Communication between Partners: A Qualitative Analysis of Heterosexual African American Men’s HIV/AIDS Risk Perceptions

1. Communication between Partners: A Qualitative Analysis of Heterosexual African American Men’s HIV/AIDS Risk Perceptions Mike F. Weaver, DrPH Guest Lecturer

3. Problem Definition For African American women and men 25-44 years, HIV/AIDS is the leading cause of death. It is estimated that 15% of men and 75% of women became infected with HIV through heterosexual contact. (CDC, 2003) • In Georgia • There were 25,485 reported AIDS cases in 2002 • 76.5% of new cases are African American • In rural Georgia • Of all diagnosed AIDS cases, 29% of the men, 45% of the women and 50% of the children and adolescents live outside of metropolitan Atlanta (GaDHR, 2003) • In South Carolina • There were 12,513 reported AIDS cases in 2002 • 68.5% (& 71.2% of HIV) are African American • In rural South Carolina • 2,157 reported AIDS cases in SC • 1,060 (14%) reported cases in Pee Dee Health District (SCDHEC, 2003)

4. Background of the Problem • African American Men • Have the highest death rates from CVD at 841 per 100,000 • Have the worst overall mortality rates by living in South Carolina and Georgia (717 and 736 respectively) • Have a 1 in 30 chance of becoming a homicide victim (1 in 132 for AA women) • For AA adolescents, the mortality rate is the highest of any ethnicity at 185 per 100,000 (53.3 for AA females) Why? • Men may have less healthy lifestyles including risk-taking at younger ages. • Society discourages healthy behaviors in men and boys. (The Men’s Health Network, 2002)

5. Statement of the Problem • In rural SC communities, Richter et al. (2003) found • AA women have accepted the notion that, due to the scarcity of eligible AA men, their male partners “fool around” with other women • AA women do not talk to their male partners about safer sex practices • AA women in long-term relationships accept the demands their male partners place on the relationship to maintain family/relationship security • Addicted AA women had sex for money to support their dependency • The relationship divide among African American women and men has… • Established communication barriers between the sexes • Impacted families and households • Abetted risky sex behaviors • Created a dilemma resulting in sexual politics and power imbalances

6. Literature Review • Safer Sex Negotiations (defined as intimate practices between partners which do not involve the exchange of body fluids) • Communication Skills • R. Rickman et al. (1994)- “adolescents who reported that they and their partners had never discussed sexual histories were more likely not to use condoms during intercourse.” • C. Dilorio et al. (2000)- “condom use among college students was significantly correlated with communication self-efficacy, communication outcome expectations, perception of partner’s attitude towards communication.” • D. Shoop (1994)- “the adolescent’s ability to communicate with a sexual partner about safer sex is significantly associated with condom use.” • Length of Relationship • D. Civic (1999)- “relationship length predicted condom use more than any other variable including Relationship Type, Perceived Risk and Hormonal Method of Birth Control.” • HIV/AIDS Risk Perceptions • High Risk Sex Behaviors • S. Taylor et al. (1997)- “AA women were more likely to engage in safer sex behaviors than their male counterparts among heterosexual college students.” • Influence of Women in Safer Sex Practices • M. Fullilove et al. (1990)- “gender roles appeared to be closely related to sexual practices among AA women. Communication with the sexual partner emerged as central to the woman’s ability to protect herself from infection, but communication was complicated by several types of emotional charge: planning, trust and fear.” • Perspectives of African American Manhood/Masculinity • Views of African American Relationships • C. Franklin (1984)- “writings on the subject of AA male-female relationships generally agree that conflict between the two is destructive and potentially explosive” • Views of Societal Influences • I. Harris et al. (1994)- “younger AA males have similar notions of masculinity as do Caucasians than do older AA males.

7. Significance of Research • Lack of HIV/AIDS literature on heterosexual AA men • AA women in current research have reported emotional dependence, economic support, scarcity of AA men, and maintaining family as rationale to oblige to their partner’s sexual desires. (Richter et al., 2003) • AA women are most likely to be infected with HIV as a result of unprotected sex with an infected man. Often women do not perceive themselves at high risk and are reluctant to negotiate safer sex practices. • Research has not examined the perspectives of AA men from rural settings.

