Identifying Factors Associated with Condom Use among Sexually Active Urban Adolescent Girls in the US Implications for Developing an HIV and Partner Abuse Prevention Intervention Anne Teitelman, PhD, FNP-BC, FAANP, FAAN University of Pennsylvania

Acknowledgements Penn Center for AIDS Research NIH 1K01MH A1 Participants Study team members Coauthors –S. Kim –A. Davis Vogel

Violence and HIV Intimate partner violence and gender inequity in relationships have been recognized as HIV risk factors for women & girls for over a decade Intimate partner violence accounts for 12% HIV (Sareen, 2009, Jewkes, 2010)

“Research and actions at the intersections of violence and HIV are expanding, but more understanding is needed of the complexities of these intersections across country contexts, in different environments, and among different population groups.” From: “Tracking Violence and HIV/AIDS: Global Health Imperatives” S. Gruskin, Assoc. Editor, American Journal of Public Health, June 2011

Interventions for adolescents: HIV and partner abuse Very few interventions available that address the intersection of HIV risk and partner abuse for adolescents This formative research was used in developing an HIV and partner abuse prevention intervention for adolescent girls –Theory-based –Gender-specific –Developmentally tailored –Contextually tailored for girls living in economically challenged urban communities in the US

Adolescent girls at risk Adolescent and young women (16-24 yrs.) seeking family planning services (urban, low income, sexually active)  are at high risk for IPV 43% 1 or more episodes of physical IPV 73% 1 or more occurrences of verbal abuse (Rickert et al 2002) 50% of adolescent girls diagnosed with an STI/HIV report physical or sexual IPV (Decker, Silverman, & Raj, 2005)

Adolescents girls at risk Adolescent females ages Highest rates of Chlamydia and Gonorrhea compared to all other ages, both male and female 16% increase in sexually transmitted infections (STIs) among adolescent girls (15-19) since 2006 American Journal of Public Health October, 2013 Adolescents with STIs had increased risk for HIV 26% increase in HIV among youth since 2006

Adolescent girls at risk Mechanisms Adolescent girls with history of partner abuse –Decreased ability to negotiate safer sex –Less control in sexual decision-making –More unprotected sex –More forced sex(CDC. 2014) Partners who perpetrate abuse, higher rates STIs/HIV (Decker et al, 2009)

HIV and partner abuse Theory-based Integrated Behavioral Model (Fishbein) - Identify beliefs underlying behavior - Beliefs influenced by relevant background factors Theory of Gender and Power (Connell) - Identify relevant background factors - Explain how background factors interrelate

Theory of Gender and Power Economic Inequalities Partner relationships (including power dynamics and abuse) Gender norms (Internalized inequality) Integrated Behavioral Theory Control Beliefs (self- efficacy) Actual Control Normative Beliefs Behavioral Beliefs Intention HIV sexual risk prevention: condom use THEORETICAL MODEL

Value of theory informed intervention Phase I: Formative Research Phase II Part 1: Intervention Development Phase II Part 2: Intervention Evaluation Assessed beliefs in the context of healthy and unhealthy relationships Specific beliefs are potential theoretical mediators Addressed salient beliefs in the curriculum Tailored the intervention to the targeted population Measured salient beliefs in evaluation before & after the intervention Able to determine which beliefs are influencing outcome (these are the core elements Core elements: cannot be modified Other aspects of intervention can be modified to specific situations or similar target groups

Attendees of family planning clinic (federally funded services) Identify causal links –Retrospective individual in-depth interviews N= 30 young women ages –Focus groups N= 60 adolescent girls ages Identify core elements –Survey N= 218 adolescent girls ages Formative research

Variables measured Condom use p3 mos. (1 item) –Frequency (Never..|..|..|..Always) Socio-demographic/ History of STIs Partner abuse (16 items) –Physical, sexual, psychological, threats Cronbach’s Alpha =.932 –Condom coercion (1 question) Had sex without a condom after telling their partner they wanted to use one

Variables measured Theoretical variables of condom use in the prior 3 months –Intention (3 items) –Attitude (3 items) –Norms (1 items) –Perceived control / Self-efficacy (6 items) –Specific beliefs (27 items)

Variables Measured Behavioral beliefs (12 items) Prevention Hedonistic Partner reaction Normative Beliefs (4 items) Partner, Friends, Mother, Father Control beliefs (11 items) Partner resistance Negotiation Access Arousal

Data Analysis Descriptive statistics were used to characterize the sample Multiple regression was used to examine the potential effects of the variables on condom use in the past 3 months

Results 46% had ever had a history of a sexually transmitted infection (STI) 35% had experienced condom coercion at some point in their life 19% used condoms consistently in the past 3 months

Results Four types of violence with a sexual partner in the past year were assessed –39% experienced physical violence –34% experienced threats –29% experienced sexual violence –69% experienced psychological violence

Results Descriptive Statistics NMinMaxMeanSD When you had vaginal sex in the past 3 months, how often were condoms used? Intention Attitude Perceived Control

Results Intention to use condoms was associated with greater condom use (p= <.000) Explained close to 40% of the variance (R 2 =. 398)

Results- Regression Model with 3 predictors of condom use intention –Favorable attitudes (p= <.000) * –Supportive norms (p= <.025) * –Perceived control (p= <.000) * *Sig. p= <.05

Results- Regression Associated with attitude –Hedonistic beliefs (p= <.000) * –Partner reaction beliefs (p= <.000)* –Prevention beliefs (p=.232) Sig: p=<.05)

Results- Regression Associated with norms –Approval from friends (p=.029) * –Approval from sexual partners (p=.076) –Approval from mother (p.=.581) –Approval from father (p=.117) Sig: p=<.05)

Results- Regression Associated with control –Partner Resistance beliefs (p= <.000) * –Negotiation beliefs (p= <.000)* –Arousal beliefs (p= <.013)* –Access beliefs (p= <.181) Sig: p=<.05

Conclusions Sexually active urban adolescent girls in US high rates of –STIs –partner abuse –condom coercion And are at increased risk for HIV

Conclusions Beliefs that influence condom use Hedonistic beliefs Partner reaction beliefs Friends supportive norm Partner supportive norm Partner resistance beliefs Negotiation beliefs

Conclusions Building positive attitudes, norms and perceived control (self-efficacy) for safer sex practices need to addressed However, if these social-cognitive predictors are favorable and safer sex practices are still impeded then it is imperative that HIV prevention interventions aimed at this population also address –Partner abuse –Condom coercion

Intervention development process Prior literature Previously published research Community advisory board Other HIV prevention intervention for adolescents Brainstorming sessions Expert Review Pilot testing with adolescent girls Revising based on feedback OUR FINDINGS Input from DV advocates