Workshop summary: National Institutes of Health (NIH) 2022 scientific workshop on gender and health.

In this manuscript, we summarize the goals, content, and impact of the Gender and Health: Impacts of Structural Sexism, Gender Norms, Relational Power Dynamics, and Gender Inequities workshop held by the National Institutes of Health (NIH) Office of Research on Women's Health (ORWH) in collaboration with 10 NIH Institutes, Centers, and Offices. Specifically, we outline the key points emerging from the workshop presentations, which are the focus of the collection of articles in this supplement. The overarching goals of the workshop were to convene NIH staff, the external scientific community, and the public to discuss methods, measurement, modifiable factors, interventions, and best practices in health research on gender as a social and cultural variable and to identify opportunities to advance research and foster collaborations on these key topics. Themes emerging from the workshop include the need for intersectional measures in research on gender and health, the role of multilevel interventions and analyses, and the importance of considering gender as a social and structural determinant of health. Careful, nuanced, and rigorous integration of gender in health research can contribute to knowledge about and interventions to change the social and structural forces that lead to disparate health outcomes and perpetuate inequities.

Biomedical, socio-behavioral, and implementation science gaps in multipurpose prevention technology research.

There is strong global need for the development of Multipurpose Prevention Technologies (MPTs) that prevent HIV, pregnancy, and/or other sexually transmitted infections (STIs). However, despite decades of research focused on the development of MPTs, numerous research gaps remain, contributing to reproductive health disparities. This commentary will highlight biomedical, socio-behavioral, and implementation science gaps in MPT research. Biomedical gaps and barriers include limited dosage forms, challenges around drug selection and stable coformulation of multiple drugs, and an unclear regulatory pathway. Behavioral, social, and structural gaps include lack of research around MPT preferences for some subgroups of potential end users, lack of knowledge around whether MPTs improve uptake, adherence, and persistence vs. separate products, and a need to further understand how social and cultural factors might impact MPT interest and use. Gaps in implementation science research will need to be addressed to better understand how to implement MPTs to maximize effectiveness and benefit. This commentary will also identify opportunities for integrating biomedical and behavioral science around MPTs.

Positive social interaction offsets impact of low socioeconomic status on stress.

BACKGROUND: Stress is associated with unhealthy behaviors and premature morbidity and mortality, especially among those of low socioeconomic status (SES). Clarifying the roles of stress-related risk and protective factors can guide interventions designed to reduce stress and improve health among socioeconomically disadvantaged populations. PURPOSE: (1) Replicate prior research showing that lower SES is associated with higher stress in a predominantly racial minority, socioeconomically disadvantaged sample, and (2) test the hypothesis that different types of social support (a protective factor) mitigate the deleterious effects of SES on self-reported perceived stress. METHODS: Low-income patients (N = 508, 54% male, 68% African American, Mage = 28) from a publicly-funded clinic provided demographic information and then completed measures of perceived stress and social support. Four types of social support were assessed (viz., affectionate, emotional/informational, positive social interaction, and tangible). Structural equation modeling tested the hypothesized associations among SES, social support, and stress. RESULTS: Individuals of lower SES, ß = -0.27 (0.08), p < 0.01, and lower overall social support, ß = -0.47 (0.05), p < 0.001, reported higher stress. Social support moderated associations between SES and stress, with participants with lower SES benefitting the most from social support. Of the four types of social support that were measured, positive social interaction was the strongest moderator, ß = 0.20 (0.08), p = 0.01. CONCLUSIONS: The associations among SES, stress, and social support corroborate prior research. Positive social interaction was particularly important for decreasing stress among socioeconomically disadvantaged persons.

Factors related to life satisfaction among urban African American adults receiving care at a publicly-funded sexual health clinic.

Life satisfaction is linked to premature morbidity and mortality and it may be compromised for individuals living in economically-disadvantaged, urban neighborhoods. The present study explores how behavioral and social-environmental health factors are associated with life satisfaction among a sample of African American young adults. Participants (N = 307, Mage = 26.6 years, 53% male) were recruited from a publicly-funded clinic for a randomized controlled trial (RCT). Data from the baseline assessment of the RCT, which included measures of sleep, depression, anxiety, social support, alcohol and drug use problems, city stress, and life satisfaction, were used for the current study. Correlation analyses assessed bivariate associations between life satisfaction and the demographic and health-related factors. Linear regression using backward elimination determined the best fitting model of factors associated with life satisfaction. Backward elimination resulted in the following variables remaining as significantly associated with life satisfaction: age (b = -2.40, p = .017), anxiety (b = -5.32, p < .001), and social support (b = 2.89, p = .004). Feeling rested upon waking also remained in the best fitting model, although this association did not achieve statistical significance (p = .099). The results suggest that African American adults who are younger, less anxious, and report adequate social support are more likely to report satisfaction with life. These findings add to the literature aimed at examining health and social factors impacting the well-being of African Americans living in low-income, urban communities.