8. Research Questions • What factors do heterosexual African American men feel affect the communication or lack of communication between AA men and women who are sexual partners regarding HIV risk? • What factors do heterosexual African American men feel influence and AA man or woman’s choice to have sex with a heterosexual partner at high-risk for HIV infection? • Do heterosexual African American men believe these factors differ by gender? • Do their perceptions of these factors differ by area of residence (rural vs. urban)? • Do their perceptions of these factors differ by age (younger vs. older)? • Do their perceptions of these factors affect condom usage? • How does being a heterosexual African American man affect risk perceptions of HIV infection?

9. Social Cognitive Theory • Social Cognitive Theory (Bandura, 1997)- An Interpersonal theory which examines the constant interaction of person, environment and behavior (reciprocal determinism): • The person component is influenced by forethought (self-efficacy, affective emotions, outcome expectancies, prior knowledge, and reinforcement). • The environment component is influenced by access to resources and observational learning. • The behavior component is guided by self-regulation, self-monitoring, self-judgment and self-reaction. • A major proposition of Social Cognitive Theory is that a person’s conscience in performing a behavior is an important predictor of that behavior. • SCT has been used in quantitative research regarding communication and HIV risk by DiIorio et al. (2000), DiClemente and Wingood (1995), Basen-Engquist (1992), and O’Leary et al. (1992)

10. PERSON (Self-efficacy, Outcome Expectancies, and Prior Knowledge) RECIPROCAL DETERMINISM ENVIRONMENT (Physical, Social, and “Cultural”) BEHAVIOR (Self-regulation, Self-judgment, and self-monitoring) UNDERSTAND HIV RISK? PRACTICE SAFER SEX BEHAVIORS? COMMUNICATE SAFER SEX?

11. Discussion Guide Questions • When you hear the term “HIV risk” what comes to mind? • How comfortable do you think African American men as a whole are communicating with their female partners about HIV? • How comfortable do you think African American women as a whole are communicating with their male partners about HIV? • Describe how a discussion of HIV risk with your female partner would go. • Even if he knows the risks, describe the reasons why you think an African American man might continue to have unprotected sex with a woman who is at high risk for HIV. • Even if she knows the risks, describe the reasons why you think an African American woman might continue to have unprotected sex with a man who is at high risk for HIV. • How do you think a discussion of HIV risk with a female partner will affect condom usage? • How do you think culture influences African American men’s decision about sexuality and sexual practices? • How do you think culture influences African American women’s decision about sexuality and sexual practices?

12. Methodology • Recruitment of Participants (n=57, 9 focus groups) • Younger are those individuals between 18 and 24 years • Older are those individuals with ages 25 years+ Urban- (MSA>50,000 residents) Morehouse College (younger) Clark Atlanta University (younger) Zion Hill Baptist Church (older) Capitol Area Mosaic (older) Greenview Community Center (older) Rural- (MSA<50,000 residents) South Carolina State University (younger)- two sessions Second Baptist Church in Aiken, SC (older) Augusta-Richmond Co. Weed ‘N Seed (older)

13. Analysis • Data Collection • Same trained moderator for all focus groups • Focus Group Discussion Guide w/ 9 questions • 9 Focus Group Transcripts prepared verbatim • Data Analysis • All data entered and analyzed via NVivo v2.1 software • Organization of data into topical categories known as Content Areas • Themes are at least four(4) responses in more than one focus group; then placed in Content Areas • An additional coder analyzed three transcripts • Coding discrepancies were resolved for accuracy and interpretation of data

14. Inherited first codebook from AA women’s research with 139 nodes, with 17 free/parent nodes. Revised codebook as appropriate for AA men resulting in 88 nodes, with 19 free/parent nodes. Coded three rural transcripts. Created definitions for free nodes. External coder coded three rural transcripts. Met w/external coder. Revised codebook to 66 nodes w/8 free nodes. Defined all nodes. Coded remaining six transcripts. Final codebook: 66 nodes with 8 free/parent nodes.

