Concurrent sexual partnerships among African American women in Philadelphia: results from a qualitative study.

BACKGROUND: African American women are disproportionately affected by HIV/AIDS. Concurrent sexual partnerships may contribute to racial disparities in HIV infection. Little is known about attitudes and practices related to concurrency among African American women, or the social, structural and behavioural factors influencing concurrency. METHODS: We recruited 19 heterosexual African American women engaging in concurrent sexual partnerships from a public clinic in Philadelphia in 2009. We conducted interviews exploring social norms, attitudes and practices about concurrency, and the structural, social and behavioural factors influencing concurrent sexual partnerships, guided by grounded theory. RESULTS: Seventeen women reported one main and one or more non-main partners; two reported no main partners. Many women used condoms more frequently with non-main than main partners, noting they trust main partners more than non-main partners. Social factors included social normalisation of concurrency, inability to negotiate partners' concurrent partnerships, being unmarried, and not trusting partners. Lack of trust was the most commonly cited reason that women engaged in concurrent partnerships. Structural factors included economic dependence on partners, partners' dependence on women for economic support and incarceration that interrupted partnerships. Behavioural factors included alcohol and cocaine use. CONCLUSIONS: Social, structural and behavioural factors strongly influenced these African American women's concurrent sexual partnerships. Many HIV interventions disseminated by the CDC focus largely on behavioural factors and may fail to address the social and structural factors influencing African American women's sexual networks. Novel HIV prevention interventions that address the social determinants of African American women's HIV risks are urgently needed.

Family Sources of Sexual Health Information, Primary Messages, and Sexual Behavior of At-Risk, Urban Adolescents.

BACKGROUND: Sources of sexual health information exert strong influence on adolescents' sexual behavior. PURPOSE: The current study was undertaken to understand how family serve as sexual information sources, the messages adolescents recall from family, and how family learning experiences affect sexual behavior among at-risk adolescents. METHODS: Individual interviews were conducted with 69 teens, ages 15-18 years, from an alternative high school and a juvenile correctional facility to capture adolescents' early sexual health learning experiences involving family and evaluate their association with teens' recent sexual behavior. Sexual learning narratives were compared among gender and sexual experience groups. RESULTS: Many participants identified family as sexual health information sources. Primary messages recalled: risks of sex, protection, and relationship advice. Many adolescents portrayed learning experiences as negative, cautionary, lacking detail and not always balanced with positive messages. Participants who reported four or more sexual risks were the only group to identify pornography as a sexual health information source. Participants who reported fewer than four sexual risks were most likely to identify family sexual health information sources. DISCUSSION: Participants identified family members as sources of sexual health information, with variations by gender. Negative/cautionary messages require teens to seek additional sexual information elsewhere (primarily friends/media). Males, in particular, appear to often lack familial guidance/education. TRANSLATION TO HEALTH EDUCATION PRACTICE: Sexual health messages should be tailored to adolescents' needs for practical and sex-positive guidance regarding mechanics of sex and formation of healthy relationships, and balanced with cautions regarding negative consequences.

Social, structural and behavioral drivers of concurrent partnerships among African American men in Philadelphia.

African Americans face disproportionately higher risks of HIV infection. Concurrent sexual relationships, or sexual partnerships that overlap in time, are more common among African Americans than individuals of other races and may contribute to racial disparities in HIV infection. However, little is known about attitudes, norms and practices among individuals engaged in concurrent partnerships. Little is also known about the processes through which structural, behavioral, and social factors influence concurrent sexual relationships. We recruited 24 heterosexual African American men involved in concurrent sexual relationships from a public health clinic in Philadelphia. We conducted in-depth interviews exploring these men's sexual practices; social norms and individual attitudes about concurrency; perceived sexual health risks with main and non-main partners; and the social, structural, and behavioral factors contributing to concurrent sexual relationships. Twenty-two men reported having one main and one or more non-main partners; two reported having no main partners. Respondents generally perceived sexual relationships with non-main partners as riskier than relationships with main partners and used condoms far less frequently with main than non-main partners. Most participants commented that it is acceptable and often expected for men and women to engage in concurrent sexual relationships. Social factors influencing participants' concurrent partnerships included being unmarried and trusting neither main nor non-main partners. Structural factors influencing concurrent partnerships included economic dependence on one or more women, incarceration, unstable housing, and unemployment. Several men commented that individual behavioral factors such as alcohol and cocaine use contributed to their concurrent sexual partnerships. Future research and interventions related to sexual concurrency should address social and structural factors in addition to conventional HIV risk-taking behaviors.

