STI Disclosure Self-Efficacy in Adolescent Females

1. STI Disclosure Self-Efficacyin Adolescent Females L. Lowery, B. Glass, P. Parham, & J. Ellen Johns Hopkins University School of Medicine Division of General Pediatrics and Adolescent Medicine I am delighted to share with you these findings on self efficacy for disclosure to sex partners in adolescent females. I would also like to thank my collaborators for their time and efforts on this project.I am delighted to share with you these findings on self efficacy for disclosure to sex partners in adolescent females. I would also like to thank my collaborators for their time and efforts on this project.

2. Background Adolescents are at higher risk for STIs Disclosure integral part of STI counseling Variable rates of disclosure Disclosure may lead to decrease STI Previous literature Self-efficacy, barriers to disclosure, partner type Correlated with disclosure and intent to refer partner Adolescents are at a higher risk for STIs. Disclosure to sex partners is an integral part of STI counseling. There are variable rates of disclosure depending on the particular STI and the measurement of disclosure and whether it was identified by the index or their sex partner. Disclosure to a partner and subsequent partner treatments may lead to decreased reinfection rates. Self-efficacy, barriers to disclosure, partner type have been shown to correlate with disclosure and intent to refer partner. There is limited data on these correlates among adolescents, there more information is needed for adolescents in order to gain a better understanding of the correlates which may improve patient education regarding STIs and subsequently decrease rates of sexually transmitted infections. Adolescents are at a higher risk for STIs. Disclosure to sex partners is an integral part of STI counseling. There are variable rates of disclosure depending on the particular STI and the measurement of disclosure and whether it was identified by the index or their sex partner. Disclosure to a partner and subsequent partner treatments may lead to decreased reinfection rates. Self-efficacy, barriers to disclosure, partner type have been shown to correlate with disclosure and intent to refer partner. There is limited data on these correlates among adolescents, there more information is needed for adolescents in order to gain a better understanding of the correlates which may improve patient education regarding STIs and subsequently decrease rates of sexually transmitted infections.

3. Correlates of Disclosure Individual-level factors Self-efficacy Perceived barriers STI-related stigma History of an STI Relationship-level factor Type of sex partner- Main vs. Casual Correlates can be grouped as individual level and relationship level. Individual-level factors include Self-efficacy, Perceived barriers, STI-related stigma, History of an STI Relationship-level factor correlated with disclosure is type of partner, main versus casual. Type of sex partner- Main vs. Casual Let�s examine some of these correlates in greater detail. Correlates can be grouped as individual level and relationship level. Individual-level factors include Self-efficacy, Perceived barriers, STI-related stigma, History of an STI Relationship-level factor correlated with disclosure is type of partner, main versus casual. Type of sex partner- Main vs. Casual Let�s examine some of these correlates in greater detail.

4. Self-Efficacy A person�s belief about their capacity to perform a specific behavior/task in a specific situation Higher levels correlated Intention for less risky health behaviors Partner notification Self efficacy is a person�s belief about their capacity to perform a specific behavior/task in a specific situation Higher levels of self-efficacy of disclosure have been correlated with Intention for less risky health behaviors Partner notification Self efficacy is a person�s belief about their capacity to perform a specific behavior/task in a specific situation Higher levels of self-efficacy of disclosure have been correlated with Intention for less risky health behaviors Partner notification

5. Stigma An undesirable attribute in a person that is viewed as setting that person apart from the rest of society Affected STI-related health care seeking Perceived reactions to disclosure to health care providers Concern cited by females after diagnoses Stigma is an undesirable attribute in a person that is viewed as setting that person apart from the rest of society. STI related stigma has been shown to impact STI-related health care seeking, affect if a female decides to disclose her history of an STI to a health care provider, and has been cited as a concern of females after being diagnosed with an STI Stigma is an undesirable attribute in a person that is viewed as setting that person apart from the rest of society. STI related stigma has been shown to impact STI-related health care seeking, affect if a female decides to disclose her history of an STI to a health care provider, and has been cited as a concern of females after being diagnosed with an STI

6. Objectives To describe self-efficacy, perceived barriers, and STI-related stigma in sexually experienced adolescent females To describe whether partner type and history of an STI influence attitudes around self-efficacy, perceived barriers, and STI-related stigma Our objectives were To describe self-efficacy for disclosure, perceived barriers to disclosure, and STI-related stigma in sexually experienced adolescent females. AND To describe whether partner type and history of an STI influence attitudes around self-efficacy, perceived barriers, and STI-related stigma Our objectives were To describe self-efficacy for disclosure, perceived barriers to disclosure, and STI-related stigma in sexually experienced adolescent females. AND To describe whether partner type and history of an STI influence attitudes around self-efficacy, perceived barriers, and STI-related stigma

