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PARTNRS
What’s Love Got to Do With It: Relationships and HIV
Prevention
Trace KershawAssistant Professor
Social and Behavioral Sciences ProgramEpidemiology and Public Health
Yale University
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The Role of Relationships in Public
Health• Much of public health research focuses
on individual mechanisms of health– Behaviors– Genetic
• Need to look at broader context • Partners, family, friends…..• Do relationships matter?
– Do partners influence health of the other individual?
– Does relationship quality influence health?
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Measuring the Impact of Relationships
• Most studies do not assess relationship quality or the partner’s influence
• The few studies that do use:– Individual’s report of partner’s behaviors– Crude measures of relationship quality
• Marital status• Relationship duration
• Need to explore couple studies to assess potential mutual influences on health
• Need to broaden measurement of relationship quality to include levels and type of relationships
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Relationships and Sexual and Reproductive Health
• Sex occurs in interpersonal context• Relationships are often ignored• Good relationships can be protective
because:– Less concurrent partnerships1
– Less partner turnover2
• New sexual partners increase risk for STDs
– Better communication about current and past risk3
• Despite this, there are few relationship-based or couple based interventions
1Choi et al (1994) AJPH; 2 Niccolai et al (2004) J Adol Health; 3Cupach and Metts (1995) J of Pers Rel
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Presentation Aims
• Do relationship perceptions influence sexual risk of young pregnant women?
• Sexual risk and relationship functioning of young couples transitioning to parenthood– Describe relationship characteristics of
young couples– Assess the association of relationship
satisfaction on sexual risk– Assess predictors of relationship
satisfaction of young couples during pregnancy
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Do relationship perceptions influence sexual risk of young pregnant women?
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Romantic Attachment and Sexual Risk
• How young women feel about relationships may contribute to their sexual risk behavior
• Romantic Attachment Theory– Partially stems from parent-child
attachment– Applies to adult relationships
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Romantic Attachment and Sexual Risk:
BackgroundHigh Anxiety
Low Anxiety
High Avoidance
Low Avoidance
Unhealthy need to be loved
Unhealthy need to be loved & Mistrust of others
Mistrust of others
Secure
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Romantic Attachment and Sexual Risk: Study
Sample• 755 pregnant women from large RCT
– 80% African-American– 13% were Latina– Age: M= 20.4 years (SD=2.6) – Gestational age at interview: M=18
weeks– 81% in current relationship
• 70% with the father of the baby
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Condoms mean do
not trust p
Condom Use
Attachment Anxiety
AttachmentAvoidance
Regression of Attachment on Condom Use
Percentage
Condoms upset
partner
Condom use self-efficacy
-.12*
.09*
-.14*
-.19*
.16*
.23*
-.09*R2= .11
Controlling for age, race, education, employment, number of children, relationship duration ; Coefficients represent standardized Beta weights
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Relationship with FOB
Multiple Partners
Attachment Anxiety
AttachmentAvoidance
Logistic Regression of Attachment on Multiple
Partners and STIs
.65*
.23*
.64*
R2= .18
STIs
R2= .05
Coefficients represent Adjusted Odds Ratios
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Romantic Attachment and Sexual Risk:
Conclusions• Attachment had direct or indirect effect on all 6 sexual risk beliefs and behaviors– Anxiety had more impact than avoidance– Anxiety had as big/bigger effect than
traditional individual-level cognitive variables (beliefs and self-efficacy)
– So is it the heart or the head?• Changing how individuals view
relationships may lead to decreased sexual risk and may facilitate change of sex related beliefs and attitudes
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Sexual Risk and Relationship Functioning
of Young Couples Transitioning to
Parenthood
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PARTNRS: Study Design
• 300 couples recruited from OB/GYN clinics in New Haven, Bridgeport, New London
• In a romantic relationship; expecting a baby; women age 14-21; men age > 14; HIV negative
• Interviewed 3 times:– 2nd-3rd trimester– 6-months postpartum– 12-months postpartum
• Both men and women followed up regardless of relationship status
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Relationships During Pregnancy
• Pregnancy is a time of stress and transition
• Relationship strain among young couples heightened during pregnancy1
– 72% of adolescents involved with father of baby during pregnancy
– 64% by 6-months postpartum– 50% by 12-months postpartum
• Need to understand the factors related to relationship functioning during this transition and how changes in these relationships influence sexual and reproductive health1 Misovich et al (1997) Review of General Psychology;
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PARTNRS: Model
SEXUAL RISK OUTCOMES
STD
COMMUNITY/PEER
FAMILY
DYAD
INDIVIDUAL
Attachment Avoidance
RELATIONSHIP FUNCTIONING OUTCOMES
Attachment Anxiety
Relationship Dissatisfaction
Unprotected Sex
Relationship Dissolution
Extra-Relationship
Partners
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Relationships and Love
“Being pregnant by someone I adore and love dearly is the best feeling in the world. Just the idea of us bringing a baby into the world is an amazing feeling and we love each other which makes every day more special. We both cannot wait for our baby boy to come so we have someone else to love and cherish in our lives.”