Career aspirations and pregnancy intentions in pregnant teens.

STUDY OBJECTIVE: To quantify the association between career aspirations and pregnancy intention in a cohort of pregnant adolescents seeking prenatal care. DESIGN: Pregnant adolescents presenting for their first prenatal visit between March 2002 and February 2005 participated in a 30-minute interview as part of a larger cohort study addressing pregnancy attitudes and outcomes. Pregnancy intention was assessed through direct questioning and career aspirations were assessed by categorizing career goal responses into three categories: those requiring less than a college education, those requiring at least a college education, and undecided. Associations between pregnancy intention and career aspirations were quantified using cross tabulations and multivariable logistic regression. SETTING: Hospital based prenatal clinic. PARTICIPANTS: Women aged 12 to 19 seeking prenatal care. MAIN OUTCOME MEASURE: Pregnancy intention. RESULTS: Of the 257 pregnant adolescents included in the study, 20% were 12-15 years old, 39% were 16-17 years old and 41% were 18-19 years old. The majority (85%) of the adolescents reported their pregnancies were unintended; 59% reported a career that requires at least a college education; 28% reported a career that requires less than a college education; and, 13% were undecided. Intended pregnancy was observed in 15% of those with career aspirations not requiring college and 17% of those with career aspirations and requiring college. CONCLUSIONS: The majority of adolescents in this study reported their pregnancy was unintended, had career aspirations requiring at least a college education, and reported plans to go back to school after the baby was born. Understanding pregnant adolescents' career aspirations may help inform pregnancy prevention and parenting support programs.

Childhood attention deficit hyperactivity disorder, substance use, and adult functioning among incarcerated women.

OBJECTIVE: To estimate prevalence of childhood ADHD among incarcerated women and determine its association with substance use and adult functioning. METHOD: 192 female participants are recruited from the Department of Corrections in Rhode Island. Childhood ADHD is defined as scoring >46 on the Wender Utah Rating Scale. RESULTS: The findings reveal that 46% met criteria for childhood ADHD. Multivariate analysis reveal that women meeting WURS criteria were more likely to be inconsistently employed (OR = 0.23, 95% CI = 0.10-0.54), recently homeless (OR = 2.09, 95% CI = 1.02-4.30), lifetime incarceration of more than 90 days (OR = 3.00, 95% CI = 1.37-6.57), current smokers (OR = 2.99, 95% CI = 1.24-7.20), and ever used marijuana regularly (OR = 3.47, 95% CI = 1.61-7.45). CONCLUSION: Among incarcerated women, childhood ADHD is associated with negative social and health behaviors.

Relationship of alcohol use and sexual risk taking among hazardously drinking incarcerated women: an event-level analysis.