7. Hypotheses Adolescent females with a history of an STI have less self-efficacy, perceive more barriers and perceive higher STI-related stigma Adolescent females have more self-efficacy and perceive more barriers related to disclosure to a main partner compared to a casual partner Our hypotheses were That Adolescent females with a history of an STI have less self-efficacy for disclosure, perceive more barriers to disclosure and perceive higher STI-related stigma and Adolescent females have more self efficacy and perceive more barriers related to disclosure to a main partner compared to a casual partnerOur hypotheses were That Adolescent females with a history of an STI have less self-efficacy for disclosure, perceive more barriers to disclosure and perceive higher STI-related stigma and Adolescent females have more self efficacy and perceive more barriers related to disclosure to a main partner compared to a casual partner

8. Design Cross-sectional study One time face to face interview Recruited adolescent females participating in larger ongoing longitudinal study Eligibility for study 14-19 years old at entry into longitudinal study English speaking Living within the local metropolitan area Vaginal or anal sex within the preceding 6 months Our design was a cross-sectional study using a one time face to face interview. We recruited adolescent females participating in larger ongoing longitudinal population based study of sexual risk behaviors. To be eligible, the participants had to be 14-19 years old at entry into longitundinal study, English speaking, Living within the local metropolitan area, and have had Vaginal or anal sex within the preceding 6 months Perceived risk for STD- study to determine whether age related patterns of STD can be replicated prospectively and patterns explained over time, condoms use, OCP use and and changes within individuals in their patterns of sex partnerships, individual relative power in a sexual relationship , whether the accuracy of adolescents' partner specific PRSTD increases with age They have a baseline interview then follow annually 6,18,24, 30 months after baseline visit GC and Chyl LCR as part of the study q6 months LCR GC-urine 94.6% sens, 100% spec LCR Chly- 87-94% sens , 99-100% specOur design was a cross-sectional study using a one time face to face interview. We recruited adolescent females participating in larger ongoing longitudinal population based study of sexual risk behaviors. To be eligible, the participants had to be 14-19 years old at entry into longitundinal study, English speaking, Living within the local metropolitan area, and have had Vaginal or anal sex within the preceding 6 months Perceived risk for STD- study to determine whether age related patterns of STD can be replicated prospectively and patterns explained over time, condoms use, OCP use and and changes within individuals in their patterns of sex partnerships, individual relative power in a sexual relationship , whether the accuracy of adolescents' partner specific PRSTD increases with age They have a baseline interview then follow annually 6,18,24, 30 months after baseline visit GC and Chyl LCR as part of the study q6 months LCR GC-urine 94.6% sens, 100% spec LCR Chly- 87-94% sens , 99-100% spec

9. Measures Individual Characteristics Age Self-efficacy for disclosure Perceived barriers to disclosure STI-related stigma Partner Type Main vs. Casual Our measures included the correlates of disclosure At the individual level we measured Age Self-efficacy Perceived Barriers to Disclosure Stigma Partner Type Main vs. Casual Main was described to the participants as someone that you have sex with and consider that person to be someone you are serious about Casual partner was described as is someone you have sex with but do not consider this person to be a main partner to you. This can be someone you�ve had sex with only once or a few times or is someone you have sex with on an on-going but casual basis. The important thing is that this person is not a main partner to you. Our measures included the correlates of disclosure At the individual level we measured Age Self-efficacy Perceived Barriers to Disclosure Stigma Partner Type Main vs. Casual Main was described to the participants as someone that you have sex with and consider that person to be someone you are serious about Casual partner was described as is someone you have sex with but do not consider this person to be a main partner to you. This can be someone you�ve had sex with only once or a few times or is someone you have sex with on an on-going but casual basis. The important thing is that this person is not a main partner to you.