Development and Refinement of a Targeted Sexual Risk Reduction Intervention for Women With a History of Childhood Sexual Abuse.

Childhood sexual abuse (CSA) is associated with sexual risk behavior in adulthood. Traditional sexual risk reduction interventions do not meet the unique needs of women who have been sexually abused. In the current paper, we describe the four-stage process we followed to develop and refine a targeted sexual risk reduction intervention for this population. First, initial quantitative work revealed that the intervention should address how maladaptive thoughts related to traumatic sexualization, trust, powerlessness, and guilt/shame (traumagenic dynamics constructs) influence current sexual behavior. Second, qualitative interviews with 10 women who reported a history of CSA (M age = 34 years; 90% African American) as well as current sexual risk behavior provided support for targeting maladaptive thoughts associated with these traumagenic dynamics constructs. Third, based on the qualitative and quantitative results, we developed a 5-session, group-delivered intervention to address the maladaptive thoughts that occurred as a result of CSA, as well as the cognitive-behavioral determinants of sexual risk behavior. This intervention drew heavily on cognitive behavioral techniques to address cognitions associated with CSA and the links between these cognitions and current sexual risk behavior. Techniques from trauma-based therapies, as well as motivational techniques, were also incorporated into the intervention. Finally, we refined the intervention with 24 women (M age = 33 years; 79% African American), and assessed feasibility and acceptability. These women reported high levels of satisfaction with the intervention. The resultant intervention is currently being evaluated in a small, randomized controlled trial.

Pilot Test of an Integrated Sexual Risk Reduction Intervention for Women with a History of Childhood Sexual Abuse.

HIV and childhood sexual abuse (CSA) are intersecting public health problems for women. We pilot tested an integrated sexual risk reduction intervention for women with a history of CSA that addressed both the consequences of CSA [based on the Traumagenic Dynamics (TD) framework] and the antecedents of sexual risk behavior (based on the Information-Motivation-Behavioral Skills [IMB] model). Women with a history of CSA who were attending a public STI clinic (n = 84) were randomly assigned to a five-session integrated TD/IMB (experimental) group intervention or to a time-matched IMB-guided sexual risk reduction (control) group intervention. Preliminary findings indicated that women in the integrated TD/IMB intervention reduced their average number of episodes of unprotected sex with a primary partner, their alcohol use, and their likelihood of being in a violent relationship, relative to women in the IMB-only group. Our findings suggest that sexual risk reduction interventions that address both the consequences of CSA and the antecedents of sexual risk behavior may be efficacious in reducing sexual risk behavior among women who were sexually abused.

Development and Preliminary Pilot Testing of a Peer Support Text Messaging Intervention for HIV-Infected Black Men Who Have Sex With Men.

BACKGROUND: Black men who have sex with men (MSM) are disproportionately infected with HIV and are less well retained along the HIV continuum of care. We report on the feasibility of a peer support text messaging intervention designed to increase retention in HIV care and HIV medication adherence among HIV-infected black men who have sex with men. METHODS: Based on formative research, a cell phone app was developed to support a peer-based text messaging intervention. The app allowed the researchers to view text messages sent between mentors and mentees, but did not allow them to view other text messages sent by these phones. Three HIV-infected black men who have sex with men were recruited to serve as volunteer peer mentors. They were trained in motivational techniques, peer support skills, and skills for improving appointment attendance and medication adherence. Mentees (N = 8) received the intervention for 1 month. Mentees completed a postintervention survey and interview. RESULTS: The peer mentor text messaging intervention was feasible. Mentors delivered support in a nonjudgmental, motivational way. However, technical and other implementation problems arose. Some mentees desired more frequent contact with mentors, and mentors reported that other commitments made it difficult at times to be fully engaged. Both mentors and mentees desired more personalized contact (ie, phone calls). CONCLUSIONS: A text messaging peer mentor intervention was feasible. Additional research with a larger sample is needed to determine optimal ways to improve mentors' engagement in the intervention and to determine intervention acceptability and efficacy. In future studies, peer support phone calls could be incorporated.

Psychological Distress Moderates the Intention-Behavior Association for Sexual Partner Concurrency Among Adults.

Research suggests that intentions are an important determinant of sexual risk behavior. However, this association is often weaker than hypothesized. This research investigated whether psychological distress (i.e., depression, anxiety) can help to explain the intentions-behavior gap. We used data from 397 patients seeking care at an STI clinic to test whether the association between partner concurrency intentions and behavior 3 months later was moderated by distress. Intentions predicted concurrency behavior only among less-distressed individuals; however, exploratory analyses for condom use did not demonstrate this effect. Comprehensive sexual health intervention programs should address affective determinants of risk behavior.

