Self-perceived risk of HIV among women with protective orders against male partners.

Self-perceived risk of HIV among women with protective orders against male partners. The rate of AIDS diagnoses for women has been increasing at agreater rate than for men (Centers for Disease Control and Prevention Centers for Disease Control and Prevention(CDC), agency of the U.S. Public Health Service since 1973, with headquarters in Atlanta; it was established in 1946 as the Communicable Disease Center. [CDC See Control Data, century date change and Back Orifice. CDC - Control Data Corporation ], 2005). Specifically, from 2000 to 2004 the annual number ofestimated AIDS diagnoses increased 10 percent among women and 7 percentamong men. For women, a significant risk factor for HIV HIV(Human Immunodeficiency Virus), either of two closely related retroviruses that invade T-helper lymphocytes and are responsible for AIDS. There are two types of HIV: HIV-1 and HIV-2. HIV-1 is responsible for the vast majority of AIDS in the United States. is sexualcontact. Data from 44 areas with confidential name-based reportingshowed that of the women who have been diagnosed with HIV through 2004,heterosexual contact was the source of 45 percent of infections, and for45 percent of the infections no source was identified. Among womenexposed to HIV through heterosexual contact, the estimated number ofAIDS cases increased each year from 2000 through 2004 (CDC, 2005). Some research has shown that individuals' assessment of theirrisk of HIV is associated with their actual risk behaviors (Holtzman,Bland, Lansky, & Mack, 2001; Schroder, Hobfoll, Jackson, &Lavin, 2001; Steers, Elliott, Nemiro, Ditman, & Oskamp, 1996).Therelationship between the two constructs is posited to be reciprocal.Specifically, there are two different hypothesized pathways for theassociation of perceived risk and actual risk behavior: (1)Individuals' perceptions of risk predict subsequent behavior, and(2) individuals' recent behavior predicts current perceptions ofrisk. The focus of this article is the examination of the association ofthe latter relationship. In a meta-analysis of perceived vulnerabilityto HIV and behavior, a weak, but statistically significant, relationshipwas found between individuals' recent behavior and their currentperceptions of risk of HIV (Gerrard, Gibbons Famous people named Gibbons include: Beth Gibbons (born 1965), British singer Billy Gibbons, guitarist for ZZ Top Cedric Gibbons (1893–1960), American art director Christopher Gibbons (1615 - 1676), English composer, son of Orlando , & Bushman, 1996). One possible explanation for why the relationship between actualbehavior and perceptions of risk is weak is that a large proportion ofindividuals who perceive themselves to be at no risk for HIV/STDsactually do engage in risky sexual practices and drug use (Brown,Outlaw, & Simpson, 2000; Klein, Elifson, & Sterk, 2003;Takahashi, Johnson, & Bradley, 2005; Theall, Elifson, Sterk, &Klein, 2003; Weinreb, Goldberg, Lessard, Perloff, & Bassuk, 1999).Klein and colleagues (2003) noted that women who perceived themselves tobe at no risk were largely overlooked in the HIV risk behaviorliterature. These authors examined the relationship betweenself-perceptions of risk for HIV and actual risk behaviors among asample of 240 largely ethnic minority, adult women from economically andsocially distressed areas. The study's findings indicated thatrisky behaviors were common among the women who did not perceivethemselves to be at risk of HIV. Other research suggests that individuals with steady intimatepartners have a lower perceived risk of HIV compared with individualsinvolved in more casual relationships (Reisen & Poppen, 1995).Individuals sometimes have the erroneous belief Noun 1. erroneous belief - a misconception resulting from incorrect informationerrormisconception - an incorrect conception that monogamy monogamy:see marriage. is asufficient safeguard against HIV infection (Timmons & Sowell, 1999),which is a belief that is maintained through a variety of heuristics heu��ris��tic?adj.1. Of or relating to a usually speculative formulation serving as a guide in the investigation or solution of a problem: (Misovich, Fisher, & Fisher, 1997) and inaccurate or incompleteinformation about a partner's past or current risky behavior(Hader, Smith, Moore, & Holmberg, 2001; Misovich et al., 1997; Seal,1997). A recent review concluded that individuals may perceive a lowerrisk of HIV when they have steady partners because of denial, trust, andnormative pressure inhibiting safer sex practices (Misovich et al.,1997). Evidence indicates that individuals' sexual behavior sexual behaviorA person's sexual practices–ie, whether he/she engages in heterosexual or homosexual activity. See Sex life, Sexual life. withsteady partners is particularly resistant to the adoption of condom 1. condom - The protective plastic bag that accompanies 3.5-inch microfloppy diskettes. Rarely, also used of (paper) disk envelopes. Unlike the write protect tab, the condom (when left on) not only impedes the practice of SEX but has also been shown to have a high failure use(Misovich et al., 1997; Theall, Sterk, & Elifson, 2003). Because HIV risk has been associated with male-perpetrated violenceagainst female partners (Beadnell, Baker, Morrison, & Knox, 2000;Gielen, McDonnell, & O'Campo, 2002; Gilbert, El-Bassel,Schilling, Wada, & Bennet bennetexcludes the devil; used on door frames. [Medieval Folklore: Boland, 56]See : Protection , 2000; Maman, Campbell, Sweat, &Gielen, 2000; Wingood & DiClemente, 1997), it is important to assessrelationships between actual sexual behaviors and self-perceptions ofrisk among female partner violence victims. What we know about steadyrelationships, in general, is that individuals often do not perceive ofrisk when engaging in unprotected sex Unprotected sex refers to any act of sexual intercourse in which the participants use no form of barrier contraception. Sexually transmitted infectionsSpecifically, unprotected sex with steady partners. Women withviolent partners might have less control over their sexual behavior andbe more likely to have unprotected sex than might women with nonviolentpartners (Beadnell et al., 2000; Neighbors & O'Leary, 2003;Pulerwitz, Gortmaker, & DeJong, 2000; Wingood & DiClemente,1997), but it is not clear whether violence by a partner heightens orreduces women's perceptions of risk. In other words Adv. 1. in other words - otherwise stated; "in other words, we are broke"put differently , is thediscrepancy between women's actual sexual risk behavior and theirself-perceived risk of HIV among women with partner violence similar tothat of women in general? Furthermore, women's