10. Self-Efficacy Belief about capacity to disclose an STI to a sex partner in specific situations Nine items Adapted from Fortenberry et al.1997 & Nuwaha et al.2001 Main/Casual specific- Sample Items �How confident are you that you could tell your main partner(s) that you had an STD?� �How confident are you that you could tell your casual partner(s) that you had an STD?� Self efficacy in the study was their Belief about their capacity to disclose an STI to a sex partner in specific situations Nine items Adapted from Fortenberry et al.1997 & Nuwaha et al.2001 Main/Casual specific- Sample Items listed below �How confident are you that you could tell your main partner(s) that you had an STD?� �How confident are you that you could tell your casual partner(s) that you had an STD?� Self efficacy in the study was their Belief about their capacity to disclose an STI to a sex partner in specific situations Nine items Adapted from Fortenberry et al.1997 & Nuwaha et al.2001 Main/Casual specific- Sample Items listed below �How confident are you that you could tell your main partner(s) that you had an STD?� �How confident are you that you could tell your casual partner(s) that you had an STD?�

11. Barriers to Disclosure Eight items assessing partner-specific barriers to disclosure i.e. violence, ending the relationship, blame for the infection, concern of partner treatment, disclosure of infection to others Adapted from Nuwaha et. al Main/Casual specific- Sample Items �If I told my main partner(s) that I had an STD, he would break up with me.� �If I told my casual partner(s) that I had an STD, he would break up with me.� To assess perceived barriers we used Eight items assessing partner-specific barriers to disclosure The items included violence, ending the relationship, blame for the infection, concern of partner treatment, disclosure of infection to others Adapted from Nuwaha et. al Main/Casual specific- Sample Items �If I told my main partner(s) that I had an STD, he would break up with me.� �If I told my casual partner(s) that I had an STD, he would break up with me.� To assess perceived barriers we used Eight items assessing partner-specific barriers to disclosure The items included violence, ending the relationship, blame for the infection, concern of partner treatment, disclosure of infection to others Adapted from Nuwaha et. al Main/Casual specific- Sample Items �If I told my main partner(s) that I had an STD, he would break up with me.� �If I told my casual partner(s) that I had an STD, he would break up with me.�

12. Stigma Assess how stigmatizing she believed having an STI would be for her in the context of her relationship with her sex partner Six items Adapted from Cunningham et al. Sample Item �If I had an STD, my sexual partner(s) would think that I was unclean.� Stigma assessed how stigmatizing she believed having an STI would be for her in the context of her relationship with her sex partner Six items Adapted from Cunningham et al. Sample Item �If I had an STD, my sexual partner(s) would think that I was unclean.� Stigma assessed how stigmatizing she believed having an STI would be for her in the context of her relationship with her sex partner Six items Adapted from Cunningham et al. Sample Item �If I had an STD, my sexual partner(s) would think that I was unclean.�

13. STI History Described as either STI at baseline of longitudinal study Incident STI during longitudinal study prior to being enrolled in this study History of an STI was described as either STI at baseline of longitudinal study and/or Incident STI during longitudinal study prior to being enrolled in this study NOW OUR RESULTS History of an STI was described as either STI at baseline of longitudinal study and/or Incident STI during longitudinal study prior to being enrolled in this study NOW OUR RESULTS

14. Participants N= 140 Mean age: 20.2 years (SD=1.3) History of an STI 120/139= 86% African American females that lived in urban area

15. Scales Internal consistency was high for the self efficacy and stigma scales. The internal consistency for perceived barriers was 0.55-0.59. For the self-efficacy scales the possible range was 9-36, and the mean was approximately 26 for both self efficacy for disclosure to both main and casual partners. For the perceived barriers scales, the potential range was 0-8, the mean was approximately 4. The potential range for the stigma scale was 6-24 and the mean was 13.8.Internal consistency was high for the self efficacy and stigma scales. The internal consistency for perceived barriers was 0.55-0.59. For the self-efficacy scales the possible range was 9-36, and the mean was approximately 26 for both self efficacy for disclosure to both main and casual partners. For the perceived barriers scales, the potential range was 0-8, the mean was approximately 4. The potential range for the stigma scale was 6-24 and the mean was 13.8.

16. History of STI & Individual Level Characteristics For the association of history of an STI and individual level characteristics, we examined the means of those with a history of an STI compared to those without, the means were statistically significant for self-efficacy for disclosure and perceived barriers for casual sex partners, but not MAIN partners. Stigma was not statistically significant.For the association of history of an STI and individual level characteristics, we examined the means of those with a history of an STI compared to those without, the means were statistically significant for self-efficacy for disclosure and perceived barriers for casual sex partners, but not MAIN partners. Stigma was not statistically significant.

