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What’s Love Got to Do With It:
Relationships and HIV Prevention
Trace Kershaw
Assistant Professor
Social and Behavioral Sciences Program
Epidemiology 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: Background
High Anxiety
Low Avoidance
Unhealthy
need to be
loved
Secure
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Unhealthy
need to be
loved &
Mistrust of
others
Mistrust of
others
Low Anxiety
High
Avoidance
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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Regression of Attachment on
Condom Use Percentage
Attachment
Avoidance
Condoms
mean do
not trust p
-.09*
Condoms
upset
partner
.23*
.16*
Attachment
Anxiety
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-.19*
Condom
use selfefficacy
R2= .11
-.14*
Condom
Use
.09*
-.12*
Controlling for age, race, education, employment, number of children,
relationship duration ; Coefficients represent standardized Beta weights
Logistic Regression of Attachment on
Multiple Partners and STIs
Attachment
Avoidance
R2= .18
.23*
Relationship
with FOB
.65*
.64*
Attachment
Anxiety
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Coefficients represent Adjusted Odds Ratios
Multiple
Partners
R2= .05
STIs
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 selfefficacy)
– 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 health
1 Misovich et al (1997) Review of General Psychology;
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PARTNRS: Model
COMMUNITY/PEER
SEXUAL RISK OUTCOMES
FAMILY
RELATIONSHIP
FUNCTIONING OUTCOMES
Relationship
Dissolution
DYAD
INDIVIDUAL
Attachment
Avoidance
Attachment
Anxiety
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Relationship
Dissatisfaction
ExtraRelationship
Partners
Unprotected
Sex
STD
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
33%
40%
27%
38%
42%
20%
18.5 (1.8)
Rng: 15-21
21.1 (3.9)
Rng: 14-38
$14,755
Rng:2.5k-42k
$15,623
Rng:2.5k-45k
40%
25%
19%
12%
4%
69%
6%
13%
6%
6%
Race
•Black
•Hispanic
•White/other
Age M (SD)*
Household Income
Main Source of Financial
Support*
•Self
•Partner
•Parent
•Public Assistance
•Other Relative
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*p<.05
Pregnancy History
First pregnancy
Age at first pregnancy*
Other children
Parents response to this
pregnancy (1-7) 7=happy*
*p<.05
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Women
Men
61%
64%
17.5 (1.8)
Rng: 11-21
19.2 (3.3)
Rng: 13-30
22%
27%
4.6 (1.8)
5.4 (1.9)
Pregnancy Intentions and
Wantedness
100%
20
28
90%
80%
12
70%
15
60%
50%
Both
Man Only
Woman Only
Neither
18
23
40%
30%
53
31
20%
10%
0%
Tried to get pregnant
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Wanted to be pregnant
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
50
*p<.05
45
45
40
*p<.05
33
35
Women
Men
Percent
30
25
22
20
*p<.05
15
10
12
9
5
2
2
0
0
Physical Abuse
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Sexual Abuse
Threats to Harm
Type of Abuse
Emotional Abuse
Sex Risk History
Women
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
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%
**p<.01 *p<.05
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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 selfefficacy, 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
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1Spanier
(1976) J of Marriage and Family
Results
Cheated
Women
Men
Intended to be faithful
Women
Men
Condom attitudes
OR=.71
(.36-1.40)
OR=.74
(.39-1.37)
-.03
-.12
Condom selfefficacy
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
Relationship
satisfaction
OR=.87
(.43-1.72)
OR=.33*
(.18-.59)
-.12
.23*
*p<.05; Controlling for age, race, and relationship duration
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Results
Sexual 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
Relationship
satisfaction
.13
.20*
.13
-.16
*p<.05; Controlling for age, race, and relationship duration
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Relationship Satisfaction and
Sexual Risk
Cheated
OR=.33*
Relationship
Satisfaction Women
Intend to be
Faithful
=.23*
Relationship
Satisfaction Men
=.20*
Sex
Communication
Condom Use
Note: Coefficients are standardized beta weights for Faithfulness Intentions
and Sex Communication, and Odds Ratios for Cheated
Controlling for age, race,, & relationship duration
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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 Satisfaction
Not Significant
•age
•income
Women
Men
Want to be pregnant: r=.13
Want to be pregnant: r=.22*
Living with partner: r=.24*
•race
Perceived equity: r=.65**
Living with partner: r=-.02
Perceived equity: r=.43**
•# children
•Relationship
duration
•Marital status
Attachment Avoidance: r=-.40**
Attachment Anxiety: r=-.35**
•Relationship
power
Frequency of Sex: r=.19*
# past sex partners: r=.06
IPV: r=-.28*
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Attachment Avoidance: r=-.61**
Attachment Anxiety: r=-.26*
Frequency of Sex: r=.12
# past sex partners: r=-.27*
IPV: r=-.25*
Multivariate Predictors
of Relationship Satisfaction
Women
Want to be pregnant: .08
Living with partner: -.05
Perceived equity: 59**
Attachment Avoidance: -.25**
Men
Want to be pregnant: .17*
Living with partner: -.14
Perceived equity: .19*
Attachment Avoidance: -.50**
Attachment Anxiety: .01
Attachment Anxiety: -.03
Frequency of Sex: .01
Frequency of Sex: -.13
# past sex partners: .10
IPV: -.07
Note: Coefficients are standardized beta weights
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# past sex partners: .06
IPV: -.16*
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
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• 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 socialcognitive 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:
– [email protected]; 785-3441
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Acknowledgements
• The PARTNRS team:
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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