Anne Teitelman, PhD, FNP-BC, FAANP, FAAN University of Pennsylvania

1. 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

2. Acknowledgements • Penn Center for AIDS Research • NIH 1K01MH080649-01A1 • Participants • Study team members • Coauthors • S. Kim • A. Davis Vogel

3. 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)

4. “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

5. 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

6. 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)

7. Adolescents girls at risk • Adolescents with STIs had increased risk for HIV • 26% increase in HIV among youth 15-19 since 2006 • Adolescent females ages 15-19 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

8. 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)

9. 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

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

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

12. Formative research Attendees of family planning clinic (federally funded services) • Identify causal links • Retrospective individual in-depth interviews • N= 30 young women ages 18- 24 • Focus groups • N= 60 adolescent girls ages 14-17 • Identify core elements • Survey • N= 218 adolescent girls ages 14-20

13. 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

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

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

16. 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

17. 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

18. 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

19. Results

20. Results • Intention to use condoms was associated with greater condom use (p= < .000) • Explained close to 40% of the variance (R2 =. 398)

21. 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

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

23. 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)

24. 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

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

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

27. 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

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