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:– trace.kershaw@yale.edu; 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