OBJECTIVE: To understand the association of alcohol use with sex and unprotected sex among hazardously drinking incarcerated women, we examined the relationship of these behaviors on any given day. METHOD: Participants endorsed unprotected sex and hazardous alcohol consumption (four or more drinks at a time on at least 3 separate days in the previous 3 months or a score of 8 or above on the Alcohol Use Disorders Identification Test). Participants recalled behaviors in the 90 days before incarceration using the Timeline Followback method. Generalized estimating equation models estimated the effect of daily alcohol use and selected covariates on the odds of sexual-risk behavior. RESULTS: The 245 participants averaged 34 years of age and were 71.4% white; 67.8% used cocaine. On most (84.7%) drinking days, women consumed four or more drinks. One hundred forty-one participants (57.6%) reported sex with only main partners, 10.6% with only casual partners, and 30.6% with both casual and main partners. The likelihood of having any sex (odds ratio = 1.78, p < .01) and unprotected sex (odds ratio = 1.95, p < .01) was higher on days when participants consumed alcohol compared with nondrinking days. However, when the analysis was restricted to days on which participants reported having sex, the odds of having unprotected sex was not significantly associated with drinking. CONCLUSIONS: Among incarcerated women who reported hazardous drinking, alcohol use was associated with an increased likelihood of sexual activity and a concomitant increase in unprotected sex. However, use of alcohol was not significantly associated with condom use on days when participants were sexually active.

Three brief alcohol screens for detecting hazardous drinking in incarcerated women.

OBJECTIVE: Screening methods for hazardous drinking have not been evaluated in a population of incarcerated women. This study examines abbreviated versions of the Alcohol Use Disorders Identification Test (AUDIT) and the National Institute on Alcohol Abuse and Alcoholism (NIAAA) heavy episodic drinking criterion in a sample of female detainees. METHOD: A total of 2,079 women at the Adult Correctional Institute in Rhode Island were approached for screening between February 2004 and June 2007. The AUDIT-consumption (AUDIT-C), AUDIT-3, and the NIAAA heavy episodic drinking criterion (four or more drinks on one occasion for women) were compared with the full AUDIT at different cut points. RESULTS: More than 55% of the sample endorsed an AUDIT score of 4 or greater--the NIAAA recommended threshold for detecting hazardous drinking. The three-item AUDIT-C with a cut score of 3 yielded a classification most consistent with the AUDIT score of 4 or more; sensitivity and specificity exceeded .9, and 91.5% of participants were correctly classified. The AUDIT-3 and NIAAA episodic drinking criteria were less sensitive measures. We found no evidence of interactions between the screening instruments and age or ethnicity. CONCLUSIONS: The three-item AUDIT-C has robust test characteristics for detecting hazardous drinking in female inmates. Universal screening for hazardous drinking is recommended for incarcerated women, given their high rates of alcohol misuse.

Prevalence and patterns of sexual assault across the life span among incarcerated women.

This study investigated the prevalence of and associations among sexual assault by life stage (childhood, adolescence, or adulthood) and perpetrator (family, stranger, friend, or partner) via a survey of a statewide sample of incarcerated women (N = 484). Participants were 18 to 56 years old, and the majority were White (56%). Results demonstrate higher rates of sexual assault in childhood (35%) and adulthood (22%) as compared with adolescence (14%). Logistic regression analyses revealed significant associations between childhood sexual assault by family and adulthood sexual assault by friend, stranger, and partner; adolescent sexual assault was not significantly associated with sexual assault in childhood or adulthood. These findings suggest that the lifetime sexual victimization pattern of incarcerated women differs from that seen in the general population.

Age group differences among pregnant adolescents: sexual behavior, health habits and contraceptive use.

