Safe Sex Behavior Questionnaire

1. Abstract

The Safe Sex Behavior Questionnaire (SSBQ) is an established psychometric assessment designed to evaluate the frequency with which individuals engage in health-protective practices and harm-reduction strategies to mitigate the transmission and acquisition of human immunodeficiency virus (HIV) and other sexually transmitted infections (STIs). Originally developed by Colleen DiIorio and colleagues in response to the landmark 1988 U.S. Surgeon General’s report Understanding AIDS, the instrument translates foundational public health guidelines into an empirically rigorous behavioral measurement framework. The questionnaire consists of 24 items structured across multifaceted operational domains, capturing critical dimensions such as barrier protection, open sexual communication, interpersonal negotiation, risk avoidance, and information acquisition regarding sexual partner history. Respondents rate the frequency of their engagement in specific behaviors using an authentic 4-point Likert scale ranging from 1 (Never) to 4 (Always), with certain revisions and adaptations utilizing an expanded 5-point format.

Extensive psychometric investigations have affirmed the robust structural, convergent, and predictive validity of the instrument across varied young adult and clinical populations. Factor-analytic studies support a stable multidimensional architecture reflecting core themes: condom use/protection, avoidance of risky behaviors, interpersonal communication/negotiation skills, and sexual history knowledge/information gathering. The SSBQ demonstrates strong internal consistency, characterized by Cronbach’s alpha coefficients consistently reported around α = .82 to .85 across diverse validation cohorts, alongside a two-week test-retest reliability coefficient of r = .82. High scores reflect greater adoption of protective sexual behaviors, rendering the SSBQ an indispensable measurement tool in public health epidemiology, behavioral medicine, clinical psychology, and intervention trial evaluations.

2. Keywords

Safe Sex Behavior Questionnaire, SSBQ, HIV prevention, condom negotiation, sexual risk behavior, sexually transmitted infections, health psychology, psychometrics, harm reduction, sexual communication

3. Authors

The Safe Sex Behavior Questionnaire was developed by Colleen DiIorio, PhD, RN, FAAN, and her research collaborators at Emory University, Atlanta, Georgia, United States.

• Colleen DiIorio, PhD, RN, FAAN: Professor Emerita, Department of Behavioral Sciences and Health Education, Rollins School of Public Health, and Nell Hodgson Woodruff School of Nursing, Emory University. Correspondence regarding the original instrument development was directed to: Department of Behavioral Sciences and Health Education, Rollins School of Public Health, 1518 Clifton Road NE, Atlanta, GA 30322; Email: [email protected].
• Mary Ann Parsons, PhD, RN, FAAN: College of Nursing, University of South Carolina, Columbia, South Carolina.
• Shannon Lehr, MSN, RN: Rollins School of Public Health and Nell Hodgson Woodruff School of Nursing, Emory University.
• Daniel D. Adame, PhD, CHES: Department of Health, Physical Education, and Dance, Emory University.
• Janice Carlone, MSN, RN: Nell Hodgson Woodruff School of Nursing, Emory University.
• William N. Dudley, PhD: Applied behavioral statistician and psychometrician collaborating on extended psychometric evaluations and communication modeling across university cohorts.
• Johanna E. Soet, PhD: Behavioral health researcher examining psychosocial correlates of safer sex negotiation.

4. Purpose

The fundamental purpose of the Safe Sex Behavior Questionnaire (SSBQ) is to systematically measure the self-reported frequency of engagement in recommended practices that eliminate, reduce, or mitigate an individual’s risk of exposure to and transmission of HIV and other STIs. Developed during the zenith of the global acquired immunodeficiency syndrome (AIDS) epidemic, the instrument operationalized empirical directives issued by public health authorities into a standardized self-report inventory suitable for behavioral research, epidemiological surveillance, and clinical intervention design.