15. Findings Eight Content Areas • AA men/women being Comfortable communicating with partner- comments regarding any and all verbal/nonverbal communication held with a partner either in intimate or non-intimate moments. • Reasons for Men/Women to have unprotected Sex- comments regarding justification (non-justification) for men/women engaging in unprotected sex. • Examples of Communication- comments whereby the respondent gives a specific example of a conversation (verbal/nonverbal) with a partner. • Discussion Affect on Condom Usage- comments on whether conversations regarding HIV risk has any impact on condom use. • Culture Influences on Men/Women- comments regarding societal influences on men’s/women’s sexual behaviors.

16. Findings Themes contained within Content Areas 1). African American Men/Women Comfortable Communicating with Female/Male Partner Physical Abuse Perception of Woman’s Knowledge Verbal Abuse Women’s Reputation 2). Reasons for African American Men/Women to have Unprotected Sex Love Partner Selection Perception of Partner Physical Needs Substance Abuse Finances Unprotected Sex with Woman/Man at High Risk for HIV 3). Examples of Communication 4). HIV Discussion Affect on Condom Usage Comfort Level Long-term Relationships HIV Testing Not Sure Resolution Pregnancy Discussion of HIV with Partner Increase Initiator Decrease 5). Culture Influences on African American Men/Women Male Peers Locale Media Future Hip-Hop Younger Days History Religion Family Relationships

17. UNDERSTAND HIV RISK (RQ2, RQ3, RQ4 & RQ5) Older/Younger Urban/Rural Women Love- Older Love- Urban Love Unprotected Sex- Younger Substance Abuse- Urban Pcpt. Ptnr. Finances- Younger Finances- Urban Finances Partner Selection- Younger Partner Selection- Rural Subs Abuse Physical Needs- Younger Physical Needs- Rural

18. COMMUNICATE SAFER SEX (RQ7, RQ3, RQ4 & RQ5) Older/Younger Urban/Rural Women Peers- Younger Peers- Urban Media Media- Younger Media- Urban Hip-Hop Hip-Hop- Younger Hip-Hop- Urban Family Family- Younger History- Rural History Community- Younger Community- Rural Religion Religion- Younger Religion- Rural Community History- Older

19. PRACTICING SAFER SEX BEHAVIORS (RQ1, RQ6, RQ3, RQ4 & RQ5) Older/Younger Urban/Rural Women Physical Abuse- Older Physical Abuse- Rural More Comfortable Perc. Wom. Knwl- Younger Reputation- Rural Reputation HIV Testing- Younger Testing- Rural Comfort Level- Older Comfort Level- Rural Long-term Rel.-Older Long-term Rel.- Urban Initiator Initiator- Urban Pregnancy- Younger Pregnancy- Rural Increase- Older Increase- Urban Decrease- Younger Decrease- Rural Not Sure Not Sure- Urban

20. Limitations • Non-random, convenience sampling which limits generalizability to a larger AA male population • Sample size (N=57) • Screening Questionnaire (sex w/ females vs. African American females) • Geographical locations • Self-reported as heterosexual

21. Implications for Practice Person (Individually) • Determine who initiates safer sex discussions • Understand the influence of male peers Environment (Health professionals) • Cultural appropriateness • Age relevant messages (older particularly) • Communication skills to convey sexual health messages Behavior (Between couples) • Communication about HIV risk gap • Initiate HIV discussion prior to sexual encounter • Discuss HIV risk regardless of age and relationship status

22. Recommendations Individual • Health message--Men should practice three primary modes of protection: 1) condom use with every sexual encounter; 2) alternative sexual acts that do not involve exchanging body fluids; and 3) abstinence. • Communicate about HIV risk to sex partner • Assumptions about one’s sexual health could be detrimental • Understand influence of culture on behavior patterns Research • Reword Screening Questionnaire • Continue Focus Groups by examining HIV risk perceptions of more heterosexual African American men w/ FGDG • Research college students vs. non-college students

24. THANK YOU!!! QUESTIONS?