STUDY OBJECTIVE: To determine differences in sexual behavior, health habits and contraceptive use among three age groups of pregnant adolescents. DESIGN: Prospective study of pregnant adolescents participating in face-to-face interviews including questions about demographic background, sexual behavior, health history and contraceptive use. SETTING: Urban prenatal clinic. PARTICIPANTS: 300 pregnant adolescents attending their first prenatal appointment. MAIN OUTCOME MEASURES: Sexual behavior, health history and contraceptive use. RESULTS: Our cohort of pregnant adolescents included 61 (20%) 12-15-year-olds, 113 (38%) 16-17-year-olds and 126 (42%) 18-19-year-olds. A greater proportion of 12-15-year-olds were currently in school (90%) compared with 16-17-year-olds (48%) and 18-19-year-olds (38%) (P = 0.01). Of the18-19-year-olds, 41% had a previous pregnancy compared with 3% of 12-15-year-olds (P = 0.01). The youngest age group also had the lowest proportion of any drug use (25%). Contraceptive use (ever) was lower for 12-15-year-olds (46%) compared with 16-17-year-olds (59%), and 18-19-year-olds (66%) (P < 0.01). Reasons for not using contraception at the time of conception also differed by age with 9% of the youngest group reporting they wanted to get pregnant compared with 27% of the 18-19-year-old group (P = 0.01). CONCLUSIONS: Sexual behavior, health habits and contraceptive use in pregnant adolescents differed by age group. Understanding that there are distinct risk behaviors associated with teen pregnancy among these three separate age groups will enhance the thoughtful development and evaluation of programs and policies targeted at preventing first pregnancies and repeat pregnancies in adolescents.

Randomized Clinical Trial of Motivational Enhancement of Substance Use Treatment Among Incarcerated Adolescents: Post-Release Condom Non-Use.

Evaluated impact of motivational enhancement (ME) of substance abuse treatment compared to relaxation training (RT) on sex without condoms (overall and involving substance use) 3 months following release among incarcerated adolescents. This randomized clinical trial involved 114 incarcerated adolescents from the Northeast. Regression analyses determined if treatment condition, baseline levels of depressive symptoms, and their interaction predicted condom non-use 3 months post-release, controlling for baseline condom non-use. Among those who reported fewer baseline depressive symptoms, those in ME condition reported significantly less condom non-use, in general and involving marijuana use compared with those in RT condition. Periods of incarceration represent opportunities to help juvenile detainees reduce behaviors that impact their health and the health of those with whom they interact in the community.

Levels of trauma among women inmates with HIV risk and alcohol use disorders: behavioral and emotional impacts.

An increasing number of women are involved in the criminal justice system. Women in corrections are often of low socioeconomic status, medically underserved and exposed to a variety of traumatic events. Programs and services provided in correctional settings should be informed by the unique profiles and needs of these women. This study sought to identify distinct sub-groups (classes) of incarcerated women based on differences in their qualitative (types of trauma) and quantitative (number of) trauma experiences. Demographics, psychosocial and behavioral characteristics were measured in 149 women entering jail, who reported recent hazardous drinking and HIV sexual risk behavior. Two classes based on trauma exposure of women were identified through latent class analysis. The classes did not differ with respect to qualitative differences in trauma exposure (both classes reported all forms of trauma), but did differ with respect to quantitative differences (Class 2 reported more exposure to trauma in all categories than Class 1). The classes also differed significantly on current psychological functioning, alcohol treatment, problems, and consequences, drug histories, sexual risk, medical conditions, and social group characteristics. In all areas, members of Class 2 were significantly more likely to report higher levels of measured variables. Nearly all women in our sample reported levels of trauma exposure, suggesting a need for intervention and attention. Through identifying these separate classes, limited resources for trauma survivors in the correctional setting could be most appropriately allocated.

Correlates of acceptance of a hypothetical gonorrhea vaccine by incarcerated women.

OBJECTIVES: This study sought to identify correlates of acceptance of a hypothetical Neisseria gonorrhea (GC) vaccine in a high-risk sample of incarcerated women. GOALS: The goal of this study was to inform efforts to promote acceptance of STI vaccines in development. STUDY DESIGN: This study consisted of a cross-sectional survey using a structured questionnaire. RESULTS: The majority (79%) of incarcerated women surveyed would accept GC vaccine. In multivariate analyses that controlled for demographics, significant health belief model psychosocial correlates of higher acceptance were perceived severity of infection (OR = 3.33) and vulnerability to infection (OR = 2.85). Fear of vaccination was significantly correlated with lower acceptance (OR = 0.42). CONCLUSIONS: Incarcerated women's willingness to accept a hypothetical GC vaccine is explained by components of the health belief model and a component of the theory of reasoned action.

