Dissolution of primary intimate relationships during incarceration and associations with post-release STI/HIV risk behavior in a Southeastern city.

BACKGROUND: Incarceration is associated with sexually transmitted infections (STIs) including human immunodeficiency virus (HIV). It may contribute to STI/HIV by disrupting primary intimate relationships that protect against high-risk partnerships. METHODS: In an urban sample of men (N = 229) and women (N = 144) in North Carolina, we assessed how often respondents experienced the dissolution of a primary intimate relationship at the time of their own (among men) or their partner's (among women) incarceration. We then measured the association between dissolution of relationships during incarceration and STI/HIV-related risk behaviors. RESULTS: Among men who had ever been incarcerated for 1 month or longer (N = 72), 43% (N = 31) had a marital or nonmarital primary partner at the time of the longest prior sentence. Among women, 22% (N = 31) had ever had a primary partner who had been incarcerated for 1 month or longer. Of men and women who were in a relationship at the time of a prior incarceration of 1 month or longer (N = 62), more than 40% of men and 30% of women reported that the relationship ended during the incarceration. In analyses adjusting for sociodemographic characteristics and crack/cocaine use, loss of a partner during incarceration was associated with nearly 3 times the prevalence of having 2 or more new partners in the 4 weeks before the survey (prevalence ratio: 2.80, 95% confidence interval: 1.13-6.96). CONCLUSIONS: In this sample, incarceration disrupted substantial proportions of primary relationships and dissolution of those relationships was associated with subsequent STI/HIV risk. The results highlight the need for further research to investigate the effects of incarceration on relationships and health.

Dissolution of primary intimate relationships during incarceration and implications for post-release HIV transmission.

Incarceration is associated with sexually transmitted infections (STIs) including human immunodeficiency virus (HIV). Incarceration may contribute to STI/HIV by disrupting primary intimate relationships that protect against high-risk relationships. Research on sexual network disruption during incarceration and implications for post-release sexual risk behavior is limited. We interviewed a sample of HIV-positive men incarcerated in North Carolina to assess how commonly inmates leave partners behind in the community; characteristics of the relationships; and the prevalence of relationship dissolution during incarceration. Among prison inmates, 52% reported having a primary intimate partner at the time of incarceration. In the period prior to incarceration, 85% of men in relationships lived with and 52% shared finances with their partners. In adjusted analyses, men who did not have a primary cohabiting partner at the time of incarceration, versus those did, appeared to have higher levels of multiple partnerships (adjusted prevalence ratio (PR), 1.5; 95% confidence interval (CI) 0.9-2.6; p = 0.11) and sex trade, defined as giving or receiving sex for money, goods, or services (adjusted PR, 2.1; 95% CI 0.9-4.8; p = 0.08) in the 6 months prior to incarceration. Involvement in financially interdependent partnerships appeared to be associated with further reductions in risk behaviors. Of men in primary partnerships at the time of prison entry, 55% reported their relationship had ended during the incarceration. The findings suggest that involvement in primary partnerships may contribute to reductions in sexual risk-taking among men involved in the criminal justice system but that many partnerships end during incarceration. These findings point to the need for longitudinal research into the effects of incarceration-related sexual network disruption on post-release HIV transmission risk.

Patient-physician agreement on the content of CHD prevention discussions.