relationship status with abusive partnersmay affect their self-perceived risk of HIV. For example, women who haveterminated the relationship with the abusive partner, and who have takensteps to end the abuse in an intimate relationship An intimate relationship is a particularly close interpersonal relationship. It is a relationship in which the participants know or trust one another very well or are confidants of one another, or a relationship in which there is physical or emotional intimacy. , such as obtaining aprotective order, may be sensitized sensitized/sen��si��tized/ (sen��si-tizd) rendered sensitive. sensitizedrendered sensitive.sensitized cellssee sensitization (2). to their risk because their publicadmission of his violence is evidence of a lack of trust. Yet not allwomen who obtain a protective order against an abusive partner terminatethe relationship (Logan, Walker, Shannon, & Cole, 2008). Women whoserelationships have ended may have different perceptions of risk thanwomen who continued the relationship with an abusive partner because forwomen who continue the relationship, acknowledging their heightened riskmay be difficult in a situation in which the needed behavioral change(that is, adoption of safer sex practices) is not within their control(Gerrard et al., 1996) . Thus, it is important to examine not only theassociation between women's self-perceptions of risk of HIV andtheir actual risk behaviors in sexual relationships with abusivepartners, but also other factors that could affect their perceptions ofrisk. For example, risky behavior outside of the violent relationship,such as women's substance use and sexual activities outside of thesteady relationship, must also be examined to control for the effects ofthese variables on women's self-perceived risk of HIV. This study contributes to the literature by examining theassociation of women's self-perceptions of risk of HIV and prioractual risk behaviors, focusing on the sexual risk behavior with theabusive partner. Other studies that have examined the relationshipbetween HIV sexual risk behavior and partner violence have typicallyexamined whether there is an association between recent HIV riskbehavior and history of partner violence, without examination of partnerspecificity. In other words, the extant literature Extant literature refers to texts that have survived from the past to the present time. Extant literature can be divided into extant original manuscripts, copies of original manuscripts, quotations and paraphrases of passages of non-extant texts contained in other works, does not link partnerviolence with sexual risk behavior with that same partner. Furthermore,other studies that have examined the relationship between HIV sexualrisk behavior and partner violence have not targeted women who haveinitiated legal protections against an abusive partner. It is importantto examine women who have initiated legal action against an abusivepartner, because they typically report more severe violence (Carlson,Harris, & Holden, 1999; Ptacek, 1999). Furthermore, victims must gobefore a judge to receive a protective order; therefore, receipt of aprotective order is an acknowledgment acknowledgment,in law, formal declaration or admission by a person who executed an instrument (e.g., a will or a deed) that the instrument is his. The acknowledgment is made before a court, a notary public, or any other authorized person. by the court that the victim has areasonable fear of future violence on the basis of the prior occurrenceof violence. The research questions guiding this analysis are as follows: (1)Are there sociodemographic, relationship characteristics and status,partner violence, and substance use differences between women whoperceive themselves to be at no risk of HIV and women who perceivethemselves to have some risk of HIV? (2) Between these two groups ofwomen, are there differences in reported sexual behavior? (3) What arethe predictors of partner violence victims' self-perceptions ofrisk of HIV? METHOD Participants The study sample was part of a larger study on women who wererecruited from domestic violence court between February 2001 andNovember 2003 when they obtained protective orders against a maleintimate partner. To be eligible for the overall study, participants hadto meet the following criteria: be female; be 18 years and older, or 17and emancipated e��man��ci��pate?tr.v. e��man��ci��pat��ed, e��man��ci��pat��ing, e��man��ci��pates1. To free from bondage, oppression, or restraint; liberate.2. ; and have obtained a protective order (also known as adomestic violence order [DVO DVO Driver, Vehicle and OperatorDVO Domestic Violence OrderDVO Digital Vision OpticsDVO Direct View OpticsDVO Dynamic Variable OrderingDVO Davao, Philippines - Mati (Airport Code)DVO Delaware Valley Opera ]) against a male partner within six monthsof entering the study. The average length of time between issuance ofthe DVO and entry into the study was 40 days. Statutory requirements forobtaining protective orders against persons to whom one is notbiologically related are that the petitioner and the respondent must becurrently or formerly married, must have lived in the same residence asintimate partners, or must have a child in common. Because we were interested in examining sexual risk with an abusivepartner and its association with self-perceptions of risk of HIV at thecurrent time, it was important to include only women who had beeninvolved in a relationship with the partner against whom they hadobtained a protective order in the recent past (past year) because it isnot reasonable to assume that their sexual risk behavior from a distantrelationship would inform their current perceptions of risk. Also,because we did not obtain data on the timing of women's most recentHIV testing, which could inform women's self-perceptions of risk(Hoffman, Koslofsky, Exner, Yingling, & Ehrhardt, 2000), we had toconsider that the window period of HIV seroconversion seroconversion/se��ro��con��ver��sion/ (-con-ver��zhun) the change of a seronegative test from negative to positive, indicating the development of antibodies in response to immunization or infection. of about threemonths might factor into women's perceptions of risk (CDC, 2001).Thus, women were included if they were involved with the abusive partnerin the past three months, or, if they had not been involved in the pastthree months, they were included if they had been involved in the pastyear and had never been tested for HIV. Furthermore, it is welldocumented that individuals who exchange sex for money or drugs engagein higher risk behaviors (Logan, Cole, & Leukefeld, 2002; Paone,Cooper, Alperren, Shi, & Des Jarlais, 1999). Tortu and colleagues(2000) found