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THE ROLE OF INTERPERSONAL POWER IN THE HIV PROTECTIVE
BEHAVIOR OF LOW-INCOME AFRICAN AMERICAN WOMEN
By

Sinead Natasha Younge

A DISSERTATION

Submitted to
Michigan State University
in partial fulﬁllment of the requirements
for the degree of

DOCTOR OF PHILOSOPHY
Department of Psychology

2005

ABSTRACT
THE ROLE OF INTERPERSONAL POWER IN THE HIV PROTECTIVE
BEHAVIOR OF LOW-INCOME AFRICAN AMERICAN WOMEN
By
SIN EAD NATATSHA YOUNGE

Given the current prevalence and incidence rates, the Human
Immunodeﬁciency Virus (HIV) that causes Acquired Immunodeﬁciency Disease
Syndrome (AIDS) is an ever-growing public health threat for women nationwide, and
African American women in particular. While HIV rates have increased for women in
general, African American women comprise 67% of the total AIDS cases among
women of all ethnicities in the United States (Center for Disease Control and
Prevention, 2004). The majority of new HIV cases among African American women
are the result of heterosexual intercourse transmission.

While the HIV risk reduction ﬁeld has focused on women’s ability to
negotiate safer sex behavior including condom use, an ecological framework, which
locates sexual behavior within the context of gender relations and its antecedents, is
emerging. Researchers have suggested that women may be constrained in negotiating
HIV protective behavior strategies because of gender and culture based imbalances in
heterosexual interpersonal relationships (Amaro, 1995; Gomez & Marin, 1996;
Wingood & DiClemente, 2000).

Previous research has provided the groundwork for the continued
development of various theories and models that have the potential to adequately

address the disparities of HIV transmission among women of color. Perhaps most

notable is Wingood and DiClemente’s (1998) Theory of Gender and Power (TGP),

which was used as the theoretical framework for the development of the proposed
model in the current study. The goal of TGP and the current study was to examine
how interpersonal power inﬂuences HIV protective behavior among low-income
Aﬁican American women, while taking into account culture, gender relations, and
various traditional cognitive behavioral factors.

The current study had two primary purposes. The ﬁrst purpose was to
contribute to the much needed descriptive literature on the HIV related behaviors,
attitudes, and beliefs of low-income, African American women. The second purpose
of this study was to propose an integrated model of HIV protective behavior which
incorporated both the traditional and contemporary ecological models of health
behavior.

While only some of the speciﬁc hypotheses were supported in the proposed
model, further analyses (e.g., correlation and regression) suggest that the model is
worthy of further investigation with relevant populations and that the hypothesized
relationships between variables may need to be further conceptualized. These data
provide important new insights into low-income Aﬁican American women’s risk for
HIV infection, in particular, the speciﬁc barriers to consistent condom use and the

factors that are relevant to women’s interpersonal relationships.

DEDICATION
This dissertation is dedicated to the village that raised me and the shoulders of my

of those who I try to stand tall on.

iv

ACKNOWLEDGMENTS

I wish to ﬁrst acknowledge more Lord and Savior Jesus Christ who is the source
of my very existence. In addition, I would like to thank my entire committee for going
above and beyond the call of duty to support me in my research efforts. Thank you to
Anne Teitelman for introducing me to the theory of gender and power. To Harriette
McAdoo, who I have had the distinct honor and privilege to work with and learn from.
To Cris Sullivan whose endless encouragement and commitment has served me well
during the uncertain times. Deb Bybee, whose unwavering support and unrivaled
patience has literally been my guiding light through the dark halls of statistics, and lastly
to Debby Salem whose tutelage has made me into the researcher I am today. Debby you
are truly one of the most intelligent people I know and can spot an unclear argument a
mile away. Your precision and guidance have given me the conﬁdence to enter the next
phase in my academic journey.

I would like to thank the American Psychological Association, HIV minority
fellowship program who have provided me with the ﬁnancial support necessary to
complete my graduate education. I would also like to thank my research assistants, Tomi
Akinyemiju, Sarah Borowiak, Oni Chambers, Jaclyn House, Ruhama Eshete, Chenai
Muzamhindo, Tonisha Shanks, and Cristal Thompson, whose generous commitment and
dedication to the project is greatly appreciated, especially at seven o’clock in the
morning. I look forward to having you all as my future colleagues. I would also like to
thank Ralph DiClemente for clarifying his theory and allowing me the opportunity to
continue my training with him at Emory. I would also like to thank the community and

service providing agencies of Lansing, Flint, Detroit, and Grand Rapids for opening their

doors to me and allowing me to come in. Thank you to all of the women who agreed to
participate in this study in order to advance the plight of HIV prevention in the Aﬁican
American community. Also, thank you to my Corolla for taking me around the state of
Michigan through the best and worst of weather conditions.

I would like to thank my mother and father for always believing in me and
supporting my goals. I would especially like to thank my mother for not allowing me the
“privilege” of complaining about what I can not do and instead the encouragement to
ﬁgure out what I can do. To my sisters, Juliet and Karen, and my niece, Imani you all are
a constant source of joy, support, motivation, and laughs. Thank you to my numerous
uncles, aunts, and cousins who always have a supportive word to give. To my ﬁiends and
“sistergirls,” your shoulders have been the constant source of many sorrows, joys, and
ﬁ'ustrations and I cannot thank you enough for your unwavering support and numerous
pep talks. Thank you to my signiﬁcant other, whose meal deliveries, long bike rides, and
listening ear have kept me partially sane throughout my entire dissertation process. Thank
you to St. Stephen’s Community Church and my colleagues and classmates throughout
the psychology department at Michigan State University and my continued support

system at San Diego State University.