Fear of inability to conceive in pregnant adolescents.

OBJECTIVE: To estimate the demographic and health history differences between pregnant adolescents who had fears that they would not be able to conceive and those without these fears. METHODS: Three hundred pregnant adolescents presenting for their first prenatal visit participated in a cohort study that addressed attitudes about pregnancy. All participants were aged younger than 20 years and gave informed consent. The outcome of interest was a positive response to the question "Did you have any fears that you wouldn't be able to get pregnant?" Independent measures included health history and demographic variables. RESULTS: Among participants, 42% stated they had fears about not being able to conceive. The total sample included 20% 12-15 year olds, 39% 16-17 year olds and 41% 18-19 year-olds. There was no statistically significant difference in fear of not being able to conceive by maternal age, reported sexually transmitted disease rates, or age at first intercourse. More adolescents who expressed fear of infertility had a previous spontaneous abortion, previous pelvic examination, and were sexually active for a longer period of time compared with those without this fear. CONCLUSION: A large proportion of pregnant adolescents in this study expressed fear that they would not be able to conceive. Understanding the basis of the fear is critical to appreciating its association with current and future adolescent pregnancy and contraceptive use. LEVEL OF EVIDENCE: III.

Correlates of condom use and reasons for condom non-use among drug users.

Two hundred and seventy-seven drug using adults were interviewed regarding details of their most recent sexual encounter. Demographic, attitudinal, and context variables were associated with condom use and non-use. Greater perceived risk of STDs/HIV and positive attitudes toward condoms' effect on sexual pleasure were associated with greater likelihood of reporting condom use. Common reasons for not using condoms included lower perceived risk of contracting HIV/STDs, negative attitudes toward condoms' effect on pleasure, and lack of condom availability. Tailoring messages to modifiable perceptions of risk and condom attitudes may be useful in reducing sexual risk among drug-using individuals.

Pregnancy attitudes and contraceptive plans among women entering jail.

Unplanned pregnancies are an important and costly public health problem. Women entering jail are at particularly high risk for unplanned pregnancies when they leave jail, given the high rates of poverty, substance abuse and sexually transmitted infections (STIs) in this population, all of which are associated with unplanned pregnancies. Attitudes toward pregnancy vary substantially, influencing openness of incarcerated women to starting a birth control method. This study was conducted as part of a Title X service evaluation and examined varying attitudes towards pregnancy and associated plans to use contraceptives. The current study included 223 women entering jail who were, under 36 years of age, fertile, sexually active with men, and not planning to become pregnant in the near future. Nearly half of the women had negative pregnancy attitudes (PAs), indicating that they did not want to become pregnant, while 41.3% endorsed ambivalent PAs. Compared to those with ambivalent PAs, those with Negative PAs were more likely to report a previous unplanned pregnancy (90.6% vs. 75.4%), a previous pregnancy termination (40.0% vs. 22.8%), and recent consistent use of contraceptives (37.0% vs. 21.7%). Women with negative PAs were significantly more likely to want to start or to continue a birth control method compared to those with ambivalent PAs (66% vs. 47%). Tailoring services to women's specific pregnancy attitudes during periods of incarceration may aid in preventing unplanned pregnancies in populations of high-risk women.

Concepts of the advantages and disadvantages of teenage childbearing among pregnant adolescents: a qualitative analysis.

