Factor Analysis

The structural dimensionality of the expanded 10-item HPSC was examined through exploratory factor analytic (EFA) procedures using the NABS Wave 2 multi-city dataset. Unweighted sample segments were merged to enhance statistical power, enabling the detection of latent structural dimensions.

The principal factor analysis revealed the following mathematical properties:

• Dominant First Factor: A single, predominant latent dimension emerged with an initial eigenvalue of 4.30, explaining approximately 37% of the total item variance. All ten items loaded meaningfully on this general factor, which reflects a unified behavioral continuum of health-protective verbal inquiry and sexual boundary establishment.
• Minor Secondary Factor: A second latent component emerged with an eigenvalue falling just above unity at 1.15, explaining an additional 6% of the variance. Inspection of the factor loading matrix indicated that this secondary component comprised items specifically targeting condom negotiation and mandate (Item 1: asking partner feelings on condoms; Item 4: refusing sex without a condom).

Catania and colleagues evaluated whether to divide the instrument into a two-factor structure (general health/history inquiry vs. condom-specific negotiation) or retain a unidimensional composite. Given the modest variance explained by the second factor (6%) relative to the primary general factor (37%), the authors concluded that the HPSC functions primarily as a unidimensional scale. The authors recommended treating total scores as an aggregate measure of overall protective communication competence, while encouraging researchers focused specifically on barrier contraception to examine condom items as a targeted operational subset when theoretically indicated.

Instrument / Measurement Tool

The operational characteristics of the Health Protective Sexual Communication Scale are detailed below:

• Instrument Name: Health Protective Sexual Communication Scale (HPSC)
• Alternative Titles in Literature: Health Communication Sexual Scale; Protective Sexual Communication Scale
• Primary Author: Joseph A. Catania, Ph.D.
• Assessment Type: Self-report questionnaire or structured interviewer-administered survey
• Construct Assessed: Frequency of verbal communication regarding sexual risk, partner sexual history, STIs, HIV testing, and prophylactic measures with a new or first-time sexual partner
• Number of Items:
  • Original Short Form: 3 items (Items 1, 2, and 4 from the expanded set)
  • Expanded Form: 10 items (heterosexual administration); 8 items (sexual minority/gay/lesbian administration, excluding Items 9 and 10)
• Recall Timeframe: Past 12 months
• Target Population: Sexually active adolescents and adults (validated for ages 12–49)
• Administration Modality: Paper-and-pencil, computer-assisted personal interviewing (CAPI), computer-assisted telephone interviewing (CATI), or digital self-administration
• Administration Time: Approximately 1 to 2 minutes
• Response Scale (Expanded 10-Item Version): 4-point Likert-type frequency scale:
  • 1 = Never
  • 2 = Sometimes
  • 3 = Almost always
  • 4 = Always
  • Non-substantive tracking codes: 6 = Don’t know; 7 = Declined to answer (treated as missing data in scoring)
• Response Scale (Original 3-Item Short Form): 3-point categorical frequency scale:
  • 1 = Happened with all partners
  • 2 = Happened with some partners
  • 3 = Didn’t happen
• Scoring Procedures:
  • Brief 3-Item Form: Items are reverse-scored (so that 1 becomes 3, 2 remains 2, and 3 becomes 1) and summed. Higher sums reflect greater protective communication.
  • Expanded 10-Item Form: Items are directly summed across all completed items (theoretical score range: 10 to 40 for heterosexual respondents completing all 10 items; 8 to 32 for respondents completing 8 items). No items require reverse-scoring. Higher total scores denote more frequent, consistent health-protective communication.
  • Tertile Threshold Scoring: In epidemiological predictive models where non-linear threshold effects on condom use are examined, researchers frequently categorize scores into tertiles, contrasting the upper one-third (consistent high communicators) against the lower two-thirds.
• Available Linguistic Adaptations: English and Spanish

Permissions & Fee and Test Year

The Health Protective Sexual Communication Scale was developed through federally funded research conducted across the early 1990s, with primary empirical validation milestones published between 1990 and 1995 (Catania et al., 1990; Catania et al., 1992; Catania et al., 1994; Dolcini et al., 1995; Catania, 1995). The development of the instrument was supported in part by research grants from the National Institute of Mental Health (NIMH) and the National Institutes of Health (NIH).

The scale items and normative tables are available in the public scientific domain for academic, clinical, and non-profit research purposes without licensing fees. Researchers and clinicians intending to utilize the scale in published investigations are requested to cite the foundational publications and maintain correspondence with the author for comparative normative data:

Joseph A. Catania, Ph.D.
College of Public Health and Human Sciences
Oregon State University
Corvallis, OR 97331
E-mail: [email protected]

References

• Catania, J. A. (1995). National AIDS Behavioral Survey (NABS) Wave 2 data and psychometric profiles (Unpublished raw dataset). University of California, San Francisco / Oregon State University.
• Catania, J. A., Coates, T. J., Golden, E., Dolcini, M. M., Peterson, J., Kegeles, S. M., Siegel, D., & Fullilove, M. T. (1994). Correlates of condom use among Black, Hispanic, and White heterosexuals in San Francisco: The AMEN Longitudinal Survey. AIDS Education and Prevention, 6(1), 12–26. PMID: 8161502
• Catania, J. A., Coates, T. J., & Kegeles, S. M. (1994). A test of the AIDS Risk Reduction Model: Psychosocial correlates of condom use in the AMEN cohort survey. Health Psychology, 13(6), 548–555. https://doi.org/10.1037/0278-6133.13.6.548
• Catania, J. A., Coates, T. J., Kegeles, S. M., Thompson-Fullilove, M., Peterson, J., Marin, B., & Hulley, S. (1992). Condom use in multi-ethnic neighborhoods of San Francisco: The population-based AMEN (AIDS in Multi-Ethnic Neighborhoods) Study. American Journal of Public Health, 82(2), 284–287. https://doi.org/10.2105/ajph.82.2.284
• Catania, J. A., Coates, T. J., Stall, R., Turner, H., Peterson, J., Hearst, N., Dolcini, M. M., Hudes, E., Gagnon, J., Wiley, J., & Groves, R. (1992). Prevalence of AIDS-related risk factors and condom use in the United States. Science, 258(5085), 1101–1106. https://doi.org/10.1126/science.1439818
• Catania, J. A., Kegeles, S. M., & Coates, T. J. (1990). Towards an understanding of risk behavior: An AIDS Risk Reduction Model (ARRM). Health Education Quarterly, 17(1), 53–72. https://doi.org/10.1177/109019819001700107
• Dolcini, M. M., Coates, T. J., Catania, J. A., Kegeles, S. M., & Hauck, W. W. (1995). Multiple sexual partners and their psychosocial correlates: The population-based AIDS in Multi-Ethnic Neighborhoods (AMEN) Study. Health Psychology, 14(1), 1–10. https://doi.org/10.1037/0278-6133.14.1.1

Items of the Scale