TABLE OF CONTENTS

INTRODUCTION ................................................................................................................. 1
Overview of the HIV epidemic ........................................................................................ 6
HIV Transmission ...................................................................................................... 9

Prevention with African American Women ...................................... 10

Theories and Models Guiding HIV Interventions ............................. 11

Interventions Targeting Men Who Have Sex with Men .................... 14

Limitations of interventions for diverse groups. .................... 17

Interventions with Heterosexual Women of Color ............................ 20

Interpersonal Power. . . . . . .. .............................................................................................. 29

Developing an Integrated Model of Gender and Power ............................................ 31

Predictors of Interpersonal Power ...................................................... 34

Partner dependency ................................................................ 35

Gender roles ........................................................................... 36

Sex-ratio imbalance ............................................................... 38

Perceived partner reactions .................................................... 39

Traditional Constructs of Behavior Change .............................................................. 41

Condom Self-Efﬁcacy ....................................................................... 41

Perception of Risk .............................................................................. 43

Construction of Perceived Risk. ........................................................ 45

Optimistic bias ........................................................... 46

Fatalism ...................................................................... 48

HIV knowledge .......................................................... 50

HIV Protective Behavior................. ..................................................................... 52

Contributions of the Proposed Study ......................................................................... 55

Research Questions ............................................................................ 57

Speciﬁc Hypotheses ........................................................................... 57

Method ....59

Procedure 60
Pilot Data Collection .......................................................................... 61
Recruitment........... ........................................................................ 61

Social Service Organizations ................................................. 62
Community Organizations ..................................................... 63
Snowballing Techniques ........................................................ 60
Research Assistant Training .............................................................. 64
Survey Administration ....................................................................... 65
Participant Incentives ............................................................. 66
Conﬁdentiality ................................................................................... 66
Study Sample ......................................................................... 66
Measures. . . .. ....................................................................................................... 67
Demographic measures .......................................................... 68
Interpersonal power ............................................................... 68
Relationship commitment ...................................................... 7O

vii

Results........ ..

HIV Protective behavior ........................................................ 70

Objective HIV protective behaviors .......................... 71

Primary partner ................................................. 71

Second partner .................................................. 71

Self-Identiﬁed HIV protective behaviors ........................................... 71

Condom self-efﬁcacy ......................................................................... 72

Perceived HIV risk ............................................................................. 73

Fatalism ...................................................................... 73

General fatalism ................................................ 74

HIV fatalism ...................................................... 74

Optimistic bias ................................................................................... 74

Sexual optimistic bias ............................................................ 75

General optimistic bias .......................................................... 75

HIV knowledge .................................................................................. 75

Gender role identity ............................................................... 76

Perceived sex ratio imbalance ................................................ 77

Partner dependency ................................................................ 78

Attitudes Toward Condom Use ................................. 79

Perceived Partner Attitudes Toward Condomse ........ 80

Participant Attitudes Toward Condom Use ............... 80

Violence ................................................................................. 80

Data Preparation ..................................................................... 80

Data Analysis Strategy ....................................................................... 81

Univarrate Analyses ........................................................................... 81

Missing Data” .............................................................. 81

Descriptives. . . . . . .. ............................................................................. 82

Interpersonal relationships ..................................................... 82

Interpersonal behaviors and HIV risky behaviors ................. 83

HIV risk and knowledge ........................................................ 83

HIV protective behavior ........................................................ 84

Self-identiﬁed HIV protective behaviors ............................... 84

Objective HIV Protective Behaviors ..................................... 85

Primary Partner .......................................................... 85

Second Partner ........................................................... 85

Birth Control .......................................................................... 86
Intercorrelations of the independent and dependent

Variables ............................................................................... 87

Interpersonal relationship control .............................. 87

Perceived HIV risk ..................................................... 87

Condom self-efﬁcacy ................................................. 87

Testing the model................... 88

Transformations ................................................................................. 89

Testing the Core Model ..................................................................... 90

Final Structural Model ....................................................................... 93

Estimating the Structural Model ........................................................ 94

viii

Results of the Hypothesis Testing .............................................................................. 95

Logistic Regression ................................................................ 96

Additional Analyses in the Subsarnple .................................. 99
Discussion... 101
The Proposed Integrated Medel ..................................................................... 102
Interpersonal Power and HIV Protective behavior ............................ 102

Additional analyses on the relationship between

power and HIV ........................................................... 104
Cultural Contextual Factors in the Proposed Model ...................................... 106
The Role of Perceived HIV Risk ....................................................... 106
Cultural Predictors of Perceived Risk .................................... 107
HIV knowledge .......................................................... 107

Optimistic bias and fatalism ....................................... 108
Optimistic bias ........................................................... 109
Fatalism ...................................................................... 110
Implications of optimistic bias and general fatalism ............. 110
The Role of Interpersonal Relationship Power .................................. 1 10
Cultural Predictors of Interpersonal Power ............................ 111

Financial independence .............................................. 1 1 1
F emininity .................................................................. 112
Sex-ration imbalance ................................................. 1 12

The role of violence ................................................... 113
The Sample: Low Income Aﬁican American Women .................................. 114
Description of intimate relationships .................................................... 115

HIV risky behaviors ................................................... 115

Condom self-efﬁcacy ................................................. 118

Relationship Status and HIV Protective

Behavior ......................................................... 1 19
Limitations of the current study ............................................. 120

Strengths of the current study.. ............................................................ 122
Implications for Interventions ............................................................... 123
FutureDirections................. .................................................................... 125
Conclusions” 126
Appendix A: Tables .............................................................................. 131
Appendix B: Consent Form ................................................................. 143
Appendix C: Health and Relationships Questionnaire ........................ 145
Appendix D: Resource Guide .............................................................. 156
Appendix D: Psychometrics of the Scales ........................................... 157

ix

Table 1:

Table 2:

Table 3:

Table 4:

Table 5:

Table 6:

Table 7:

Table 8:

Table 8

Table 9:

Table 10:

Table 11:

Table 12:

Table 1 3:

Table 13:

Table 14:

Table 15:

Table 16:

Table 17:

LIST OF TABLES

Recruitment Strategies ................................................................................... 130
Demographic Characteristics of sample ........................................................ 131
Relationship Descriptives within the Last 3 Months ........................... 132
Types of Birth Control Used ........................................................ 133

Please list all the ways that you protect yourself from getting HIV/ AIDS?.133

Psychometric Properties ............................................................. 134
HIV Knowledge Frequency of Correct Responses ........................................ 135
Correlations of Independent and Dependent Variables .......................... 136
Correlations of Independent and Dependent Variables cont’d ...................... 137
Skew and Kurtosis values for log transformed variables ............................... 138

Correlations Among Exogenous Variables and error terms in the SEM

Model ............................................................................................................. 138
Standardized Indirect Effects of SEM Model ................................................ 139
Standardized Direct Effects of SEM Model .................................................. 140
Unstandardized, Standardized Measurement Coefﬁcients (N = 196) ........... 141
Unstandardized, Standardized Structural Coefﬁcients (N=196) ................... 142
Measurement and Structural Model Comparison Table ................................ 142

Summary of Logistic Regression Analysis for Interpersonal Relationship
Control Predicting Condom Use as an HIV Protective Behavior (n=196)....97

Moderated hierarchical regression analysis: HIV risk as a moderator of the
effect of relationship control on condom frequency with oral, anal, and
vaginal intercourse (N =1 96). ......................................................................... 99