Mobile technology use and desired technology-based intervention characteristics among HIV+ Black men who have sex with men.

HIV positive Black men who have sex with men (MSM) are retained in HIV medical care at suboptimal rates. Interventions targeted to Black MSM are needed to help to improve their retention in care. The purposes of this study were to investigate the use of mobile technology among HIV+ Black MSM and to explore participants' thoughts about the use of mobile technology for HIV retention in care interventions. Twenty-two HIV+ Black MSM completed a technology use survey and participated in a qualitative interview regarding technology-based interventions. The majority of participants (95%) had access to a cell phone, and used their phones frequently (median 3 hours/day). Men preferred interventions that would allow for anonymous participation and that would provide individually tailored support. Mobile technology is a promising approach to intervention delivery for both younger and older HIV+ Black MSM. These interventions should incorporate features that are desirable to men (i.e., anonymous participation and individual tailoring).

The Potential of Pre-Exposure Prophylaxis for Women in Violent Relationships.

HIV and intimate partner violence (IPV) are significant intersecting threats to women's health. Women in violent relationships have few feasible HIV risk reduction options as traditional prevention methods are largely dependent on a partner's cooperation. The purpose of this review is to explore potential benefits and drawbacks of pre-exposure prophylaxis (PrEP) use among women in the United States experiencing IPV. Advantages of PrEP use in this population include the potential for covert or autonomous use, coital independence, dual protection against sexual and injection risk, and facilitated connections to social services. A number of barriers, however, may interfere with the effective use of PrEP, including partner resistance, cost, frequent medical visits, gendered norms regarding sexuality, and stigma. To realize its potential for women in violent relationships, it will be necessary to incorporate PrEP into behavioral and structural interventions that encourage uptake, facilitate adherence, ensure women's safety, and challenge existing gender norms.

Mediators of the Relation Between Community Violence and Sexual Risk Behavior Among Adults Attending a Public Sexually Transmitted Infection Clinic.

Prior research shows that violence is associated with sexual risk behavior, but little is known about the relation between community violence (i.e., violence that is witnessed or experienced in one's neighborhood) and sexual risk behavior. To better understand contextual influences on HIV risk behavior, we asked 508 adult patients attending a publicly funded STI clinic in the U.S. (54 % male, M age = 27.93, 68 % African American) who were participating in a larger trial to complete a survey assessing exposure to community violence, sexual risk behavior, and potential mediators of the community violence-sexual risk behavior relation (i.e., mental health, substance use, and experiencing intimate partner violence). A separate sample of participants from the same trial completed measures of sexual behavior norms, which were aggregated to create measures of census tract sexual behavior norms. Data analyses controlling for socioeconomic status revealed that higher levels of community violence were associated with more sexual partners for men and with more episodes of unprotected sex with non-steady partners for women. For both men and women, substance use and mental health mediated the community violence-sexual risk behavior relation; in addition, for men only, experiencing intimate partner violence also mediated this relation. These results confirm that, for individuals living in communities with high levels of violence, sexual risk reduction interventions need to address intimate partner violence, substance use, and mental health to be optimally effective.

Alcohol Use Predicts Number of Sexual Partners for Female but not Male STI Clinic Patients.

This study tested the hypothesis that greater alcohol involvement will predict number of sexual partners to a greater extent for women than for men, and that the hypothesized sex-specific, alcohol-sexual partner associations will hold when controlling for alternative sex-linked explanations (i.e., depression and drug use). We recruited 508 patients (46 % female, 67 % African American) from a public sexually transmitted infections (STI) clinic. Participants reported number of sexual partners, drinks per week, maximum drinks per day, frequency of heavy drinking; they also completed the AUDIT-C and a measure of alcohol problems. As expected, men reported more drinking and sexual partners. Also as expected, the association between alcohol use and number of partners was significant for women but not for men, and these associations were not explained by drug use or depression. A comprehensive prevention strategy for women attending STI clinics might include alcohol use reduction.

Recalled Explanations for Adolescent Girls' Engagement in Age-Discordant Sexual Relationships.

Age-discordant sexual relationships are associated with negative sexual health outcomes for adolescent females. We were particularly interested in females' motivations for engaging in these relationships, and in contextual factors that increase receptivity to age-discordant relationships in the United States (U.S.). However, recent research addressing this topic in the U.S. has been sparse. To address this gap in the literature, we recruited 15 women (Mdn age = 26 years; 93 % African American) from an urban, publicly funded sexually transmitted disease clinic to qualitative interviews. Reasons given by women for their involvement in age-discordant sexual relationships as adolescents included: (a) desire for an actively engaged father figure, (b) to obtain material support, (c) to escape from a troubled home life, and (d) to express independence and maturity. Thus, familial, economic, and developmental factors motivate socioeconomically disadvantaged adolescent females to enter into age-discordant sexual relationships. Efforts to reduce females' participation in these relationships will need to address socioeconomic vulnerability and family relationships.

