What’s Love Got to Do With It: Relationships and HIV Prevention

1. What’s Love Got to Do With It: Relationships and HIV Prevention Trace Kershaw Assistant Professor Social and Behavioral Sciences Program Epidemiology and Public Health Yale University

3. 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?

4. 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

5. 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

6. 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

7. Do relationship perceptions influence sexual risk of young pregnant women?

8. 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

9. High Anxiety Low Avoidance High Avoidance Low Anxiety Romantic Attachment and Sexual Risk: Background Unhealthy need to be loved & Mistrust of others Unhealthy need to be loved Mistrust of others Secure

10. 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

11. Regression of Attachment on Condom Use Percentage Attachment Avoidance Condoms mean do not trust p -.09* R2= .11 Condoms upset partner -.14* Condom Use .23* .09* Condom use self-efficacy .16* -.19* Attachment Anxiety -.12* Controlling for age, race, education, employment, number of children, relationship duration ; Coefficients represent standardized Beta weights

12. Logistic Regression of Attachment on Multiple Partners and STIs Attachment Avoidance R2= .18 Multiple Partners .23* Relationship with FOB R2= .05 .65* STIs .64* Attachment Anxiety Coefficients represent Adjusted Odds Ratios

13. 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

14. Sexual Risk and Relationship Functioning of Young Couples Transitioning to Parenthood

15. 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

16. 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 health 1 Misovich et al (1997) Review of General Psychology;

17. PARTNRS: Model

18. 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

19. Demographics • 118 couples interviewed during pregnancy *p<.05

20. Pregnancy History *p<.05

21. Pregnancy Intentions and Wantedness

22. 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)

23. 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

24. Victims of Abuse *p<.05 *p<.05 *p<.05

25. Sex Risk History **p<.01; *p<.05

26. Sex Risk History **p<.01 *p<.05

27. 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

28. 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

29. 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

30. 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

31. Results *p<.05; Controlling for age, race, and relationship duration

32. Results *p<.05; Controlling for age, race, and relationship duration

33. Relationship Satisfaction and Sexual Risk Cheated Relationship Satisfaction Women OR=.33* Intend to be Faithful =.23* Relationship Satisfaction Men Sex Communication =.20* Condom Use Note: Coefficients are standardized beta weights for Faithfulness Intentions and Sex Communication, and Odds Ratios for Cheated Controlling for age, race,, & relationship duration

34. 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

35. Bivariate Predictors of Relationship Satisfaction Not Significant Women Men • age Want to be pregnant: r=.13 Want to be pregnant: r=.22* • income Living with partner: r=.24* Living with partner: r=-.02 • race Perceived equity: r=.65** Perceived equity: r=.43** • # children Attachment Avoidance: r=-.40** • Relationship duration Attachment Avoidance: r=-.61** Attachment Anxiety: r=-.35** • Marital status Attachment Anxiety: r=-.26* • Relationship power Frequency of Sex: r=.19* Frequency of Sex: r=.12 # past sex partners: r=.06 # past sex partners: r=-.27* IPV: r=-.28* IPV: r=-.25*

36. Multivariate Predictors of Relationship Satisfaction Women Men Want to be pregnant: .08 Want to be pregnant: .17* Living with partner: -.05 Living with partner: -.14 Perceived equity: 59** Perceived equity: .19* Attachment Avoidance: -.25** Attachment Avoidance: -.50** Attachment Anxiety: .01 Attachment Anxiety: -.03 Frequency of Sex: .01 Frequency of Sex: -.13 # past sex partners: .10 # past sex partners: .06 IPV: -.07 IPV: -.16* Note: Coefficients are standardized beta weights

37. 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

38. 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

39. 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

40. For more information visit our website at www.partnrstudy.com • If interested in joining our team, contact me: • trace.kershaw@yale.edu; 785-3441

41. 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