OBJECTIVE: We sought to enhance our understanding of pregnant adolescents' concepts of the advantages and disadvantages of teen pregnancy and childbearing. METHODOLOGY: This is a qualitative study of 247 pregnant adolescents recruited during their first prenatal health care visit to a women's primary care clinic in Providence, Rhode Island. Participants responded in writing to open-ended questions assessing their ideas about what was advantageous and disadvantageous about having an infant during their teen years rather than waiting until they were older. Themes and patterns in responding were coded, and subgroup differences based on age, ethnicity, intendedness of current pregnancy, and pregnancy/parenting history were assessed. RESULTS: Themes related to advantages of teen pregnancy included enhancing connections, positive changes/benefits, and practical considerations. Themes related to disadvantages included lack of preparedness, changes/interference, and others' perceptions. Differences among groups based on age, ethnicity, intendedness of the current pregnancy, and pregnancy/parenting history were examined and noted. CONCLUSIONS: Pregnant adolescents do not represent a homogeneous group. Considering differences in how pregnancy and childbearing are conceptualized along developmental, cultural, attitudinal, and experiential lines will strengthen our ability to tailor pregnancy-prevention messages.

Improving birth control service utilization by offering services prerelease vs postincarceration.

OBJECTIVES: We examined whether incarcerated women would substantially increase birth control initiation if contraceptive services were available within the prison compared with after their release back into the community. METHODS: During phase 1 of the study, a nurse educator met with women at the Rhode Island Adult Correctional Institute and offered them referrals for contraceptive services at a community health clinic after their release. During phase 2, contraceptive services were offered to women during their incarceration. RESULTS: The majority of the participants (77.5%) reported a desire to initiate use of birth control methods. Within 4 weeks of their release, 4.4% of phase 1 participants initiated use of a contraceptive method, compared with 39.1% of phase 2 participants (odds ratio [OR]=14.6; 95% confidence interval [CI]=5.5, 38.8). CONCLUSIONS: Provision of contraceptive services to women during their incarceration is feasible and greatly increases birth control initiation compared to providing services only in the community.

Reproductive health care and family planning needs among incarcerated women.

OBJECTIVES: Women in correctional institutions have substantial reproductive health problems, yet they are underserved in receipt of reproductive health care. We assessed the level of risk for sexually transmitted diseases (STDs) and the reproductive health needs of 484 incarcerated women in Rhode Island to plan an intervention for women returning to the community. METHODS: We used a 45-minute survey to assess medical histories, pregnancy and birth control use histories, current pregnancy intentions, substance use during the past 3 months, histories of childhood sexual abuse, and health attitudes and behaviors. RESULTS: Participants had extremely high risks for STDs and pregnancy, which was characterized by inconsistent birth control (66.5%) and condom use (80.4%), multiple partners (38%), and a high prevalence of unplanned pregnancies (83.6%) and STDs (49%). Only 15.4% said it was not likely that they would have sexual relations with a man within 6 months after release. CONCLUSION: Reproductive health services must be offered to incarcerated women. Such interventions will benefit the women, the criminal justice systems, and the communities to which the women will return.

Violence against women associated with arrests for sex trade but not drug charges.

The current study was designed to examine associations between gender-based violence and arrests due to sex trade or drug-related charges among a statewide sample of incarcerated women in Rhode Island. Incarcerated women were asked to participate in brief pre- and posttest surveys of their experiences of violence, sexual risk and substance use behaviors, as part of a study on the effectiveness of a family planning program in a state correctional facility; data from pretest surveys (N=447) were used for current analyses. Logistic regression analyses adjusted for demographics were used to assess significant associations between gender-based violence variables (i.e., adolescent intimate partner violence (IPV), adult IPV, childhood sexual assault (SA), adolescent SA, and adult SA) and arrests due to sex trade or drug-related charges. Significant relationships were observed between arrests for sex trade and adult SA (OR=2.1, 95%CI=1.2-3.6), adolescent IPV (OR=2.5, 95%CI=1.5-4.1), and adult IPV (OR=1.7, 95%CI=1.1-2.6); no significant associations were observed for drug-related charges. Findings from the current study demonstrate that experiences of gender-based violence are associated with arrests for sex trade but not drug-related charges. Interventions for incarcerated women are needed to consider and address history of victimization from gender-based violence and its relation to women's historic and future sex trade involvement.