that sex exchange was an independent, significant,behavioral predictor of HIV infection. Because only 10 participants inthis study reported exchanging sex for money or drugs in the precedingyear, these cases were dropped from this analysis. Finally, six caseswere dropped from the analysis because the participants answered"don't know" to the question about perception of risk ofHIV. The final sample for the analysis was 569. Measures Demographic and Socioeconomic Data. Questions regarding samplecharacteristics were taken from the Risk Behavior Assessment (RBA RBA Rare Bird AlertRBA Reserve Bank of AustraliaRBA Run Book AutomationRBA Rochester Business AllianceRBA Rights-Based ApproachRBA Royal Brunei Airlines (ICAO code)RBA Relative Byte AddressRBA relative binding affinity )(Coyle, 1993)--(a) age, (b) race, (c) education level, (d) past yearincome and from pilot study work (Logan, Walker, Cole, Ratliff, &Leukefeld, 2003), (e) current employment status, (f) number of children,(g) relationship to the DVO partner, and (h) length of involvement withthe DVO partner. HIV Risk Perception. Self-perceived risk of HIV was measured withthe following item from the RBA: "Which statement best describesyour chance of getting HIV? Would you say you have ...?" Responseoptions were as follows: no chance = 0 percent, some chance = 25percent, half chance = 50 percent, high chance = 75 percent, sure chance= 100 percent, NA = has HIV/AIDS, and don't know. Percentages forresponses were as follows: no chance (59.9 percent), some chance (32.3percent), half chance (5.8 percent), high chance (1.4 percent), and surechance (0.5 percent). The following two groups were developed on thebasis of self-reported perceptions of risk of HIV at the time of theinterview: no chance (n = 341, 59.9 percent) and some to sure chance (n= 228, 40.1 percent). HIV Sexual Risk Behaviors. Questions about the number of sexpartners and condom use with sex partners were adapted from the RBA. TheRBA primarily inquires about the past 30 days, and because the focus ofthis study was on the past year as the reference period, questions weremodified to ask about the past year. With a larger reference period, itwas necessary to modify questions about condom use from the originalform in the RBA (number of times) by providing response options on aLikert scale Likert scaleA subjective scoring system that allows a person being surveyed to quantify likes and preferences on a 5-point scale, with 1 being the least important, relevant, interesting, most ho-hum, or other, and 5 being most excellent, yeehah important, etc , because asking individuals to estimate the number of timesthey engaged in particular sexual acts over an entire year is likely toyield inaccuracies. The response options were the following: 0 = never,1 = rarely, 2 = occasionally, and 3 = always. In addition, questionswere included about whether participants and their DVO partner had othersex partners during their relationship and the proportion of time theyused condoms with other sex partners. Participants were asked whetherthey had ever injected drugs in their lifetime and whether their DVOpartner had ever injected drugs. Substance Use. These measures were adapted from the AddictionSeverity Index (ASI ASI,n See Anxiety Sensitivity Index. ) (McLellan, Luborsky, O'Brien, & Woody,1980). Illicit drugs included marijuana marijuanaor marihuana,drug obtained from the flowering tops, stems, and leaves of the hemp plant, Cannabis sativa (see hemp) or C. indica; the latter species can withstand colder climates. , cocaine, crack cocaine,hallucinogens, club drugs Club DrugsDefinitionClub drugs is the generic term for psychoactive drugs, usually illegal, that are used by participants of the rave and dance club and recreational drug subculture. , and illicit use of sedatives, opiates OpiatesAnalgesic, pain killing drugs, such as heroin and morphine that depress the central nervous system.Mentioned in: Withdrawal Syndromes , andamphetamines AmphetaminesSympathomimetic amines; sometimes called speed; synthetic chemicals that stimulate the central nervous system.Mentioned in: Weight Loss Drugsamphetamines . Participants were asked to report whether they had everused each class of substance, and if so, by using an event historycalendar, they were asked to report in which months they had used eachclass of substance. Two separate variables were computed for the numberof months women used alcohol to intoxication intoxication,condition of body tissue affected by a poisonous substance. Poisonous materials, or toxins, are to be found in heavy metals such as lead and mercury, in drugs, in chemicals such as alcohol and carbon tetrachloride, in gases such as carbon monoxide, and and any illicit drug illicit drugStreet drug, see there in thepast year. Partner Violence Victimization victimizationSocial medicine The abuse of the disenfranchised–eg, those underage, elderly, ♀, mentally retarded, illegal aliens, or other, by coercing them into illegal activities–eg, drug trade, pornography, prostitution. . This was measured with questionsadapted from a study examining incidents reported on protective orderpetitions (Harrell, Smith, & Newmark, 1993) and from the ConflictTactics Scales (CTS (1) (Clear To Send) The RS-232 signal sent from the receiving station to the transmitting station that indicates it is ready to accept data. Contrast with RTS.(2) (Common Type System) The data typing used in . and CTS2) (Straus, 1995; Straus, Hamby, Boney-McCoy,& Sugarman, 1996). Tolman's (1989, 1999) PsychologicalMaltreatment maltreatmentSocial medicine Any of a number of types of unreasonable interactions with another adult. See Child maltreatment, Cf Child abuse. of Women Inventory (PMWI PMWI Pagemart Wireless Incorporated ) was used in addition to pilotwork with the target study population (Logan et al., 2003).The scalesused for adaptation, the CTS, CTS2, and PMWI, inquired about differenttime frames for victimization and used different question structures anddifferent response categories. Therefore, it was necessary to adapt thescales to make them compatible for face-to-face interviews with timeframes that were consistent with the overall purpose of the study.Questions adapted from other research examining victimization amongwomen with protective orders (Harrell et al., 1993) were structured tobe consistent with items adapted from the CTS, CTS2, and the PMWI. Thetime frame for partner violence reported is for the past year. An index on the severity of physical violence by the DVO partner inthe past year was computed on the basis of weights assigned in theweighted severity index of the CTS. The following weights were assignedfor acts perpetrated by the DVO partner: one