Relationship control as a predictor of HIV protective behavior (condom
frequency with oral, anal, and vaginal intercourse), while controlling for
perceived risk (N =69). ................................................................................... 100

LIST OF FIGURES

Figure 1: Proposed Protective Behavior Model ............................................................ 34
Figure 2: Core Measurement Model ............................................................................. 90
Figure 3: Final Structural Model ................................................................................... 93

xi

INTRODUCTION

Given the current prevalence and incidence rates, the Human Immunodeﬁciency
Virus (HIV) that causes Acquired Immunodeﬁciency Disease Syndrome (AIDS) is an
ever-growing public health threat for women nationwide, and Aﬁican American women
in particular. Poverty, racism, and gender inequality are fundamental social conditions
that foster risk taking and create conditions of disease vulnerability for disenfranchised
women domestically and worldwide. While HIV rates have increased for women in
general, African American women comprise 67% of the total AIDS cases among women
of all ethnicities in the United States (Center for Disease Control and Prevention, 2004).
The majority of new HIV cases among Aﬁican American women are the result of
heterosexual intercourse transmission. HIV risk reduction requires the cooperation of
both partners; however, male controlled condom use remains a banier to HIV protective
behavior for women in heterosexual relationships (CDC, 2004).

While the HIV risk reduction ﬁeld has focused on women’s ability to negotiate
safer sex behavior including condom use, an ecological framework, which locates sexual
behavior within the context of gender relations and its antecedents, is emerging. In
addition to examining the ecological contexts, which consider the ability of women to
negotiate safer sex, the motivation and deterrents of HIV protective behavior are being
ﬁrrther investigated. Researchers have suggested that women may be constrained in
negotiating HIV protective behavior strategies because of gender and culture based
imbalances in heterosexual interpersonal relationships (Amaro, 1995; Ehrhardt &

Wasserheit, 1991; Fullilove, Fullilove, Haynes, & Gross, 1990; Gomez & Marin, 1996;

Wingood & DiClemente, 2000). This perspective has engendered a number of women
speciﬁc HIV interventions.

Traditional prevention research on HIV risk reduction focuses primarily on
individual level cognitive behavioral factors without taking into account the other
inﬂuential factors including intimate interpersonal relationships. It has become
increasingly evident that Aﬁican American women of lower socioeconomic status are at
increased risk for HIV infection, not entirely because of their own behaviors, but because
of the behaviors of their male partners (Hobfoll, Jackson, Lavin, Britten, & Shepherd,
1994). It is the dynamics of intimate relationships that can heavily inﬂuence a woman’s
actual and perceived HIV risk and in turn, her ability or desire to engage in HIV
protective behaviors (Amaro, 1995).

Behavioral health theories that are widely used to understand risk behaviors and
behavior change, stress the importance of knowledge, attitudes and beliefs. Traditional
health theories assume that behavior change can be explained by models that are
generalizable to all individuals (Amaro, 1995). Findings from some intervention studies
suggest that these models may fail to account for behavior change among speciﬁc
understudied or non-mainstream groups (e.g., low-income African American women)
(Cantania et al., 1992). In an attempt to speciﬁcally address the experiences of low-
income Aﬁican American women, in terms of HIV prevention, there have been a number
of conceptual studies that have theoretically hypothesized the gender and culture speciﬁc
factors related to HIV protective factors. Among the most inﬂuential factors identiﬁed

are a combination of cognitive behavioral and biopsychosocial issues.

The HIV epidemic does not uniformly affect African American women. Instead,
the increasing incidence rates are most commonly found among women of lower
socioeconomic statuses. Socioeconomic status factors have been suggested to inﬂuence
women’s vulnerability to HIV in a number of different ways, including the link between
lower income levels and HIV protective behaviors (Bowleg, Belgrave, & Reisen, 2000;
Peterson et al., 1992; Wingood & DiClemente, 1998), and less access to optimal and
quality preventative health care (Mays & Cochran, 1988). As demonstrated, the
relationship between lower socioeconomic status and increased HIV susceptibility is not
a direct one. There are a number of predictors and mitigating factors that inﬂuence this
relationship. A model that empirically examines these factors is proposed in the current
study to help further understand the contextual factors that contribute to the disparate
rates of HIV infection among low-income Aﬁican American women. Speciﬁcally,
interpersonal power has demonstrated to be necessary to engage in HIV protective
behaviors within the context of dyadic relationships and there exist a number of cultural
factors that are hypothesized to predict interpersonal relationship power. The cultural
factors that are identiﬁed by the current study include traditional feminine gender roles,
ﬁnancial dependency, and perceived sex ratio imbalances. Some of these factors are
generalizable to all women; however, the dynamics of the African American community
interact with these factors to create unique relationships not previously examined in the
empirical research literature.

Essential for interpersonal relationship power to be relevant for HIV protective
behaviors is the presence of perceived susceptibility or risk of HIV infection. The Health

Belief Model (HBM) posits that people who perceive themselves as susceptible to a

negative outcome are more likely to reduce risky behaviors than those who do not see
themselves as being at risk (J anz & Becker, 1984). Contemporary HIV speciﬁc models
(i.e., the AIDS Risk Reduction Model) state that individuals need to recognize that their
behaviors are risky before change can occur (Cantantia, Kegeles, & Coaates, 1990).
Many HIV theories endorse the underlying assumption that perceived risk is constructed
by a “rational” simple cost-beneﬁt analysis, rather than a multiplicity of risk construction
(Estrada & Quintero, 2000). The social underpinnings of risk construction have been
speculated to be inﬂuenced by a number of cultural and traditional behavioral factors.
The cultural predictors of perceived risk identiﬁed in the current study include optimistic
bias, fatalism, and HIV knowledge. Furthermore, partners and relationship status can also
have an inﬂuence on risk reduction efﬁcacy judgments, depending on partners’ attitudes
and characteristics (Wingood & DiClemente, 2002).

Previous research has provided the groundwork for the continued development of ~
various theories and models that have the potential to adequately address the disparities
of HIV transmission among women of color. Perhaps most notable is Wingood and
DiClemente’s (1998) Theory of Gender and Power (TGP), which was used as the
theoretical framework for the development of the proposed model in the current study.
The goal of TGP and the current study was to examine how interpersonal power
inﬂuences HIV protective behavior among low-income Aﬁican American women, while
taking into account culture, gender relations, and various traditional cognitive behavioral
factors.

Upon entering into the third decade of the HIV epidemic, there is no vaccine or

cure for HIV/AIDS. However, treatment advances are continually improving. There are a

number of individuals who are beneﬁting substantially ﬁom treatment advances such as
Highly Active Antiretroviral Treatments, and unlike a generation ago, many of these
individuals are able to remain contributing and fully functioning integrated members of
society, whose disease status is often unknown to the general population.

