Development and Validation of the Risk Rapport Scale (R2): A Measure of Therapeutic Relationship Aimed at Primary and Secondary HIV Prevention

Background and Purpose: We recently had an opportunity to conduct both primary and secondary HIV prevention intervention RCTs with adults with severe mental illness (SMI) for whom HIV infection is disproportionately high in comparison to other populations. In both studies, case managers played key roles in engaging in HIV prevention counseling with their clients. The case manager/client relationship was conceptualized as a mediating factor to the targeted outcomes of increased condom use and reduced drug and alcohol use. This study assesses the psychometric properties of the Risk Rapport Scale (R2), a brief 16-item four factor measure designed to capture specific elements of the client /provider relationship thought to reduce high risk sex and drug behaviors associated with HIV infection. Methods: Participants were 403 severely mentally ill individuals receiving case management services who reported on the degree of case manager rapport. In developing the items for the scale, we derived main foci from the central tenets of HIV risk reduction, the CDC's Project RESPECT and NIDA's Community Based Outreach Model (CBOM). The four factors we identified as needing to be negotiated in the context of the relationship were sex, drugs, alcohol, and comfort. From these foci, our aim was to create a lean measure that applied Bordin's theoretical model. A multidimensional item response theory (IRT) model for polytomously scored items, based on the graded response model, was used. Results: Factors related to discussion of specific high risk behaviors are presented. Three of the four factors showed adequate psychometric properties. An increase in the comfort risk rapport factor was associated with a slight increase in reported condom use at 6 months. Conclusions and Implications: The Risk Rapport Scale (R2) did demonstrate adequate psychometric properties for three factors (alcohol, drugs and comfort), while the sex factor was only marginally reliable. When discussing sensitive issues such as personal sexual behavior and drug use, comfort between provider and client is relevant and utility of and further validation of the Risk Rapport Scale is discussed.