for twist arm or pull hair,push or shove, grab, slap; two for kick, bite, punch, or hit withsomething, slam against the wall; five for beat up, burn or scald onpurpose, strangle StrangleAn options strategy where the investor holds a position in both a call and put with different strike prices but with the same maturity and underlying asset. This option strategy is profitable only if there are large movements in the price of the underlying asset. ; six for threaten with a knife or gun, try to run downwith a car; and eight for used a knife or fired a gun on the victim. Thepossible range in scores was 0 to 49. Severe physical violence includedany abuse item that received a weight of two or more in the index forseverity of physical violence. Sexual violence committed by the DVO partner in the past year wasmeasured with questions from the Sexual Coercion coercion,in law, the unlawful act of compelling a person to do, or to abstain from doing, something by depriving him of the exercise of his free will, particularly by use or threat of physical or moral force. subscale of the CTS2related to threatened or forced sex (for example, threatened sexualactivity other than intercourse, threatened sexual intercourse sexual intercourseor coitus or copulationAct in which the male reproductive organ enters the female reproductive tract (see reproductive system). , forcedsexual activity other than intercourse, and forced sexual intercourse).Sexual insistence was not included in this analysis because so manyindividuals who reported threatened and forced sex reported the samefrequency of sexual insistence for particular months, thus it appearedthat some participants were double counting Double counting may refer to: Double counting (proof technique), a proof technique in combinatorics whereby one set is counted in two different ways Double counting (fallacy), a fallacy in combinatorics and probability theory whereby objects are counted more than once events. Participants wereasked whether the DVO partner had ever used any of the sexual coerciontactics, and if so how many times in each of the months for the 12months before the interview, using the event history calendar. Procedure Women were recruited out of four court jurisdictions. A femalestaff member approached women who had received a DVO against a maleintimate partner. Recruitment from this courtroom population yielded avery high participation rate. Of the women approached in court, 83.4percent provided contact information, only 2.4 percent initially refusedparticipation, and 14.3 percent took information about the study but didnot provide contact information. Of those with valid contact informationwho were actively pursued by the study staff, 73.5 percent completed theinterview. Out of the 26.5 percent not interviewed, 8.2 percent decidednot to participate, and 23.7 percent were never successfully contactedor scheduled. Female interviewers collected data from participants inface-to-face interviews, which took an average of 3.5 hours and beganafter women gave informed consent. Participants were compensated fortheir time. Each participant was provided with a verbal educationalprotocol about safety and a referral resource pamphlet containingpertinent physical health, mental health, and safety planning resourcestailored for the community in which she lived. Data Analysis Bivariate bi��var��i��ate?adj.Mathematics Having two variables: bivariate binomial distribution.Adj. 1. analyses were conducted to describe the sample by the HIVrisk perception group, and to inform the selection of variables to beincluded in the multivariate analysis. Nonetheless, all violencemeasures were included in the multivariate analysis, even if a bivariateassociation was not found, because of the importance of violence to thepurpose of the analysis. Bivariate associations between self-perceivedrisk of HIV and (1) demographic variables, (2) relationship variables,(3) partner violence variables, (4) actual sexual risk behaviors withthe DVO partner, and (5) risky behavior outside the relationship withthe abusive partner were examined with chi-square tests for categorical That which is unqualified or unconditional.A categorical imperative is a rule, command, or moral obligation that is absolutely and universally binding.Categorical is also used to describe programs limited to or designed for certain classes of people. variables and one-way analysis of variance for continuous variables. Toreduce the likelihood of Type I error, the p value was adjusted to .01(Lipsey, 1990). Decisions about the variables to include in the multivariateanalysis were guided by the literature on factors associated withgreater risk of HIV and greater perceptions of risk: age (Gerrard etal., 1996; Klein et al., 2003; Wingood & DiClemente, 2000), race(Schroder et al., 2001), education (Wingood & DiClemente, 2000),relationship status (Wyatt et al., 2000), length of relationship (Reisen& Poppen, 1995), number of partners (Klein et al., 2003), substanceuse (Thompson, Kao, & Thomas, 2005; Wingood & DiClemente, 2000),and partner violence. RESULTS Demographics Demographic variables were examined by women'sself-perceptions of their risk of HIV. No significant differences werefound between women in the no chance group and the some to sure chancegroup. The typical participant was in her thirties (M = 31.8, SD = 9.7),was white (83.0 percent), reported low annual income (M = $10,299), wasunemployed (57.6 percent), and had a high school diploma/GED or higherlevel of education (71.2 percent).Thirteen percent of the sample wasAfrican American African AmericanMulticulture A person having origins in any of the black racial groups of Africa.See Race. . Just less than one-half of the women (46.2 percent)had minor children in common with the DVO partner. Victimization by the DVO Partner Characteristics of participants' relationships with the DVOpartner and the abuse tactics used by the DVO partner in the past yearby HIV risk perception group are presented in Table 1. The majority ofthe sample had been married to the DVO partner. Significantly more womenin the no chance group had been married to the DVO partner than women inthe some to sure chance group. Women's relationships with the DVOpartner were typically lengthy. The vast majority of women were brokenup with the DVO partner when interviewed. All women reportedpsychological abuse, and the vast majority of women experienced severephysical violence in the past year. A sizeable minority of each groupreported that the DVO partner had stalked stalked?adj.Having a stalk or stem. Often used in combination: long-stalked; short-stalked.Adj. 1. them and had insisted thatthey have sex when they did not want to, and a little less