Prior to the formulation of the SSBQ, existing behavioral measures suffered from critical psychometric limitations. Many inventories treated safe sexual practices as a unidimensional construct focused exclusively on condom usage during penile-vaginal intercourse, completely ignoring broader harm-reduction behaviors such as substance use context, sexual history disclosure, verbal boundary setting, and proactive health screening. Other assessments relied on rudimentary single-item indicators (e.g., "Do you use condoms? Yes/No") that failed to capture behavioral frequency, situational variability, interpersonal power dynamics, or the complex spectrum of sexual practices. The SSBQ addressed these conceptual gaps by providing an exhaustive, multidimensional profile of preventative behavioral repertoires.

From a theoretical and clinical perspective, the SSBQ serves several key functions:

• Epidemiological Surveillance and Baseline Assessment: It enables clinical researchers and behavioral epidemiologists to quantify baseline risk levels in high-risk groups, including collegiate cohorts, young adults, sexually active adolescents, and marginalized sexual and gender minorities.
• Intervention Efficacy and Outcome Evaluation: The questionnaire provides a sensitive, standardized evaluative metric for public health programs, randomized controlled trials (RCTs), and sex education curricula designed to foster behavioral modification, condom assertion, and assertive interpersonal communication.
• Clinical Consultation and Risk Stratification: In sexual health clinics, primary care, and university wellness centers, the SSBQ can identify specific behavioral deficiencies. For instance, a patient may demonstrate high scores in mechanical condom use but critically low scores in interpersonal assertiveness, partner history verification, or substance moderation during intimate encounters.
• Theoretical Modeling: It serves as a benchmark behavioral outcome variable in testing psychosocial theories of health behavior, such as the Health Belief Model, the Theory of Planned Behavior, and Social Cognitive Theory.

5. Psychological Construct

The Safe Sex Behavior Questionnaire is grounded in an expanded, multidimensional conceptualization of sexual health. Rather than conceptualizing "safe sex" merely as an isolated physical act of prophylactic barrier placement, the construct is defined as the integrated constellation of cognitive, communicative, assertive, and physical harm-reduction behaviors executed before, during, and between sexual encounters to minimize biological pathogen transmission. The scale measures four primary operational dimensions:

1. Condom Use and Physical Barrier Protection

This operational domain assesses the mechanical and situational consistency of barrier protection during sexual intercourse. It taps behaviors required to ensure barrier efficacy, from continuous implementation to preemptive planning. Items reflect the active insistence on condom utilization, stopping intimate encounters to apply barrier devices, checking manufacturing integrity and expiration parameters, using compatible water-based lubricants to prevent latex degradation, and carrying condoms proactively when entering contexts where sexual activity may occur. Exemplar behaviors include carrying protection, refusing intercourse if a partner objects to condom usage, and ensuring a condom is worn from start to finish.

2. Interpersonal Communication and Negotiation Skills

A central tenet of the SSBQ is that safer sex is inherently interpersonal. This dimension evaluates an individual’s proactive communicative agency, assertiveness, and communicative competence in discussing sexual health boundaries with prospective partners prior to engaging in physical intimacy. Subscale behaviors include initiating explicit dialogues about safer sex, negotiating barrier use despite partner resistance, inquiring whether a partner has been tested for HIV, and stating one’s personal safety boundaries firmly when conflicting viewpoints emerge. Deficits in this dimension reflect communicative apprehension, passive compliance, or perceived power asymmetries within intimate relationships.

3. Knowledge and Partner History Gathering

Protective health behavior necessitates information gathering to assess potential risk exposure. This dimension assesses whether individuals systematically evaluate the behavioral history of potential partners. It captures active inquiries regarding a partner’s past sexual exposures, known history of sexually transmitted infections, and intravenous drug use history. Furthermore, it measures selective behavioral restraint, such as abstaining from intercourse with casual acquaintances or individuals whose sexual histories remain completely unknown.

4. Avoidance of Risky Behaviors and Environmental Risk Factors

This dimension captures the mitigation of behavioral contexts that undermine rational risk appraisal and heighten biological susceptibility to pathogen transmission. It operationalizes high-risk practices, which are reverse-coded within the instrument scoring system. Measured elements include avoiding sexual engagement while under the disinhibiting influence of alcohol or recreational substances, avoiding having sex with casual encounters or multiple concurrent partners, and refraining from unprotected penetrative anal intercourse. Additionally, it encompasses the deliberate avoidance of exposure to partner bodily fluids, particularly when mucosal disruptions or genital lesions are present.