Among Aﬁican American women, HIV is mostly transmitted through social
interactions with sexual partners within their social networks. The behaviors that place
individuals at risk for HIV are capable of being changed; however, effective prevention
programs must motivate individuals to make and maintain behavioral changes that reduce
the probability of HIV transmission. While low-income African American women
represent a disproportionate number of increased HIV incidence rates, there remains a
dearth of empirical culture and gender speciﬁc research on this population.

The current study had two primary purposes. The ﬁrst purpose was to contribute
to the much needed descriptive literature on the HIV related behaviors, attitudes, and
beliefs of low-income, Aﬁican American women. The second purpose of this study was
to propose an integrated model of HIV protective behavior which incorporates both the
traditional and contemporary ecological models of health behavior. The following
literature review examines the current theoretical and empirical HIV research literature
for all “high risk” populations, followed by a review of the HIV research literature on
African American women. Lastly, the literature on Aﬁican American women’s cultural
context is examined in order to place the aforementioned health behaviors into their

proper cultural context.

Overview of the HIV Epidemic

The HIV/AIDS epidemic is stabilizing and declining in some of the populations
ﬁrst and hardest impacted by the disease. However, women are among one of the few
groups whose rates are quickly increasing. Since 1985, the proportion of all AIDS cases
reported among adult and adolescent women has more than tripled, from 7% in 1985 to
25% in 1999 (Center for Disease Control and Prevention, 2000). The increasing
incidence rates are especially evident among women of color. Aﬁican American and
Hispanic women comprise less than one-fourth of all US women, yet they account for
more than three-fourths (80%) of all reported AIDS cases among women. African
American women have an HIV incidence rate 23 times that of their White counterparts,
and HIV /AIDS is currently the leading cause of death for Aﬁican American women aged
25-34 (CDC, 2000).

The disparities in HIV incidence rates are due in part to the fact that a signiﬁcant
proportion of Aﬁican American women live below the poverty line (US Census, 2002).
Studies have demonstrated a direct relationship between higher HIV incidence rates and
lower income (Diaz, Chu, & Buehler et al., 1994). A variety of socioeconomic problems
associated with poverty directly or indirectly increase HIV susceptibility, including
limited access to quality health care and HIV prevention education, as well as increased
substance use compared with the general population. Confronted with high
unemployment, poverty and disproportionately high indices of morbidity and mortality,
many Blacks may see HIV as relatively unimportant in comparison to other more
imminent problems, such as paying rent and putting food on the table (Icard, Schilling,

El-Bassel, & Young, 1992).

Weeks et al. (1999) argues that biologically, “the virus is the agent of the disease,
however, various social structures and relationships of disempowerrnent create pathways
of least resistance or greatest opportunity for the virus to traverse, resulting in the
predominance of the disease among those least empowered and facing the greatest
barriers to making behavioral changes for the sake of HIV prevention” (p. 193). Research
has suggested that membership in a minority group and lower socioeconomic status are
linked to risky sexual behavior, but are not directly as a function of ethnicity and
socioeconomic status (Becker et al., 1998; Schilling et al., 1991). These studies, however,
do not explore how race and poverty may interact with one another to inﬂuence HIV risk
behaviors (Ickovitz et al., 2002).

Upon entering into the third decade of the epidemic, it is evident that new at-risk
groups have emerged. Heterosexual transmission has taken the place of intravenous drug
use as the number one mode of transmission for women. In 2000, 38% of women
reported with AIDS were infected through heterosexual exposure to HIV, while injection
drug use accounted for only 25% of new cases. In addition to the direct risks associated
with injection drug use (e.g. sharing needles), drug use is also fueling the heterosexual
spread of the epidemic. A signiﬁcant proportion of women infected heterosexually were
infected through sex with an injection drug user (CDC, 2004).

Similar to women in general, African American women are most likely to be
infected with HIV as a result of sexual intercourse with infected men, followed by
infection through injection drug use. While preventative interventions have been effective
in some populations, diverse populations require a diverse range of interventions that

target speciﬁc risk behaviors and the contextual factors that facilitate or inhibit risk

behaviors (Carey et al., 1997). Data on transmission suggests that prevention efforts with
Aﬁican American women should focus on prevention of transmission through
heterosexual intercourse. Therefore, the nature of sexual negotiation in male-female
relationships is an important domain for examining the behaviors and contexts that place
Aﬁican American women at risk for HIV infection (Bowleg, Lucas, & Tschann, 2004;
CDC, 2002). In order to prevent HIV transmission we must understand the aspects of
relationships that facilitate or impede HIV protective behaviors.

The HIV epidemic varies among populations and across communities. For some
populations, prevention efforts have dramatically aided in declining incidence rates
(CDC, 2000). In the US, collaborative prevention efforts have contributed to a 50%
decrease in HIV seroprevalence among White men who have sex with men (MSM).
Between 1988 andl993, there was a more than 40% decrease in the HIV seroprevalence
among injection drug users in New York City. Between 1992 and 1998, there was a 75%
decrease in perinatal infections. Overall, from 1998 and 2002, HIV incidence rates
decreased among Whites and Latinos (CDC, 2004). Although these declines are
remarkable, the number of annual new infections in other groups has increased over the
last decade and is unacceptably high, warranting a need for continued prevention efforts
to curtail the epidemic. From the beginning, the epidemic affected White gay males
disproportionately and as a result, it had a powerful male proﬁle. Women did not realize
their own risk for HIV transmission from male partners through heterosexual
transmission, and HIV incidence rates among women of color in particular, surged due to
the early neglect of prevention and intervention activities. For White gay males, the HIV

epidemic was instrumental in altering the context of sexual relationships by inﬂuencing

both internal and external structures that were related to behavior change maintenance.
As noted, diverse groups have diverse needs, suggesting that strategies that helped
facilitate change in the White gay male community are different from those that need to
be addressed in Aﬁican American community.

HIV Transmission

According to the Center for Disease Control and Prevention (2004), the most
effective way to avoid transmission of sexually transmitted diseases is to abstain from
sexual intercourse, or to be in a long-term mutually monogamous relationship with a
partner who has been tested and who is not infected. For persons whose sexual behaviors
place them at risk for sexually transmitted diseases (STDs), correct and consistent use of
the male or female latex condom can reduce the risk of STD transmission. However,
there is no protective method that is 100 percent effective. In order to achieve the
protective effects of condoms, they must be used correctly and consistently. Incorrect use
can lead to condom slippage or breakage, thus diminishing their protective effect.