thanone-fourth of the women reported threatened or forced sex in the pastyear. There were no differences in measures of stalking Criminal activity consisting of the repeated following and harassing of another person.Stalking is a distinctive form of criminal activity composed of a series of actions that taken individually might constitute legal behavior. , severity ofphysical violence, or threatened or forced sex by group. HIV Risk Behavior and Indicators HIV risk behavior and indicators, by HIV risk perception group, arepresented in Table 2. The majority of women had been tested for HIV,with significantly more women in the some to sure chance group havingbeen tested compared with women in the no chance group. Women in thesome to sure chance group reported a greater number of sex partners inthe past year than did women in the no chance group. Participantlifetime injection drug use, treatment for a sexually transmittedinfection (STI STIsystolic time intervals. ) in the past year, and condom use with other partners inthe past year did not differ significantly by risk group. When sexual behavior with the DVO partner was examined, resultsindicated that about nine out of 10 women reported that they did notalways use condoms with the DVO partner in the past year, even thoughthe majority of women reported that the DVO partner had other sexpartners. Of those women who reported that the DVO partner had other sexpartners, more women in the some to sure chance group reported that theDVO partner did not always use condoms with other sex partners, andsignificantly more women in the no chance group reported that they didnot know whether the DVO partner had used condoms. A sexual risk index was computed on the basis of the women'sresponses about the DVO partner's risk behaviors as well as theirown sexual risk behaviors. Participants who reported always usingcondoms with the DVO partner or who reported not having sex with the DVOpartner even though they were involved in a relationship with the DVOpartner were assigned a value of "0." Not always using acondom with the DVO partner was coded as "1," with reports ofeach of the following given an additional value of "1": theDVO partner ever having injected drugs, participant having other sexpartners during the relationship with the DVO partner, DVO partnerhaving other sex partners during the relationship, the DVO partner notusing condoms always with other sex partners, or the participant beinguncertain about the DVO partner's extradyadic sexual activities(which is mutually exclusive Adj. 1. mutually exclusive - unable to be both true at the same timecontradictoryincompatible - not compatible; "incompatible personalities"; "incompatible colors" from the previous two categories). Scoresranged from 0 to 4. There was no significant difference on the indexscores by group (see Table 2). Significant differences between the groups were found on substanceuse variables. Women in the some to sure chance group reportedsignificantly more months of alcohol use to intoxication and illicitdrug use in the past year than did women in the no chance group. Multivariate Analysis The index for sexual risk in the relationship with the DVO partner,rather than the separate variables used to calculate it, was used as apredictor variable Noun 1. predictor variable - a variable that can be used to predict the value of another variable (as in statistical regression)variable quantity, variable - a quantity that can assume any of a set of values in the logistic regression In statistics, logistic regression is a regression model for binomially distributed response/dependent variables. It is useful for modeling the probability of an event occurring as a function of other factors. for the following reasons.First, one of the variables that described participants' sexualrisk in their relationship with the DVO partner did not apply to asizeable proportion of participants--DVO partner's condom use withother sex partners. For example, when the participant reported that theDVO partner had not had other sex partners during their relationship.Second, including the variable about participants not knowing theextradyadic sexual behavior of the DVO partner with the variable aboutparticipants' more definitive reports of the DVO partners'extradyadic sexual behavior would create multicollinearity problems in alogistic regression analysis if it were included as a separatecovariate. Logistic regression was conducted to determine which predictorvariables were associated with women's perceptions of their risk ofHIV. Predictor variables included age, race, education, marital status marital status,n the legal standing of a person in regard to his or her marriage state. with the DVO partner, currently broken up, severity of physicalviolence, frequency of sexual violence, number of sex partners in thepast year, the index for sexual risk in the relationship with the DVOpartner, number of months of alcohol use to intoxication, and number ofmonths of illicit drug use (see Table 3). Months of alcohol use tointoxication was included rather than months of any alcohol use becauseproblem drinking is a predictor of risk behavior (Wingood &DiClemente, 2000). Area of residence was considered as a covariate, butbecause it was heavily confounded with race (all women in the rural areawere white), it was not included. Multicollinearity was not found forthe predictor variables. Wald statistics indicate that only twovariables significantly predicted women's self-perceptions of theirrisk of HIV: the number of sex partners in the past year and the numberof months of illicit drug use. Although the results indicate that theoverall model was statistically reliable, the overall model accounts foronly a modest percentage of the variance (Nagelkerke [R.sup.2] = .158). DISCUSSION Previous research suggests that many individuals who perceivethemselves to be at no risk of HIV have recently engaged in risky sexualbehaviors, even though the individuals who are at greatest risktypically perceive themselves to be at risk (Klein et al., 2003;Schroder et al., 2001). The relationship between self-perceptions ofrisk and prior sexual risk behaviors among this sample was examined toexplore whether women in abusive relationships typically accuratelyassess their sexual risk. There are three main findings from this study:(1) The number of sexual partners and illicit drug use were associatedwith women's self-perceived risk of HIV; (2) sexual behaviorswithin the relationship with the abusive partner were not associatedwith women's self-perceived risk, once other variables werecontrolled; and (3) the severity of physical violence and frequency ofsexual violence in the abusive relationship were not associated