6. Theoretical Framework

The construction and validation of the Safe Sex Behavior Questionnaire are anchored in robust psychosocial paradigms of health behavior change, specifically integrating Social Cognitive Theory (Bandura, 1986), the Health Belief Model (Rosenstock, 1974), and the Information-Motivation-Behavioral Skills (IMB) Model (Fisher & Fisher, 1992).

Social Cognitive Theory and Self-Efficacy

Albert Bandura’s Social Cognitive Theory emphasizes the triadic reciprocal interaction between cognitive/personal factors, environmental influences, and behavioral patterns. Within the SSBQ framework, the central cognitive mechanism is self-efficacy—an individual’s confidence in their capability to execute specific courses of action required to manage prospective situations. Safe sexual behavior is not viewed simply as a cognitive decision; it requires complex behavioral performance, emotional regulation, and social assertiveness. An individual may possess complete factual knowledge regarding HIV transmission yet fail to practice safe sex due to low self-efficacy in negotiating condom application, refusing unwanted unprotected intercourse, or confronting partner objections. The SSBQ explicitly operationalizes these enactments, capturing self-regulatory behaviors such as premeditated planning, carrying protection, and halting foreplay to establish protective barriers.

The Information-Motivation-Behavioral Skills (IMB) Model

The theoretical framework of the SSBQ aligns directly with the IMB model formulated by William and Jeffrey Fisher. The IMB model posits that HIV prevention information and prevention motivation are necessary, but often insufficient, prerequisites for behavioral alteration. Rather, prevention behavioral skills represent the critical, proximate determinants of whether an individual enacts preventive actions. These behavioral skills include objective competencies (e.g., proper barrier application, lubrication use) and social negotiation skills (e.g., discussing past partners, HIV testing, resisting coercive partner pressure). The SSBQ provides a comprehensive measure of whether these behavioral skills are consistently realized across real-world social scenarios.

The Health Belief Model and Risk Appraisal

The Health Belief Model provides an additional lens, proposing that preventative health actions depend on perceived susceptibility to a disease, perceived severity of the health threat, perceived benefits of preventative actions, and perceived physical, social, or emotional barriers. The SSBQ operationalizes the behavioral manifestation of these appraisals: individuals who perceive themselves at risk and value protection actively manage external cues, avoid substance-fueled disinhibition, and refuse unverified sexual encounters.

7. Validity

The psychometric integrity of the SSBQ has been established through comprehensive content, construct, convergent, and discriminant validity analyses across multiple independent investigations.

Content and Face Validity

The original content validity of the instrument was derived directly from the primary public health guidance published in the 1988 U.S. Surgeon General’s report, Understanding AIDS. DiIorio and colleagues extracted all explicit behavioral directives and categorized them into protection during intercourse, avoidance of risky behaviors, bodily fluid protection, and interpersonal communication. A panel of recognized expert judges in HIV epidemiology, adolescent medicine, and nursing science evaluated the generated items for semantic clarity, clinical fidelity, and construct relevance. Items meeting rigorous threshold criteria for inter-rater congruence were retained.

Construct, Convergent, and Discriminant Validity

Construct validity was demonstrated via formal hypothesis testing in collegiate cohorts (DiIorio et al., 1992, 1993). In empirical tests:

• Assertiveness: Scores on the SSBQ correlated positively and significantly with validated measures of generalized and sexual assertiveness (such as the College Self-Expression Scale), affirming that individuals possessing higher interpersonal assertion skills engage more frequently in safer sex communication and boundary setting (p < .001).
• Risk-Taking Propensity: The SSBQ exhibited significant negative correlations with generalized sensation-seeking and risk-taking behavior scales. Participants exhibiting high propensities for generic physical and social risk-taking scored systematically lower on the SSBQ, underscoring convergent and discriminant construct validity.
• Self-Efficacy: In subsequent path-analytic and structural equation modeling studies (DiIorio et al., 2000), total and subscale SSBQ scores demonstrated robust positive correlations with safer sex self-efficacy scales (r ranging from .42 to .58, p < .001).