17. Comparison of Main vs. Casual Lastly, when we compared the difference between partner types for self efficacy and perceived barriers. Paired t test demonstrated no statistically significant difference between main and casual partners for self-efficacy or perceived barriers. t test= -0.59 The two-sample t-test is used to determine if two population means are equal.The data may either be paired or not paired. For paired t test, the data is dependent, i.e. there is a one-to-one correspondence between the values in the two samples.For example, same subject measured before & after a process change, or same subject measured at different times.Given two paired sets and of n measured values, the paired t-test determines if they differ from each other in a significant way. Lastly, when we compared the difference between partner types for self efficacy and perceived barriers. Paired t test demonstrated no statistically significant difference between main and casual partners for self-efficacy or perceived barriers. t test= -0.59 The two-sample t-test is used to determine if two population means are equal.The data may either be paired or not paired.

18. Summary History of an STI Lower level of self-efficacy for disclosure for casual partners Lower level of perceived barriers for casual partners STI-related stigma was not associated with a history of an STI No difference in means for partner types History of an STI was associated with a lower level of self-efficacy for disclosure and a lower level of perceived barriers for casual but not main sex partners. The experience of having an STI did change their perception and they felt less confident about disclosing to their partner and yet have perceived fewer barriers. Additional studies are necessary to explore this association in more depth. The association of STI-related stigma and history of an STI was not statistically significant. And there was no difference in means for partner types. History of an STI was associated with a lower level of self-efficacy for disclosure and a lower level of perceived barriers for casual but not main sex partners. The experience of having an STI did change their perception and they felt less confident about disclosing to their partner and yet have perceived fewer barriers. Additional studies are necessary to explore this association in more depth. The association of STI-related stigma and history of an STI was not statistically significant. And there was no difference in means for partner types.

19. Limitations Generalizability Instrument not previously validated Also, the sample was one that was already involved in an on-going study, urban African American females and therefore limits some of its generalizibilty. Although the instrument was adapted from previous studies, the instrument had not been previously validated. Also, the sample was one that was already involved in an on-going study, urban African American females and therefore limits some of its generalizibilty. Although the instrument was adapted from previous studies, the instrument had not been previously validated.

20. Conclusion Adolescents had a moderate level Self-efficacy Perceived Barriers History of STI not associated with stigma Potential normalization of having STI Lack of difference May relate to rapid serial monogamy among adolescents Sexually experienced adolescents in the study did have a moderate level of self efficacy for disclosure. As well as they perceived a moderate level of barriers to disclosure. Therefore finding ways to enhance their self-efficacy and help adolescents better navigate these barriers will likely improve overall disclosure and decrease subsequent STI. In this group, history of an STI was not significantly associated with stigma. this may be due to development of a level of normalcy for these adolescents or that having an STI is viewed as an inevitable part of their lives. The findings that there was no difference in the partner type could relate to the overall lower numbers of casual partners and a higher turnover of main partners and rapid serial monogamy among adolescents.Sexually experienced adolescents in the study did have a moderate level of self efficacy for disclosure. As well as they perceived a moderate level of barriers to disclosure. Therefore finding ways to enhance their self-efficacy and help adolescents better navigate these barriers will likely improve overall disclosure and decrease subsequent STI. In this group, history of an STI was not significantly associated with stigma. this may be due to development of a level of normalcy for these adolescents or that having an STI is viewed as an inevitable part of their lives. The findings that there was no difference in the partner type could relate to the overall lower numbers of casual partners and a higher turnover of main partners and rapid serial monogamy among adolescents.

21. Policy Implications Better understanding of self-efficacy related to disclosure, barriers to disclosure, and STI-related stigma Programs to improve disclosure by affecting self-efficacy; disclosure and partner referral; and decreasing STI-related stigma We hope to gain a Better understanding of the relationship self efficacy for disclosure, barriers to disclosure, and STI-related stigma among adolescents and the goal would be implementation of programs to improve disclosure rates by affecting self-efficacy; assisting patients in disclosure and partner referral; and decreasing STI-related stigma We hope to gain a Better understanding of the relationship self efficacy for disclosure, barriers to disclosure, and STI-related stigma among adolescents and the goal would be implementation of programs to improve disclosure rates by affecting self-efficacy; assisting patients in disclosure and partner referral; and decreasing STI-related stigma

22. Acknowledgements Special Thank You to Shang-en Chung, ScM and Omolara Olaniyan, MD