Willingness to use couples HIV testing and discussion of sexual agreements among heterosexuals.

Couples HIV Testing and Counseling (CHTC) has been used as an HIV prevention strategy in Africa for over 20 years where the HIV epidemic is largely concentrated among sexually active heterosexuals. In recent years, CHTC has been adapted for men who have sex with men (MSM) in the US. A central element of the CHTC intervention as adapted for male couples in the US is the discussion of sexual agreements by the dyad during the CHTC session. Given the success of CHTC for heterosexual couples in Africa, it seems appropriate that CHTC could also be provided to heterosexual couples in the US. However, little is known about heterosexual's willingness to utilize CHTC services including discussion of sexual agreements. This small, preliminary qualitative study sheds new light on the potential for CHTC adoption among heterosexuals in the US. Four focus groups were conducted with heterosexual men and women attending a publicly-funded STI clinic, to explore the potential feasibility and acceptability of CHTC with heterosexuals. The results are similar to those seen for MSM: high levels of willingness to use CHTC, perceptions of the advantages of using CHTC, and willingness to discuss sexual agreements; all necessary conditions for the successful roll-out of CHTC. Further work is now needed with larger samples of high-risk heterosexuals to more completely understand the typologies of sexual agreements and the common language used for sexual agreements in heterosexual relationships. These early data show great promise that CHTC can achieve the same levels of willingness, fit, and acceptability among heterosexual couples as currently experienced by male couples in the US.

Evaluating a Brief, Video-Based Sexual Risk Reduction Intervention and Assessment Reactivity with STI Clinic Patients: Results from a Randomized Controlled Trial.

We report results from a randomized controlled trial designed to evaluate the efficacy of a video-based sexual risk reduction intervention and to measure assessment reactivity. Patients (N = 1010; 56 % male; 69 % African American) receiving care at a sexually transmitted infection (STI) clinic were assigned to one of four conditions formed by crossing assessment condition (i.e., sexual health vs. general health) with intervention condition (i.e., sexual risk reduction intervention vs. general health promotion). After completing their assigned baseline assessment, participants received their assigned intervention, and subsequently returned for follow-up assessments at 3, 6, 9, and 12 months. Participants in all conditions reduced their self-reported sexual risk behavior, and the incidence of new STIs declined from baseline through the follow-ups; however, there was no effect of intervention or assessment condition. We conclude that further risk reduction will require more intensive interventions, especially in STI clinics that already provide excellent clinical care.

The mediating roles of perceived stress and health behaviors in the relation between objective, subjective, and neighborhood socioeconomic status and perceived health.

BACKGROUND: Objective, subjective, and neighborhood socioeconomic status (SES) are associated with perceived health, morbidity, and mortality. PURPOSE: We investigated whether perceived stress and health behaviors mediated the relation between the three types of SES and perceived health. METHODS: Participants (N = 508) attending a public clinic completed a computerized survey assessing objective SES (income, education, employment); health behaviors; perceived stress; and perceived health. They also indicated their social standing relative to others (subjective SES) and provided their current address to determine neighborhood SES. RESULTS: In a structural equation model including all three SES types, lower objective and subjective SES were related to poorer perceived health. When mediators were included in the model, there were significant indirect effects of (a) SES on health through stress and (b) SES on health through stress and health-compromising behaviors. CONCLUSIONS: Interventions to reduce the impact of stressors could improve the health of socioeconomically disadvantaged individuals.

Relationship-specific condom attitudes predict condom use among STD clinic patients with both primary and non-primary partners.

Although condom use differs by partner type (i.e., primary vs. non-primary partner), attitudes towards condom use are typically measured without consideration of partner type. This study investigated the predictive utility of condom attitudes measured separately by partner type. Participants were 270 patients (37 % women, 72 % Black) recruited from a publicly-funded STD clinic who reported having both primary and non-primary partners. They completed a computerized survey assessing relationship-specific condom attitudes by partner type, condom attitudes related to pleasure and respect, and condom use with primary and non-primary partners. Participants reported more positive relationship-specific condom attitudes with a non-primary versus primary partner. When considering pleasure-related, respect-related, and relationship-specific condom attitudes simultaneously, only relationship-specific condom attitudes predicted unprotected sex, with both primary and non-primary partners. In general, pleasure and respect-related condom attitudes did not predict unprotected sex; however, pleasure-related attitudes predicted unprotected sex with a non-primary partner for men. Future research should assess relationship-specific condom attitudes. Sexual risk reduction interventions that address interpersonal consequences of condom use in both primary and non-primary relationships should be a priority.