For many women, abstinence is not a desirable option. Long term monogamy and
condom use are not prevention strategies that are completely under the control of the
individual woman. Rather, they require the cooperation of another a partner. Research on
the sexual behavior of women demonstrates that women are more likely to protect
themselves ﬁom sexual outcomes (e. g. pregnancy) using methods that do not require
partner cooperation, such as oral contraceptives, than they are in using methods that
require partner cooperation (U CSF CAPS, 1998). Research on women's attitudes toward
condom use suggests that many African American women in particular, appraise

condoms negatively, viewing condoms as unromantic, interfering with spontaneity, and

detracting from sexual pleasure (Hinkle et al., 1992; Kline, Kline, & Oken, 1992).
Condoms also are viewed negatively within the Aﬁican American community because of
their association with casual relationships, inﬁdelity, disease, and because of beliefs that
they detract from trust, intimacy, and commitment in a relationship (Sobo, 1993; Weeks
et al., 1995). These ﬁndings suggest that increasing incidence rates are not necessarily
due to lack of motivation to engage in protective behaviors, but may be attributed to the
complexities of engaging in behaviors within the context of a dyadic relationship.
Prevention with Aﬁ'ican American Women

Traditional HIV sex-related research, which has been based on the medical
model, has taken a deﬁcit-based approach to Aﬁican American sexuality when
examining disparate HIV incidence rates. A serious limitation of previous theoretical
frameworks is the belief that protective behavior is largely under an individual’s control,
and an inability to account for the combined effects of gender and race and how these
factors play out in the contexts of dyadic relationships (Amaro & Raj, 2000). Widely
utilized cognitive behavior models place HIV behavior largely under the control of the
individual without regard for the external factors like social norms and gender roles
which, within a sexual relationship, shape women’s choices for engaging in protective or
risky HIV behaviors. Lack of understanding the social factor, which interact with internal
factors to create the conditions for HIV risk does not provide a complete and accurate
picture of the epidemic. Research must recognize the conditions speciﬁc to Aﬁican
American women that creates their risk of exposure to HIV (Weeks et al., 1999). For
instance, all women must balance sexual scripts that include passion, romance, trust, and

sexual passivity with mistrust, fear of unprotected sex, and sexual assertiveness to ensure

10

personal safety (Amaro, 1995). Among African American women, social inequalities in
terms of racism, access to resources (e. g. income, education and health care), and their
intersection with other contextual factors such as unequal sex ratios, substance abuse,
incarceration, and gender ideologies may contribute to the disproportionate incidence and
prevalence of HIV among Aﬁican American women (Bowleg et al., 2004). Moreover,
African-American women may not have the desire or the ability to negotiate condom use,
because they think it would interfere with physical and emotional intimacy, imply
inﬁdelity by themselves or their partner, or possibly result in physical/emotional abuse.
Interventions that fail to take these complexities into account are not likely to assist
women of color with HIV prevention.

Traditional research has focused on individual responsibility for personal
behavior change, rather than focusing on the dyadic nature of sexual relationships
(Amaro & Raj, 1995). Recently, HIV/AIDS researchers have made signiﬁcant strides
towards developing integrated models of HIV risk behavior that include the intersection
of race, class, and gender (Connell, 1987 ; Harlow et al., 1998; Wingood & DiClemente,
1998; Wyatt et al., 2000). More conceptually complex models that take the social
complexities of sexual behavior into account are still needed (Weeks et al., 1999).
Theories and Models Guiding HIV Interventions

In health research, theoretical approaches are used to direct attention to the
understanding of the modiﬁable psychological determinants of risk behavior. Theory
driven research has been a useful tool in helping to understand, predict, and modify
behaviors in order to decrease HIV transmission rates. Some of the traditional, pre-HIV

health models and theories currently used in HIV research and interventions include the

11

health belief model (Rosenstock, Strecher, & Becker, 1994), the theory of reasoned
action (Ajzen & Fishbein, 1977, 1980; Fishbein, 1980; Fishbein & Ajzen, 1975), and
social cognitive theory (Bandura, 1977). The central tenant of these theories and models
is that individuals who recognize that their behavior places them at risk for a disease or
illness are more likely to adopt less risky behaviors than those who do not (Kowalewski,
Henson, & Longshore, 1997). An additional assumption is that these behaviors are
voluntary and are fully within an individual’s control (Logan et al., 2002). These
dominant traditional theories do not easily accommodate contextual, personal, and
sociocultural variables such as gender and racial/ethnic culture.

Fisher and Fisher (2000) discuss some of the limitations of HIV prevention
interventions that rely solely on traditional health theories. Among some of their
noteworthy ﬁndings are the methodological weaknesses in the operationalization of some
of the theories. For instance, while the health belief model (HBM) is one of the most
widely used models in HIV research and interventions, the relationships between some of
the variables in the HBM remain “unconceptualized” and “unspeciﬁed” (Fisher & Fisher,
1994). The authors of the theory (Rosenstock et al., 1994) acknowledge that the
relationships among the key variables in the model have never been adequately addressed
and as a result, the HBM is typically used in conjunction with other models and theories.
This lack of speciﬁcation found in many traditional theories has led to inconsistent
empirical support in the area of HIV and health research in general (Fisher & Fisher,
2000).

The application of traditional models and theories to HIV prevention has resulted

in information based interventions. These models have several limitations. First, many of

12

these models do not take into account the relevance of the information to HIV
preventative behavior for a particular population (e. g., transmission of HIV in regard to
condom negotiation). Second, there remains a strong focus in most interventions on
efforts to change general patterns of behavior (e.g., having sexual intercourse) as opposed
to focusing on increasing individuals’ inclination and ability to practice speciﬁc risk
reduction acts. Third, many interventions fail to motivate individuals to change their risky
behavior or provide training to help them acquire, rehearse, and reﬁne the behavioral
skills necessary for HIV risk behavior change (Fisher & Fisher, 2000). Fourth, many
prevention programs target middle class populations and do not adequately address the
needs of high risk groups (Weeks et al., 1995). Traditional theories and models were
conceptualized using populations of convenience (e. g., White middle class college
students), suggesting that these theories may not be generalizable to diverse populations.