withwomen's self-perceived risk of HIV. This study found a positive association between some riskybehaviors and women's subsequent assessments of their risk of HIV;however, other risky sexual behaviors were not related to women'sperceptions of risk. The number of sexual partners in the past year wasthe strongest predictor for women's perceptions of risk. Thisfinding is consistent with other research that has found thatindividuals with more sex partners perceive themselves to be at higherrisk of contracting HIV (Britton, Levine, Jackson, Hobfoll, &Shepherd, 1998; Maurier & Northcott, 2000; Weinhardt, Carey, &Carey, 2000). Also, the findings indicate that women were consideringillicit drug use as increasing their risk of HIV. Illicit drug use hasalso been found to be associated with greater sexual risk, such as moresex partners (Logan et al., 2002; Sly, Quadagno, Harrison, Eberstein,& Riehman, 1997; Wingood & DiClemente, 1998). Women were betterable to modify their behavior on the basis of the public health messagesthat greater numbers of sexual partners and illicit drug use areassociated with greater risk of HIV than on the basis of the publichealth messages about sexual risk with a steady partner, which was insome part probably due to the abuse. In this study, sexual risk practices with the abusive partner,specifically lack of condom use and the partner's extradyadicsexual activity, were not related to women's perceptions of risk.This analysis was partly undertaken to build on the current literaturethat has examined actual risk behavior and self-perceptions of risk withwomen (Klein et al., 2003) to examine whether findings were similar withwomen with recent partner violence experiences. One reason for assumingthat the findings might be different for this sample was that abusiveintimate relationships have low levels of trust (O'Leary, 2000),and therefore, women may be more suspicious of their partner'ssexual activity; yet the findings do not provide evidence to supportthis hypothesis. Like the sample of women in the Klein et al. (2003)study, many women who had engaged in risky behavior perceived themselvesto be at no risk. Educating women in abusive relationships about HIV risk isimportant. However, it is also important to note that research suggeststhat asking steady partners, especially abusive partners, to use condomscan increase risk of negative outcomes, including increased risk offurther abuse (Neighbors & O'Leary, 2003; Neighbors,O'Leary, & Labouvie, 1999). Developing approaches that womencan adopt to present condom use in positive ways that minimize thelikelihood of negative attributions and reactions on the part of theirpartners is critical to women's ability to persuade their partnersto use protection. Various factors that were not measured in this study may explainthe finding that many women who had engaged in risky sexual behaviorswith their steady partner did not perceive themselves to be at any riskof HIV. For example, the perception of no risk may be partly explainedby the relatively low prevalence rate of HIV/AIDS in the state (AIDSprevalence among female adolescents and adults in Kentucky in 2004 was2.6 per 100,000). Individuals living in communities that have higherprevalence rates of HIV/AIDS are at greater risk of HIV infection thanare people living in communities with lower HIV/AIDS prevalence rates(Kalichman & Cain, 2005). In a study of 723 individuals receivingmedical care at an STI clinic, individuals who perceived theircommunities to have lower prevalence rates of HIV/AIDS compared withother communities engaged in more sexual risk behaviors than didindividuals who perceived their community to have higher HIV/AIDSprevalence rates (Kalichman & Cain, 2005). In this study, eventhough many individuals reported sexual behaviors that allow for thetransmission of HIV, the risk of infection may seem remote toindividuals living outside of communities that have high prevalence ofHIV/AIDS. Second, perceptions of risk have been found to be low inindividuals who have engaged in risky sexual behaviors because thoseindividuals perceived risk to be assigned to groups rather than tospecific behaviors (Brown et al., 2000). Many of the women in thissample, in particular those who did not use illicit drugs and had onesteady partner, may not have perceived themselves to be at risk becausethey did not belong to a "high-risk group" (Public HealthAgency of Canada The Public Health Agency of Canada (French: Agence de la sant�� publique du Canada) is an agency of Health Canada a department of the Government of Canada that is responsible for public health, emergency preparedness, and response and infectious and chronic disease control , 2004). Third, cognitive dissonance cognitive dissonanceMental conflict that occurs when beliefs or assumptions are contradicted by new information. The concept was introduced by the psychologist Leon Festinger (1919–89) in the late 1950s. and rationalizationmay factor into the mismatch mismatch1. in blood transfusions and transplantation immunology, an incompatibility between potential donor and recipient.2. one or more nucleotides in one of the double strands in a nucleic acid molecule without complementary nucleotides in the same position on the other between some women's perceptions ofrisk of HIV and their reported sexual behaviors (Buunk & Dijkstra,2001). Risky behavior that occurs in a context over which an individualhas no or little control may arouse denial as a coping strategy to dealwith the anxiety of the threatening situation (Brown et al., 2000).Certainly, being in a relationship with an abusive partner fits thedefinition of a situation over which a person may perceive littlepersonal control. Moreover, prior research indicates that individualsmay minimize risks to their health because they perceive the cost ofadopting lower risk behavior to incur too many personal or social costs,such as loss of pleasure, and relationship strain (Logan et al., 2002).Brown et al. also found that distancing and downward comparison wereimportant antecedents to low perceptions of individual risk of HIV.Fourth, women's knowledge of behaviors that increase risk of HIVmay not be accurate (Klein et al., 2003). There was no significant association between severity of sexualviolence and perceptions of risk of HIV. It was expected that threatenedor forced sex in particular would be associated with higher perceptionsof risk. However, the operationalization of sexual violence in thisstudy may have missed important dimensions of sexual coercion that couldinfluence perceptions of risk. Sexual coercion within the context of anabusive relationship may have dimensions that are rare in nonabusiverelationships. For example, in a study of women who were recentlystalked by a physically abusive partner, many women who did not reportexperiencing threatened or forced sex by the abusive partner did reportcoercive co��er��cive?adj.Characterized by or inclined to coercion.co��ercive��ly adv. and degrading TO DEGRADE, DEGRADING. To, sink or lower a person in the estimation of the public. 