Predictive and Criterion Validity

Criterion-related validity has been demonstrated by the questionnaire’s ability to predict documented biological and behavioral outcomes. Longitudinal and cross-sectional evaluations have shown that higher scores on the SSBQ are significantly predictive of consistent barrier protection during subsequent sexual encounters, lower rates of concurrent sexual partnerships, increased rates of voluntary clinical HIV/STI screening, and a markedly reduced incidence of self-reported post-baseline STIs.

8. Reliability

The reliability of the Safe Sex Behavior Questionnaire has been extensively confirmed across multiple empirical studies, establishing both internal consistency and temporal stability.

Internal Consistency Reliability

In the initial pilot validation study conducted by DiIorio et al. (1992) among sexually active university students (N = 89), the original 27-item instrument yielded a Cronbach’s alpha coefficient of α = .82. Following exploratory factor analyses that pruned three problematic items, the revised 24-item SSBQ was administered to a large cohort of sexually active college students (N = 531), yielding an identical, highly robust internal consistency estimate of α = .82. A subsequent large-scale replication conducted in 1994 involving 584 sexually active young adults reaffirmed an alpha coefficient of α = .82 (DiIorio, Dudley, Lehr, & Soet, 2000). Across specific dimensional subscales, alpha coefficients generally range between .74 and .86, reflecting high homogeneity among item clusters without redundancy.

Test-Retest Stability

Temporal stability was formally assessed by administering the instrument to a sample of 100 sexually active college students across a two-week testing interval. The resulting test-retest reliability coefficient was r = .82 (p < .001), indicating remarkable stability over time while maintaining adequate sensitivity to detect authentic behavioral interventions.

9. Factor Analysis

The underlying dimensionality of the Safe Sex Behavior Questionnaire has been evaluated through exploratory factor analysis (EFA) and confirmed in subsequent psychometric modeling.

Exploratory Factor Structure

In the seminal psychometric investigation by DiIorio et al. (1992), principal components analysis with varimax orthogonal rotation was conducted on the initial 27 candidate items. Five distinct factors emerged with eigenvalues exceeding the Kaiser-Guttman criterion of 1.0, accounting for substantial aggregate variance in safer sex behaviors. During this iterative factor extraction, three items were found to exhibit poor psychometric performance (insufficient primary factor loadings < .35 or severe cross-loadings across divergent dimensions) and were excised, resulting in the refined 24-item instrument:

• Factor 1: Risky Behaviors / Disinhibition: Captured items indexing engagement in sexual activity under the influence of chemical substances, rapid engagement with casual partners, and non-monogamous concurrent partnerships (e.g., Items 6, 9, 11, 19).
• Factor 2: Interpersonal Assertiveness and Communication: Captured communicative initiatives, boundary articulation, and verbal negotiation of safer sex (e.g., Items 1, 5, 12, 18).
• Factor 3: Condom Use and Mechanical Prophylaxis: Loaded heavily on behaviors directly involving condom carriage, routine application, and maintaining barrier integrity (e.g., Items 2, 3, 7, 10, 13, 14, 15).
• Factor 4: Avoidance of Bodily Fluids and Partner History Inquiries: Tapped partner screening regarding past STIs, HIV testing, IV drug use, and fluid avoidance (e.g., Items 4, 8, 20, 21, 22, 24).
• Factor 5: Avoidance of Anal Intercourse: Captured explicit avoidance of high-risk mucosal exposure (e.g., Item 17).

Confirmatory Structural Modeling

Subsequent psychometric investigations (e.g., DiIorio et al., 2000) have modeled the instrument utilizing higher-order structural equation modeling (SEM) frameworks. Four-factor and second-order single-factor models exhibit acceptable model fit parameters (Comparative Fit Index [CFI] > .90, Root Mean Square Error of Approximation [RMSEA] < .06), demonstrating that while individual subscale dimensions provide nuanced clinical data, summing all 24 items into an omnibus global safer sex score is statistically and conceptually justified.

