1. www.aids2014.org 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. www.aids2014.org Acknowledgements Penn Center for AIDS Research NIH 1K01MH080649-01A1 Participants Study team members Coauthors –S. Kim –A. Davis Vogel

3. www.aids2014.org 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. www.aids2014.org “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. www.aids2014.org 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. www.aids2014.org 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. www.aids2014.org Adolescents girls at risk 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 Adolescents with STIs had increased risk for HIV 26% increase in HIV among youth 15-19 since 2006

8. www.aids2014.org 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. www.aids2014.org 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 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

11. www.aids2014.org 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

12. www.aids2014.org 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 Formative research

13. www.aids2014.org 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. www.aids2014.org 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)

15. www.aids2014.org 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

16. www.aids2014.org 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. www.aids2014.org 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. www.aids2014.org 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. www.aids2014.org Results Descriptive Statistics NMinMaxMeanSD When you had vaginal sex in the past 3 months, how often were condoms used? 214152.751.49 Intention 2181.005.003.691.15 Attitude 2172.005.004.41.68 Perceived Control 2162.605.004.53.55

20. www.aids2014.org Results Intention to use condoms was associated with greater condom use (p= <.000) Explained close to 40% of the variance (R 2 =. 398)

21. www.aids2014.org 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. www.aids2014.org Results- Regression Associated with attitude –Hedonistic beliefs (p= <.000) * –Partner reaction beliefs (p= <.000)* –Prevention beliefs (p=.232) Sig: p=<.05)

23. www.aids2014.org 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. www.aids2014.org 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. www.aids2014.org Conclusions Sexually active urban adolescent girls in US high rates of –STIs –partner abuse –condom coercion And are at increased risk for HIV

26. www.aids2014.org Conclusions Beliefs that influence condom use Hedonistic beliefs Partner reaction beliefs Friends supportive norm Partner supportive norm Partner resistance beliefs Negotiation beliefs

27. www.aids2014.org 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. www.aids2014.org 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