Female Participant
“I feel excited and really can’t wait for this life changing experience. I know love will become redefined.”
Male Participant
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Demographics• 118 couples interviewed during
pregnancy Women Men
Race•Black•Hispanic•White/other
33%40%27%
38%42%20%
Age M (SD)* 18.5 (1.8)Rng: 15-21
21.1 (3.9)Rng: 14-38
Household Income $14,755Rng:2.5k-
42k
$15,623Rng:2.5k-45k
Main Source of Financial Support*•Self•Partner•Parent•Public Assistance•Other Relative
40%25%19%12%4%
69%6%
13%6%6%
*p<.05
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Pregnancy HistoryWomen Men
First pregnancy 61% 64%
Age at first pregnancy* 17.5 (1.8)Rng: 11-
21
19.2 (3.3)Rng: 13-30
Other children 22% 27%
Parents response to this pregnancy (1-7) 7=happy*
4.6 (1.8) 5.4 (1.9)
*p<.05
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Pregnancy Intentions and Wantedness
53
15
12
20
31
23
18
28
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Tried to get pregnant Wanted to be pregnant
Both
Man OnlyWoman Only
Neither
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Relationship Characteristics
• Duration: M=2.3 years (Range: 0.5-7.6)• 64% currently living together• 10% married• 84% see each other ever day• Seriousness of the relationship
– Very committed: 88% of women vs. 77% of men (p<.05)
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Relationship Conflict• Among couples
– 53% have broken up at least once• Mean=1.5 (range 0-100)
– 64% have physical, sexual, or emotional abuse present• 37% have physical or sexual abuse present
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Victims of Abuse
9
02
22
33
2
12
45
0
5
10
15
20
25
30
35
40
45
50
Physical Abuse Sexual Abuse Threats to Harm Emotional AbuseType of Abuse
Pe
rce
nt
WomenMen
*p<.05
*p<.05
*p<.05
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Sex Risk HistoryWomen Men
Age at First Sex* 14.9 (1.7) 14.2 (3.0)
Total Number of Partners**
4.95 (5.7) 10.01 (10.2)
Ratio of Sex Partners to Serious Relationships**
2.74(2.4) 4.33(3.3)
**p<.01; *p<.05
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Sex Risk History
**p<.01 *p<.05
Women Men
STI History** 32.5% 11.9%
STI Since Start of Relationship**
21.7% 7.5%
Cheated 14.2% 17.8%
IVDU Ever* 1.7% 6.8%
Jail** 5.0% 27.0%
Sex for Money 1.7% 3.4%
Same Sex Partner**
10.2% 1.7%
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Sexual Risk Behavior• Among couples
– Months going out before sex: • M=3.0 (3.3)• 43% had sex within 1 month of going out
– Months having sex, before sex without a condom:• M=2.6 (3.1)• 44% had sex without a condom within 1 month
– Unprotected Sex Acts• M=9.5 (11.9)
– Condom Use Past 6 Months• M=19.2% (31.2)• 60% never used condoms• 3.5% always used condoms
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Sexual Risk Behavior• However, 47.5% of the couples
are low risk– Neither member of couple IVDU,
recent STD, jail history, msm, had sex for money, had concurrent partner;
– tested for HIV since relationship began
• No difference between low risk and high risk couples on condom use (p=.58)– Low risk: M=19.8– High risk: M=17.9
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Does Relationship Satisfaction Influence
Sexual Risk?• Looked at influence of relationship
satisfaction for men and women on:– Cheating– Intention to be faithful– Sexual communication– Condom use past 6 months
• Controlled for age, race, relationship duration
• Assessed key cognitive psycho-sexual variables including: condom attitudes, condom self-efficacy, HIV/STI knowledge, safe sex norms
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Relationship Satisfaction
• Measured by the Dyadic Adjustment Scale1
– 32 questions that measure relationship quality of romantic relationships
– Agreement on variety of topics (e.g., finances, friends; showing affection;religion)
– General satisfaction with relationship (e.g., “how often do you think that things between you and your partner are going well?”)