10. Instrument / Measurement Tool

• Instrument Name: Safe Sex Behavior Questionnaire (SSBQ)
• Primary Author: Colleen DiIorio, PhD, RN, FAAN
• Original Publication Date: 1992
• Construct Measured: Frequency of engagement in protective safer sex practices and harm-reduction behaviors to prevent HIV and STI acquisition/transmission
• Administration Format: Self-report paper-and-pencil questionnaire, computer-assisted interview (CAI), or digital survey platform
• Number of Items: 24 items
• Estimated Completion Time: Approximately 5 to 10 minutes
• Authentic Response Scale: 4-point Likert scale: 1 = Never, 2 = Sometimes, 3 = Often, 4 = Always (or 5-point Likert scale in some revisions: 1 = Never, 2 = Rarely, 3 = Sometimes, 4 = Often, 5 = Always)
• Scoring Protocol:
  • Positively worded items reflecting protective practices are scored directly according to their numerical response: 1 (Never) to 4 (Always).
  • Negatively worded items assessing high-risk practices (such as having sex while intoxicated, engaging in sex with partners of unknown history, having multiple concurrent partners, or engaging in unprotected intercourse) are reverse-scored: 1 → 4, 2 → 3, 3 → 2, 4 → 1 (or 1 → 5, 2 → 4, 3 → 3, 4 → 2, 5 → 1 on a 5-point metric).
  • An overall total score is computed by summing the numerical values across all 24 items.
  • On the standard 4-point scale, total scores range from 24 to 96. Higher cumulative scores indicate greater adherence to and frequent execution of recommended safer-sex behaviors.
• Subscale Dimensions:
  • Avoidance of Risky Behaviors
  • Communication / Negotiation Skills
  • Condom Use / Protection
  • Knowledge / Information Gathering

11. Permissions & Fee and Test Year

The Safe Sex Behavior Questionnaire was developed in 1992 by Dr. Colleen DiIorio and colleagues at Emory University, with psychometric refinements published through 2000 and 2009. The instrument is generally considered an academic, non-commercial assessment tool. In accordance with standard academic practice, the scale is available for non-commercial research, clinical evaluation, and educational applications without licensing fees, provided that appropriate bibliographic attribution is accorded to the original authors in all resulting presentations and scholarly publications.

Modifications of the instrument for computer-assisted survey platforms or clinical interview formats are permitted for research investigations. Researchers or commercial organizations wishing to adapt, incorporate, or republish the SSBQ within proprietary clinical testing platforms should contact the primary author:

Colleen DiIorio, PhD, RN, FAAN
Department of Behavioral Sciences and Health Education
Rollins School of Public Health, Emory University
1518 Clifton Road NE, Atlanta, GA 30322, USA
Email: [email protected]

12. References

Bandura, A. (1986). Social foundations of thought and action: A social cognitive theory. Prentice-Hall.

DiIorio, C., Dudley, W. N., Lehr, S., & Soet, J. E. (2000). Correlates of safer sex communication among college students. Journal of Advanced Nursing, 32(3), 658–665. https://doi.org/10.1046/j.1365-2648.2000.01525.x

DiIorio, C., Parsons, M., Lehr, S., Adame, D., & Carlone, J. (1992). Measurement of safe sex behavior in adolescents and young adults. Nursing Research, 41(4), 203–208. https://doi.org/10.1097/00006199-199207000-00003

DiIorio, C., Parsons, M., Lehr, S., Adame, D., & Carlone, J. (1993). Factors associated with use of safer sex practices among college freshmen. Research in Nursing & Health, 16(5), 343–350. https://doi.org/10.1002/nur.4770160505

Fisher, J. D., & Fisher, W. A. (1992). Changing AIDS-risk behavior. Psychological Bulletin, 111(3), 455–474. https://doi.org/10.1037/0033-2909.111.3.455

Rosenstock, I. M. (1974). Historical origins of the Health Belief Model. Health Education Monographs, 2(4), 328–335. https://doi.org/10.1177/109019817400200403

U.S. Department of Health and Human Services. (1988). Understanding AIDS (HHS Publication No. CDC-AIDS-88-8432). Centers for Disease Control and Prevention.

13. Items of the Scale