BACKGROUND: Little is known about agreement between patients and physicians on content and outcomes of clinical discussions. A common perception of content and outcomes may be desirable to optimize decision making and clinical care. OBJECTIVE: To determine patient-physician agreement on content and outcomes of coronary heart disease (CHD) prevention discussions. DESIGN: Cross-sectional survey nested within a randomized CHD prevention study. SETTING AND PARTICIPANTS: University internal medicine clinic; 24 physicians and 157 patients. METHODS: Following one clinic visit, we surveyed patients and physicians on discussion content, decision making and final decisions about CHD prevention. For comparison, we audio-recorded, transcribed and coded 20 patient-physician visits. We calculated percent agreement between patient/physician reports, patient/transcription reports and physician/transcription reports. We calculated Cohen's kappas to compare patient/physician perspectives. RESULTS: Patients and physicians agreed on whether CHD was discussed in 130 visits (83%; kappa = 0.55; 95% CI 0.40-0.70). When discussions occurred, they agreed about discussion content (pros versus cons) in 53% of visits (kappa = 0.15; 95% CI -0.01-0.30) and physicians' recommendations in 73% (kappa = 0.44; 95% CI 0.28-0.66). Patients and physicians agreed on final decisions to take medication in 78% (kappa = 0.58; 95% CI 0.45-0.71) and change lifestyle in 69% (kappa = 0.38; 95% CI 0.24-0.53). They agreed less often, 43% (kappa = 0.13; 95% CI -0.11-0.37) about degree of involvement in decision making. Audio-recorded results were similar, but showed very low agreement between transcripts and patients' and physicians' self-report on discussion content and decision making. CONCLUSIONS: Disagreements about clinical discussions and decision making may be common. Future work is needed to determine: how widespread such agreements are; whether they impact clinical outcomes; and the relative importance of the subjective experience versus objective steps of shared decision making.

Effect of adding a values clarification exercise to a decision aid on heart disease prevention: a randomized trial.

BACKGROUND: Experts have called for the inclusion of values clarification (VC) exercises in decision aids (DAs) as a means of improving their effectiveness, but little research has examined the effects of such exercises. OBJECTIVE: To determine whether adding a VC exercise to a DA on heart disease prevention improves decision-making outcomes. DESIGN: Randomized trial. SETTING: UNC Decision Support Laboratory. PATIENTS: Adults ages 40 to 80 with no history of cardiovascular disease. INTERVENTION: A Web-based heart disease prevention DA with or without a VC exercise. MEASUREMENTS: Pre- and postintervention decisional conflict and intent to reduce coronary heart disease (CHD) risk and postintervention self-efficacy and perceived values concordance. RESULTS: The authors enrolled 137 participants (62 in DA; 75 in DA + VC with moderate decisional conflict (DA 2.4; DA + VC 2.5) and no baseline differences among groups. After the interventions, they found no clinically or statistically significant differences between groups in decisional conflict (DA 1.8; DA + VC 1.9; absolute difference VC-DA 0.1, 95% confidence interval [CI]: -0.1 to 0.3), intent to reduce CHD risk (DA 98%; DA + VC 100%; absolute difference VC-DA: 2%, 95% CI: -0.02% to 5%), perceived values concordance (DA 95%; DA + VC 92%; absolute difference VC-DA -3%, 95% CI: -11% to +5%), or self-efficacy for risk reduction (DA 97%; DA + VC 92%; absolute difference VC-DA -5%, 95% CI: -13% to +3%). However, DA + VC tended to change some decisions about risk reduction strategies. LIMITATIONS: Use of a hypothetical scenario; ceiling effects for some outcomes. CONCLUSIONS: Adding a VC intervention to a DA did not further improve decision-making outcomes in a population of highly educated and motivated adults responding to scenario-based questions. Work is needed to determine the effects of VC on more diverse populations and more distal outcomes.

Individuals' responses to global CHD risk: a focus group study.

OBJECTIVE: To explore how individuals respond to global coronary heart disease (CHD) risk and use it in combination with treatment information to make decisions to initiate and maintain risk reducing strategies. METHODS: We conducted four focus groups of individuals at risk for CHD (n=29), purposively sampling individuals with each of several risk factors. Two reviewers coded verbatim transcripts and arbitrated differences, using ATLAS.ti 5.2 to facilitate analysis. RESULTS: Participants generally regarded the concept of global CHD risk as useful and motivating, although had questions about its precision and comprehensiveness. They identified several additional influential factors in decision-making (e.g. achievable risk, the quickness and self-evidence of results) and generally preferred lifestyle changes to medications (although most would accept medications under certain circumstances). They also noted the importance of participating in decision-making. CONCLUSION: Our results underscore the motivating potential of global CHD risk and the importance of patient participation in decision-making. PRACTICE IMPLICATIONS: Global CHD risk is a useful adjunct to CHD prevention and can be presented in ways, and with information, that might improve CHD outcomes.