– Overall togetherness (e.g., share outside interests; engage in interesting discussions)
– Intimacy and emotional expression (e.g., displaying affection, not showing love)
– Has demonstrated good reliability (alpha=.80-.96) and validity1
1Spanier (1976) J of Marriage and Family
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ResultsCheated Intended to be faithful
Women Men Women Men
Condom attitudes OR=.71(.36-1.40)
OR=.74(.39-1.37)
-.03 -.12
Condom self-efficacy
OR=.59(.32-1.09)
OR=1.28(.64-2.53)
.38* .14
HIV/STI knowledge
OR=.62(.35-1.10)
OR=.99(.55-1.57)
.17 .01
Safe sex norms
OR=1.61(.85-3.03)
OR=1.37(.74-2.56)
-.18 -.06
Relationshipsatisfaction
OR=.87(.43-1.72)
OR=.33*(.18-.59)
-.12 .23*
*p<.05; Controlling for age, race, and relationship duration
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ResultsSexual Communication Condom Use
Past 6-Months
Women Men Women Men
Condom attitudes .24* .05 .11 -.01
Condom self efficacy
.20* .09 -.13 .11
HIV/STI knowledge
-.18 .16 -.02 -.30*
Safe sex norms
-.09 -.05 .21* -.02
Relationshipsatisfaction
.13 .20* .13 -.16
*p<.05; Controlling for age, race, and relationship duration
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Relationship Satisfaction Women
Relationship Satisfaction and Sexual Risk
Note: Coefficients are standardized beta weights for Faithfulness Intentions and Sex Communication, and Odds Ratios for Cheated Controlling for age, race,, & relationship duration
SexCommunication
Cheated
Intend to be Faithful
Relationship Satisfaction Men
OR=.33*
=.23*
=.20*
Condom Use
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Conclusions• Relationship satisfaction was related to
sexual risk for men but not for women– Men with high relationship satisfaction
were less likely to cheat, had better sexual communication, and were more likely to intend to have sex with other people in the future
– Sexual psychosocial variables did not relate to sexual risk for men
• Sexual psychosocial variables did relate to sexual risk for women – More condom self-efficacy related to
better sexual communication and more intention to be faithful
– More positive condom attitudes related to better sexual communication
– More safe sex norms related to more condom use
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Bivariate Predictors of Relationship
SatisfactionNot
Significant
Want to be pregnant: r=.13
Want to be pregnant: r=.22*
Women Men
Living with partner: r=.24*
Living with partner: r=-.02
Perceived equity: r=.65** Perceived equity: r=.43**
Attachment Avoidance: r=-.40**Attachment Anxiety: r=-.35**
Attachment Avoidance: r=-.61**Attachment Anxiety: r=-.26*Frequency of Sex: r=.19*
# past sex partners: r=.06Frequency of Sex: r=.12
# past sex partners: r=-.27*
• age
• income
• race
• # children
• Relationship duration• Marital status
• Relationship power
IPV: r=-.28* IPV: r=-.25*
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Multivariate Predictors of Relationship
Satisfaction
Want to be pregnant: .08
Want to be pregnant: .17*
Women Men
Living with partner: -.05
Living with partner: -.14
Perceived equity: 59** Perceived equity: .19*
Attachment Avoidance: -.25**Attachment Anxiety: .01
Attachment Avoidance: -.50**Attachment Anxiety: -.03
Frequency of Sex: .01
# past sex partners: .10Frequency of Sex: -.13
# past sex partners: .06IPV: -.07 IPV: -.16*
Note: Coefficients are standardized beta weights
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Predictors of Relationship Satisfaction• Demographic variables (age, race, income) did
not relate to relationship satisfaction • Proxies for relationship quality (duration,
marital status) did not relate to relationship satisfaction
• Strongest predictors were perceived equity in the relationship, and attachment
• There were several differences between men and women on predictors of relationship satisfaction– An equitable relationship mattered more for
women– Low levels of attachment avoidance
mattered more for men
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Future Directions for PARTNRS
• Conduct true dyadic analyses– Influence of man’s behavior and
characteristics on women’s sexual and reproductive health
– Influence of women’s behavior and characteristics on men’s sexual and reproductive health
• Conduct longitudinal analyses to assess how changes in relationships influences reproductive and sexual health
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Future Directions
• Use results to create public health interventions that integrate social-cognitive behavioral change with “relationship strengthening” programs
• Create interventions that strengthen relationships by targeting attachment, equity, and communication
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• For more information visit our website at www.partnrstudy.com
• If interested in joining our team, contact me:– [email protected]; 785-3441
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Acknowledgements• The PARTNRS team:
– Anna Arnold, Project Coordinator– Cynthia Palmieri, Research Assistant– Kwaku Ayebi-Awuah, Research Assistant– Rachael Gerber, Research Assistant – Urania Magriples, Investigator– Linda Niccolai, Investigator– Jeannette Ickovics, Investigator– Derrick Gordon, Investigator– Yale New Haven Hospital– St. Raphael’s Hospital– Lawrence and Memorial Hospital– Bridgeport Hospital