2. As a man's character is of great importance to him, and it is his interest to retain the good opinion of all mankind, when he is a witness, he cannot be compelled to disclose tactics within the context of sexual activity(Logan, Cole, & Shannon, 2007). Many women who did not reportthreatened or forced sex spoke of their partners controlling theirsexual activity through a variety of tactics, including threatening tohave an affair, making accusations of infidelity, claiming that sex washer duty, normalizing his sexual needs, continually pestering her forsex, and having sex while she slept. Therefore, it is possible in thisstudy that some women who did not experience threatened or forced sexdid experience other sexually coercive tactics, wherein they lacked adegree of control over their sexual activities with the abusive partner.Broadening measures of sexual coercion to better explore control insexual relationships is recommended for future research on HIV riskbehavior among partner violence victims. One reason this study may not have found an association betweenphysical violence severity and self-perceptions of risk may be due tothe sample. Specifically, research suggests that only small percentagesof women who experience partner violence obtain protective orders,ranging from 12 percent to 40 percent (Hathaway, Silverman, Aynalem,Mucci, & Brooks, 2000; Holt, Kernic, Lumley, Wolf, & Rivara,2002; Logan, Shannon, Walker, & Faragher, 2006; Tjaden &Thoennes, 2000). Women who obtain protective orders against maleintimate partners experience more severe levels of violence comparedwith women who do not obtain protective orders (Ptacek, 1999).With ahigh prevalence rate of severe physical violence, as was found in thissample, it is possible that diminished variability in this measureobscured a possible relationship between severe physical violence andperception of risk. Of course, it is also possible that physicalviolence within an abusive relationship does not factor intowomen's perceptions. More comparative studies of women with abusivepartners and women with nonabusive partners is needed to betterunderstand which aspects of abusive relationships may influencewomen's self-perceptions of risk of HIV. Other limitations to this study must be mentioned. First, thesampling frame limits the generalizability of the findings. Because thisstudy used a nonprobability sample, it is not clear whether the findingscan be generalized to other populations of women with protective ordersagainst a male partner. Finally, use of self-report measures may bebiased by underreporting of risky behavior (Seal, 1997), yet there issome evidence that for individuals in a committed relationship A committed relationship is an interpersonal relationship based upon a mutually agreed upon commitment to one another involving exclusivity, honesty, or some other agreed upon behavior. , it maybe socially approved to report having frequent unprotected sex(Scandell, Klinkenberg, Hawkes, & Spriggs, 2003). Social Work Implications Policy and practice implications for social workers include theneed for more assessment, education, and intervention efforts related toHIV risk with women who present for services related to partnerviolence. Securing funds for prevention interventions to be administeredto women seeking services for partner violence, such as in domesticviolence shelters, counseling services, and primary health caresettings, should be a priority for policymakers. Previous research hasfound that it is easier to establish a pattern of safer sexual practicesat the onset of a relationship than it is to adopt these practices in anestablished relationship after couples have engaged in riskier behavior(Maxwell & Boyle, 1995). Thus, targeting women who have recentlyterminated a relationship is potentially a critical time to presentprevention education. However, because many women who obtain servicesfor partner violence also remain involved with their abusive partners(Logan et al., 2008), educational programs and interventions mustdeliver interventions with attention to the complex and potentiallydangerous situations that women with abusive partners face, all of whichshould begin with a nonjudgmental non��judg��men��tal?adj.Refraining from judgment, especially one based on personal ethical standards.Adj. 1. nonjudgmental assessment by the social worker.Interventions that address the complex needs of women who are currentlyinvolved or who were recently involved with abusive partners, with thegoal of sensitizing sen��si��tize?v. sen��si��tized, sen��si��tiz��ing, sen��si��tiz��esv.tr.1. To make sensitive: "The polarity principle . . . women to their actual risks for HIV, should help toprovide coping strategies The German Freudian psychoanalyst Karen Horney defined four so-called coping strategies to define interpersonal relations, one describing psychologically healthy individuals, the others describing neurotic states. so that women are not overwhelmed with theadditional anxiety associated with the risk of HIV infection as well asdealing with the risk of future violence. Moreover, it is important thateducation efforts sensitize sen��si��tizev.To make hypersensitive or reactive to an antigen, such as pollen, especially by repeated exposure. women to the fact that lack of uncertaintyabout their partners' sexual activities outside of theirrelationship indicates potential risk to their own health and a seriousneed to use protection against HIV when that is within their control.The need for female-controlled methods of protection that areundetectable by male partners has been asserted before (Logan et al.,2002; O'Leary, 2000), but it cannot be stated enough. Although themeans for developing female-controlled methods of protection are outsideof social work's scope of practice, advocating for increasedfunding for research into vaginal vag��i��naladj.1. Of or relating to the vagina.2. Relating to or resembling a sheath.vaginalpertaining to the vagina, the tunica vaginalis testis, or to any sheath. microbicides may be within socialwork's realm. Interventions that increase women's personal andexternal resources may also be essential to increasing women'slevel of control in their relationships, to taking measures to stop theviolence, and to practicing protective health behaviors. Original manuscript received August 28, 2006 Final revision received September 13, 2007 Accepted February 6, 2008 REFERENCES Beadnell, B., Baker, S. A., Morrison, D. M., & Knox, K. (2000).HIV/STD risk factors for women with violent male partners. Sex Roles,42, 661-689. Britton, EJ., Levine, O. H., Jackson, A. P., Hobfoll, S. E., &Shepherd, J. B. (1998). Ambiguity of monogamy as a safer-sex goal amongsingle, pregnant, inner-city women: Monogamy by whose definition?Journal of Health Psychology, 3, 227-232. Brown, E.J., Outlaw, F. H., & Simpson, E. M. (2000).Theoretical antecedents to HIV risk perception. Journal of the AmericanPsychiatric Nurses Association, 6, 177-182. Buunk, B. P., & Dijkstra, E (2001). 