Monodisciplinary, Multidisciplinary, Interdisciplinary, and Transdisciplinary Approaches to Reproductive Health Research II William A. Fisher, Ph.D Department of Psychology Department of Obstetrics and Gynaecology University of Western Ontario London Ontario Canada Center for Health Intervention and Prevention University of Connecticut Storrs Connecticut USA

Transdisciplinary Approach to Research on Sexual Activity and Reproductive Health Risk Behavior Infectious Disease Obstetrics and Gynaecology Pediatrics Psychology

The Problem: Sexual Freedom and Reproductive Health Roulette

Sex Leads to Babies

Sex Leads to Abortions

Sex Leads to Infections: Bacterial (Chalmydia, Gonorrhea) Viral (HSV, HPV, HIV)

STI Risk and STI Preventive Behavior: Single Canadian Women and Their Partners Age 15-17Age 18-24Age Had intercourse? 27% 82% 91% Had > 1 partner? 53% 59% 53% Always use condoms? 33% 19% 25% Ever had STI? 5% 17% 22% Fisher, Boroditsky, & Bridges (2000), Canadian Journal of Human Sexuality.

Understanding the Problem: Bio-Psycho-Social Determinants of Reproductive Health Risk and Prevention Sexual Activity Pathogen Incidence Contraceptive Utilization Pregnancy Risk and Prevention STI Risk and Prevention

Don’t Get Pregnant < Don’t Get Infected

Onset of Oral Contraception and Offset of Condom Use: Sexually Active Canadian Women’s Use of Oral Contraception, Condoms, and STD History as a Function of Number of Sexual Partners Number of Sexual Partners /more Regular Users of Condoms 20% 18% 11% 14% 8% Regular Users of Oral Contraceptives 66% 72% 78%82% 85% Reported STI history 3% 4% 5%11% 24% Percentages are based on a Canadian national survey of approximately 2,710 university women. Macdonald et al. High risk STD/HIV behavior among college students, JAMA, 1990:

Transdisciplinary Approach to Research on the Individual and Public Health Impact of Highly Active Antiretroviral Therapy for HIV Disease -Psychology -Infectious Disease -Ethics

Principles of Antiretroviral Therapy, Individual Health, Public Health Rapid, error-prone viral replication Role of early, multidrug intervention Role of adherence to therapy, viral load, viral escape Role of adherence to safer sexual practices

When Ethical Principals Conflict: “Testosterone Replacement Therapy to Improve Sexual Desire and Function among HIV+ Persons”

Safer and Risky Sex Among HIV+ Patients 52/497 HIV+ Participants Engaged in Risky Vaginal or Anal Sex With 197 HIV- or HIV Unknown Partners In 1072 Unprotected Sexual Events In The Past Three Months

Intervention Effects on Unprotected Vaginal and Anal Penetrative Events with HIV – or HIV Status Unknown Partners

Total Number of Partners Exposed # Partners

Medication Adherence Issues in Antiretroviral Therapy Patients must maintain a very high level of lifelong adherence to a complicated, toxic, expensive, illness-disclosing therapeutic regimen. Failure to maintain a high level of adherence to aversive regimen can permit selective replication of drug-resistant virus. Approximately 50% of HIV+ patients have detectable viral loads, 30% resistant species, in large part due to adherence problems.

Adherence Motivation An Information-Motivation-Behavioral Skills Model of Adherence to Antiretroviral Therapy Adherence Behavioral Skills Adherence Information Adherence Behavior Health Outcomes (W. Fisher & Fisher, 2003; J. Fisher, et al., In press, Health Psychology) Moderating Factors Affecting Adherence

Creating and Maintaining Transdisciplinary Teams No one is trained in transdisciplinary approaches to any reproductive health research question Everyone must acquire relatively broad expertise re: knowledge base, methodology, scope of relevant disciplines Create comprehensive working model of phenomenon under study Create team committed to comprehensive and synergistic transdisciplinary approach

Creating and Maintaining Transdisciplinary Teams Everyone must be willing to learn –Language –Knowledge base –Research methods –Research culture Everyone must have lots of respect Everyone must have “just enough ego” –Assert cross-disciplinary ideas Defend them Abandon them