Since the emergence of the HIV/AIDS epidemic and dramatic changes in the
epidemiology of the disease, some of the traditional theories and models have been
modiﬁed or expanded, and a number of new theories have been developed or applied to
the problem of HIV, with the speciﬁc purpose of addressing the complexity of issues
surrounding the disease not previously addressed. Some of the more recent theories and
models applied to HIV transmission include the AIDS risk reduction model (ARRM)
(Catania, Kegeles, & Coates, 1992), the transtheoretical model (Prochaska, DiClemente,
& Norcross, 1992), the diffusion of innovations theory (Rogers, 1995), and the theory of
gender and power (Connell, 1987; DiClemente & Wingood, 1998). The various

traditional and contemporary health theories and models have been used with varied

l3

success in preventing the spread of the disease. One group with which prevention effects
have been particularly effective has been White gay males.
Interventions Targeting Men Who Have Sex with Men

The HIV literature has a wealth of examples of effective interventions that have
utilized traditional and contemporary theories and models that target men who have sex
with men (MSM). Researchers and providers have worked collaboratively with the gay
community to bridge the gap between science and application. As a result, interventions
have been successfully tailored to the speciﬁc needs of this particular population. The
Center for Disease Control and Prevention (1999) has published a compendium of what
they judge to be successful interventions; however, there remain lirrrited scientiﬁc
evaluations of many of these programs. Publication bias has also contributed to the
dissemination of only successful interventions, resulting in little knowledge about
interventions that have had limited success. An exhaustive review of interventions has
demonstrated that the most common and successful interventions among men who have
sex with men are small group or workshop programs that provide participants with risk
reduction information, while simultaneously focusing on modifying group norms (Kelly
et al., 2000). Most of these interventions have utilized aspects of social cognitive theory
and diffusion of innovation theory. A brief review of theoretically driven and
scientiﬁcally evaluated interventions targeting men who have sex with men is provided.

As a forerunner in HIV research and interventions, Kelly and colleagues have

documented changes in safer sex norms and behaviors in urban gay communities. Kelly
et a1. (1992) reasoned that they could encourage condom use among communities of

small-city gay men efﬁciently by identifying the natural opinion leaders in the

14

community and enlisting them to endorse behavior change. Taking an ecological
community psychology approach and employing aspects of the diffusion of innovation
theory and social cognitive theory, the intervention model assumed that community-wide
change in this community could be facilitated by changing group social norms. This
method was chosen because of the belief that many gay men have a sense of group
identity. As such, changing the views of opinion leaders can be expected to reach and
inﬂuence other members of the community. This model does not require that all members
of a community have direct contact with an opinion leader, because the opinion leader's
message is assumed to diffuse through the communication networks in which the opinion
leader is embedded. This method is based on the assumption that the opinion leader is
representative of the actual community and that the target population identiﬁes with the
community.

To test these assumptions, Kelly and colleagues designed a bar-based opinion
leader intervention (Kelly, St. Lawrence, Diaz, et al., 1991; Kelly, St. Lawrence,
Stevenson, et al., 1992) which produced community-level adoption of condom use in
two-city and three-city comparison group studies (Kelly, St. Lawrence, Diaz, et al., 1991;
Kelly, St. Lawrence, Stevenson, et al., 1992) and in a multiple-city randomized ﬁeld trial
(Kelly et al., 1993). This work highlighted the distinctive nature of urban gay male bar
networks and how they provide a particularly powerful place in which diffusion might
occur for this population. The ﬁndings of Kelly and colleagues highlight the important
role that perceived peer norms can play in inﬂuencing an individual’s behavior. Kelly’s
intervention is likely one of the most replicated models of HIV prevention with men who

have sex with men.

15

Building on the work of Kelly and colleagues, Kegeles et al. (1996) developed
and implemented a community-level HIV prevention program also utilizing aspects of
the difﬁrsion of innovation theory. The peer-led program had three components: outreach,
small groups, and a publicity campaign. Independent of the prevention program, a cohort
of young gay men (n = 300) was surveyed in this and in a similar comparison
community, pre- and post-intervention. Following the intervention, the proportion of men
engaging in any unprotected anal intercourse decreased signiﬁcantly with both non-
primary partners and primary boyfriends. No signiﬁcant changes occurred in the
comparison community over the same period. Another study conducted by Valdiserri et
al. (1989) found that gay men attending group interventions that taught risk reduction
skills including: condom use, safer sex negotiation, sexual assertiveness when confronted
with risk coercions, self-management of risk “triggers,” and problem-solving strategies,
exhibited substantial reductions in high-risk sexual behavior practices.

Miller et a1. (1998) conducted a study to explore the effectiveness of HIV
prevention programs for male prostitutes and other patrons (n= 1,741) in New York City
"hustler" bars. The ﬁndings from this study indicated signiﬁcant reductions in paid,
unprotected sexual intercourse and oral sex following the intervention. Irnportantly
however, Miller et al. found variation in the intervention's effects by bar and by
participants' race/ethnicity. Latino and White men beneﬁted from the intervention,
whereas Black men did not. These ﬁndings suggest that race/ethnicity may represent a
boundary of social networks within the bars and selected opinion leaders may only be
able to promote change within their own peer group (Miller et al., 2001). The researchers

did ﬁnd behavior change among Latinos in places where the opinion leaders were also

16

Latino and among Whites where the opinion leaders were also White (Miller et al.,
1998). Previous research has demonstrated that individuals are more likely to be
persuasive role models if they are similar to the people they are attempting to persuade
(Fisher, 1988; Rogers, 1995). This premise is consistent with the ﬁndings of Miller and
colleagues.

Miller’s study targeted three bars. Two bars were predominately White with
approximately 20% of clients identifying as men of color. The third bar was diverse in
terms of men of color who were the male prostitutes, however, their clientele was
primarily White. Miller found that when bars had multiple, nonoverlapping social
networks, rather than being a homophilious setting (e. g. having a single network or
several overlapping networks), this can act as a limitation to opinion leader interventions.
She suggests that communication may be more effective in a homophilious setting. The
bars in this intervention were characterized as heterophilious or containing diverse groups
of people of varying social status (Fisher, 1988; Rogers, 1995). Miller and colleagues
speculated that the success of the intervention among particular sites and groups was
attributed to ownership of the intervention by community collaborators and that the
enthusiasm and solidarity of the opinion leaders and target populations led to more
persuasive communication. These ﬁndings suggest that when interventions are matched
to community cultures and settings, they are more likely to be successful.