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Jennifer Cole Jennifer Victoria Cole (b. 1973) is a model, actress and game show/talk show host originally from Atlanta, Georgia. In addition to being a former Hawaiian Tropic model and winner of that company's swimsuit competition, Cole has either starred and/or hosted a number of shows , PhD, is assistant professor; TK Logan, PhD, isprofessor, and Lisa Shannon, PhD, is assistant professor, Center on Drugand Alcohol Research, University of Kentucky Coordinates: The University of Kentucky, also referred to as UK, is a public, co-educational university located in Lexington, Kentucky. . The research for andpreparation of this article were supported by the National Institute onAlcohol Abuse and Alcoholism alcoholism,disease characterized by impaired control over the consumption of alcoholic beverages. Alcoholism is a serious problem worldwide; in the United States the wide availability of alcoholic beverages makes alcohol the most accessible drug, and alcoholism is grant number AA12735-01 and the Universityof Kentucky General Clinical Research Organization funded by theNational Institutes of Health grant number M01RR02602. Addresscorrespondence to Jennifer Cole, University of Kentucky, 1141 Red MileRoad, Suite 20I, Lexington, KY 40503; e-mail: jecole2@uky.edu.Table 1: Relationship Characteristics and PartnerVictimization, by Self-Perceived Risk of HIV (in Percentages) Some to No Chance Sure ChanceCharacteristic (n = 341) (n = 228)Relationship to DVO partner Married 57.5 46.5 Cohabited 40.8 48.7 Other relationship (child in common) 1.8 4.8 Mean no. of years involved with the DVO partner 7.5 6.0Currently broken up with the DVO partner 88.3 85.5Victimization experiences in the past year of the relationship with the DVO partner Psychological abuse 100 100 Stalking 41.6 48.7 Severe physical violence 82.4 86.8 Sexual insistence 41.3 44.3 Threatened/forced sex 21.4 25.0 Severity of physical violence index (minimum = 0, maximum = 47) 13.9 15.6 Mean frequency of threatened/ forced sex (minimum = 0, maximum = 360) 2.7 5.2 [chi square] orCharacteristic F StatisticRelationship to DVO partner (2, N = 569) = 9.356 * Married Cohabited Other relationship (child in common) Mean no. of years involved with the DVO partner (1, 568) = 6.521Currently broken up with the DVO partner (1, N= 569) .920Victimization experiences in the past year of the relationship with the DVO partner Psychological abuse Stalking (1, N= 569) = 2.744 Severe physical violence (1, N= 569) = 2.021 Sexual insistence (1, N= 569) = .486 Threatened/forced sex (1, N= 569) = 1.000 Severity of physical violence index (minimum = 0, maximum = 47) (1, 567) = 3.444 Mean frequency of threatened/ forced sex (minimum = 0, maximum = 360) (1, 567) = 1.735Note. DVO = domestic violence order.* p < .01.Table 2: HIV Risk Indicators, by Self-PerceivedRisk of HIV (in Percentages). Some to No Chance Sure ChanceIndicator (no = 341) (n = 228)Ever tested for HI 75.1 85.1Participant ever injected drugs in lifetime 4.5 7.0Mean no. of sex partners in the past year (minimum = 0, maximum = 12) 1.3 1.8Received medical care for an STI in the past year 3.2 5.7Those participants who had sex with other partners in the past year did not always use condoms with other sex partners 52.4 57.3Sexual risk in the relationship with the DVO partner DVO partner had ever injected drugs 5.3 7.7 Participant did not always use condoms with DVO partner 89.9 92.9 DVO partner had other sex partners No 37.5 33.8 Yes 49.9 58.3 Doesn't know 12.6 7.9 DVO partner's use of condoms with other sex partners (for those who said the DVO partner had other sex partners) Not always 46.5 64.7 Doesn't know 40.0 24.1 Participant had other sex partners during the relationship with the DVO partner 18.5 25.0 Index for sexual risk in the relationship with the DVO partner (0 to 4) 1.8 2.1Substance use in the past year No. of months in the past year used alcohol 1.4 2.6 No. of months in the past year used illicit drugs 1.4 3.2 [chi square] orIndicator F StatisticEver tested for HI (1, N- 569) = 8.285 *Participant ever injected drugs in lifetime (1, N= 569) = .543Mean no. of sex partners in the past year (minimum = 0, maximum = 12) (1, 568) = 35.635 **Received medical care for an STI in the past year (1, N= 569) = 2.073Those participants who had sex with other partners in the past year did not always use condoms with other sex partners (1, N= 194) _ .461Sexual risk in the relationship with the DVO partner DVO partner had ever injected drugs (1, N= 569) = 1.536 Participant did not always use condoms with DVO partner (1, N= 553) = 1.438 DVO partner had other sex partners (2, N= 569) = 5.216 No Yes Doesn't know DVO partner's use of condoms with other sex partners (for those who said the DVO partner had other sex partners) (2, N= 303) = 10.581 * Not always Doesn't know Participant had other sex partners during the relationship with the DVO partner (1, N= 569) = 3.496 Index for sexual risk in the relationship with the DVO partner (0 to 4) (1, 567) = 6.384Substance use in the past year No. of months in the past year used alcohol (1, 567) = 18.048 ** No. of months in the past year used illicit drugs (1, 567) = 31.097 **Notes: STI = sexually transmitted infection.DVO = domestic violence order.* p <.01. ** p <.001.Table 3: Logistic Regression Predicting Self-Perceptionsof Risk of HIVCharacteristic [beta] Wald Odds RatioAge .003 .078 .997Race (0 = white) .357 1.590 1.429Education (0 = less than college) .294 2.343 1.341Married to DVO partner (0 = not married) -.176 .838 .838Currently broken up -.229 .708 .795Severity of physical violence in the past year .006 .376 1.006Frequency of sexual violence in the past year .003 1.041 1.003No. of sex partners in the past year .499 15.024 1.647 **Sexual risk in the relationship with the DVO partner .198 5.388 1.219No. of months used alcohol to intoxication in the past year .032 1.206 1.033No. of months used illicit drugs in the past year .081 10.001 1.084*Notes: Throughout table, df = 1. DVO = domestic violence order.* p < .01. ** p < .001.