Limitations of interventions for diverse groups. It is important to recognize that
published, or evidence—based, approaches to HIV prevention developed for White gay
males may not be effective with men who have sex with men (MSM) of color. The

Compendium of HIV Prevention (CDC, 1999) previously noted, identiﬁes 24 effective

17

interventions across a variety of at-risk populations. Only four of these interventions
speciﬁcally target gay men and surprisingly, none speciﬁcally target ethnic minority
MSM or men who have sex with men and women (MSM/W). A review of culturally
sensitive interventions conducted by Miller et a1. (2003) concluded that even when
interventions acknowledge the role of culture and claim to provide culturally sensitive
interventions, culture is typically not deﬁned explicitly and is almost unanimously
operationalized as synonymous with race/ethnicity. Possible explanations for the elevated
HIV risk among MSM and MSM/W of color may lie in the sociocultural and structural
factors facing many members of minority groups not addressed in interventions (Ayala &
Diaz, 2001). Available research on the association between experiences of social
discrimination and HIV risk demonstrate that ﬁnancial hardship, racism, and homophobia
heighten the risk for HIV infection by decreasing self-esteem and increasing social
isolation, alienation, and personal shame for MSM and MSM/W of color (Carballo-
Dieguez & Dolezal, 1996; Choi et al., 1999; Diaz & Ayala, 1999; Diaz, Ayala, Bein,
Henne, & Marin, 2001;; Ramirez-Valles, Zimmerman, & Newcomb, 1998). If these
issues are not addressed in an intervention, the goals of the intervention may be
compromised or usurped.

A history of activism, group solidarity, and sense of community that pre-date the
HIV epidemic have helped to create an environment in which HIV interventions can be
fostered and disseminated in the White gay community. The inability to reach men of
color who have sex with men has been a point of contention in HIV interventions, further
highlighted by these groups’ increasing incidence rates. There remain cultural,

socioeconomic, and other differences that exist among MSM of color, that limit the

18

effectiveness of interventions targeting individuals who identify with the “gay culture”
(CDC, 2004). For instance, there remain a substantial number of African American men
who have sex with men who, due in part to the stigmatized nature of homosexuality in
the Aﬁican American community, lead dual lives and have sex with men and women
without informing their female partners. This has been dubbed the “down low
phenomena.” This lack of openness can promote riskier behaviors and the lack of open
identiﬁcation with the gay community limits the ability to gain from interventions that
target this group. To date no published interventions have speciﬁcally targeted men who
live “on the down low,” further demonstrating a need for more diverse research and
interventions.

Some of the underlying factors related to the limited success of interventions
among men of color that target the gay communities are also seen in interventions that
target women of color. While a commonality with most interventions targeting men who
have sex with men is the community level intervention approaches, these interventions
incorporate and build on pre-existing strengths that exist within the gay community to
promote individual level behavior change. The opinion leader interventions in the gay
community are particularly effective because the intervention is tailored speciﬁcally for
men who identify as gay. These interventions utilize the natural social group networks
and peer group culture in the gay community along with its norms to create effective
behavior change (Miller et al., 2003). The ability to generalize these ﬁndings to
heterosexual women of color has not been met with the same success.

The impact of structural barriers facing African American women contributes to

the limited effectiveness of HIV interventions as compared to that seen in the gay

19

community. Communities of color are less able to organize and they have fewer ﬁnancial
and other resources available to them to support HIV prevention efforts. This means that
the skills, resources, personnel, and procedures necessary to organize Aﬁican American
women may differ markedly from those employed successfully in the predominantly
White gay community (Friedman et al., 1992). In order for interventions that target
Aﬁican American women to be effective, they must take into account the culmination of
structural, cultural, and individual factors that contribute to HIV transmission.

It has become increasingly evident that a multidimensional framework is
necessary to understand HIV risk behaviors for African American women. This
framework locates sexual behavior within a context of gender relations and considers the
aspects of the intersection of race, gender, and class that make Aﬁican American women
more susceptible to HIV transmission in comparison with women of other ethnic racial
groups (Amaro, 1995). The disproportionately high rates of HIV /AIDS among Aﬁican
American women point to the need to examine the ecological factors within which these
behaviors occur. These include: gender norms, cultural values, the role of interpersonal
power in relationships, and the factors that contribute to power imbalances. A substantial
number of empirical studies have examined many of these factors as one-dimensional
predictors of risky behavior, however, few studies have examined these issues from a
multidimensional framework focusing on understanding the processes of risk rather than
the outcome of engaging in risky behavior.

Interventions with Heterosexual Women of Color
Not surprisingly, interventions that have been successful in the gay community

have been attempted with African American women. Peer education has not been met

20

with the same success for Aﬁican American women as demonstrated in the White gay
community. Unfortunately, these approaches depend on a sense of uniﬁcation on the part
of the target population. Several researchers (Fishbein & Ajzen, 197 5; Fisher &
Misovich, 1990) have argued that for many heterosexual women of color, there is no
unifying group solidarity like that demonstrated in the gay community. Furthermore,
women at risk for HIV are not always visible as a speciﬁc population or community. In
addition to the limitations of peer education, an over reliance on information based
interventions fails to take into account the particular context of practicing protective
behaviors in an intimate relationship for Aﬁican American women. Among African
American women, attitudes of male partners have been demonstrated to be a salient
factor determining whether Aﬁican American women are willing or able to introduce
condoms into sexual relationships (Kline et al., 1992; Quinn, 1993). Many Aﬁican
American women believe their partners dislike condoms and perceive condom-protected
sex as less enjoyable, reducing the likelihood that women will attempt to introduce
condom use into the relationships (Libbus, 1995). During long-term relationships women
may perceive the trust and care in the relationship to be deeply imbedded. Conversely, if
a man suggests that condoms be used during sex, he may be implying that either he has
been unfaithful or that he suspects that his partner has been unfaithﬁrl (Nichols, 1990)
possibly placing the relationship in jeopardy.

HIV prevention research has successfully identiﬁed the behaviors associated with
risky sexual practices, however, the context within which these behaviors occur is still
vastly misunderstood. Taking a gender related approach allows researchers to understand

the social inﬂuences that shape sexual relationships for women, and is imperative in the

21

development of efﬁcacious interventions programs. A gender related approach requires
the examination of cultural, gender-speciﬁc, and psychosocial factors that are
determinants and antecedents of behavior (O’Leary & Wingood, 2000).

Programs that address issues such as relationship power or negotiation by training
interpersonal and negotiation skills have shown considerably more promise than have
their information-based predecessors. DiClemente and Wingood (1995) developed the
ﬁrst experimental study of HIV prevention among low-income, African American
women that took into account some of the aforementioned contextual issues. The
components of this intervention were tailored and personalized by including cultural
contextual themes that ﬁt the lives of the targeted population. In some cases entire
portions of the sessions dealt with issues relevant to the target population but only
indirectly related to risk behavior. The theory of gender and power (TGP) was used to
guide this intervention (Connell, 1987; Wingood & DiClemente, 2000). Researchers
recruited 100 African American women into a ﬁve-session skill based intervention, a
single-session HIV education group, or a control group. DiClemente and Wingood’s
intervention operationalized TGP in an integrated manner utilizing aspects of social
learning theory (SLT) and cognitive behavior modiﬁcation (CBM) to implement behavior
change. At three-month follow-up, women in the social skills intervention group
demonstrated increased consistent condom use, greater self-efﬁcacy, greater sexual
communication, greater sexual assertiveness, and increased partner’s adeption of norms
supporting consistent condom use. There were no signiﬁcant changes detected for the

HIV education condition and the delayed HIV education condition.

22

Kalichman, Rompa, and Coley (1996) conducted a skill training intervention with
92 high-risk African American women randomly assigned to receive sexual
communication skills, behavioral self-management skills, a combination of the two, or a
risk education group. These researchers realized that skill building alone has little effect
if people are resistant to engaging in condom use. Therefore, the intervention included
videotapes with basic information related to HIV transmission, followed by facilitator-
guided discussions. These discussions were directed at issues that addressed barriers to
condom use and were also used to clarify misconceptions, dispel myths about AIDS, and
discuss prevention options. This intervention encouraged participants to assess their own
risk, beneﬁts, and limitations of condom use. At three-month follow-up, more of the
women who received interventions that included communication skills training were
using condoms in comparison with women in the control condition, suggesting that a
combination of skills was necessary for women to reduce their actual risk.

In a recent experimental intervention, St. Lawrence, Wilson, Eldridge, Brasﬁeld,
and O’Bannon (2001) assigned 445 African American women into one of three
theoretically driven experimental interventions based on either the theory of gender and
power (TGP), social learning theory (SLT), or cognitive-behavioral theory (CBT). While
the SLT and CBT groups were operationalized to involve some aspect of skill
observation or rehearsal, the TGP group was unstructured with no skills training or
rehearsal of risk reduction skills. This group consisted entirely of a video followed by
discussions among the participants, with minimal engagement of the facilitators. At one-
year follow-up the results demonstrated that condom use, knowledge, communication

comfort, and self-efﬁcacy increased for all three experimental groups in comparison with

23

the control group. Contrary to expectations, those in the SLT and CBM conditions
exhibited greater increases than did women in the TGP groups. These ﬁndings are
attributed to differential operationalization of the theories to the interventions, suggesting
that skill training may be an essential component. Findings from this study provide
further support for the efﬁcacy of skill-based interventions over purely information-based
interventions with this population.

In the past couple of years, researchers have begun to examine the utility of
community level interventions for Aﬁican American women, like those seen in the gay
community. Lauby et a1. (2000) examined the effects of a multisite community level HIV
prevention intervention on condom-use behaviors among women of color and peer
educators. The intervention was implemented in four communities in three metropolitan
areas: two public housing communities, a low-income neighborhood, and a group of
inner city neighborhoods. The intervention targeted sexually active women of
childbearing age and consisted of multiple activities conducted throughout the
community designed to reach a large number of women through repeated contacts. These
activities included the development and distribution of prevention materials, mobilization
of peer networks of community volunteers, a network of community organizations and
businesses that supported the project, and the delivery of prevention messages by trained
outreach specialists through individual contacts and small group activities. In addition,
theory-based, culture speciﬁc role model stories were deve10ped by trained staff. The
stories were produced and distributed by community volunteers. The main outcome
variable measured was condom use. Data was collected ﬁom a total of 1,836 women at

baseline. At two-year follow-up, the effects of the intervention on women’s condom use

24

behaviors with their main partners and with other sex partners was measured. Although
the intervention did not have a direct effect on consistent condom use, an increased
willingness to discuss the subject and to initiate use was detected. The ﬁndings from this
study demonstrate that, while the desired outcome was not obtained, there are other
noteworthy ﬁndings that can be incorporated into ﬁrture interventions, including the
importance of increased communication. Communication in particular is related to sexual
negotiation and sexual assertiveness, components necessary for protective behavior to
occur. Consequently, while the intervention did not achieve its desired effects, increased
communication is an indication that individuals may be developing the antecedents to the
skills necessary to engage in protective behaviors.

In another community level intervention, Sikkema et al. (2000) conducted a study
targeting 690 minority women living in 18 inner city housing developments across ﬁve
US cities. This intervention utilized a community level approach similar to Kelly et a1.
(1991), to create positive attitudes towards behavior change and strengthen social norms
to avoid risk with outreach workshops and community forums. Women voted by their
peers as opinion leaders were invited to give their input into the development of the
intervention. These opinion leaders then formed health councils where they invited their
friends and neighbors to participate in workshops about HIV. The leaders also assisted
with the implementation of community events. The intervention groups consisted of nine
to 14 women who participated in four, ninety-minute workshops. Women who
participated in the workshops were expected to disseminate the information to the rest of
their community. The community events attracted a large number of individuals (15-

200). The results were reported for the entire community, rather than women who had

25

directly received the intervention (n=1,265). Outcomes including condom use, perceived
risk, condom carrying, and knowledge were examined. At two-month follow up,
unprotected intercourse had decreased 36% in the intervention community, while rates
remained unchanged in the comparison communities. At one-year follow up, women
reported a signiﬁcant decline in unprotected intercourse by 30%. The strength of this
intervention was attributed to the inclusion of community members into the intervention
design, along with the acknowledgment and incorporation of contextual factors and the
taking of female roles and power dynamics into account when delivering the intervention.
For instance, the intervention presented taking care of themselves as a way to protect
their families and communities, a role that was already familiar to them.

There remain various strengths and limitations to interventions that utilize
traditional and contemporary theories and models. These ﬁndings provide encouragement
for the promise of future interventions. Limitations of many published interventions
include the lack of critical information, such as participation rates or whether or not
randomization was performed, making it difﬁcult to evaluate and compare studies
(O’Leary & Wingood, 2000). Individual level interventions that focus on skill building
demonstrate more success than information-based interventions (DiClemente, 2000).
These ﬁndings provide further support for the notion that African American women may
reduce their HIV risk after receiving negotiation and condom skill training. However,
despite primary partners being the main mode of transmission for Aﬁican American
women, there remains evidence of the difﬁculty of negotiating condom use in “long

term” stable relationships (O’Leary & Wingood, 2000).

26

 

Interventions targeted at the community level are designed to promote HIV
preventive behavior change by providing individuals with information and skills to
change behavior through naturally occurring channels of inﬂuence in the community, and
helping to create an environment that promote or sustain the ongoing adoption of
preventative behaviors (DiClemente, 2000). The community level interventions presented
(e. g., Sikkema et al., 2000) are limited by the fact that not all women in the intervention
developments were exposed to intervention activities. Additionally, there remains
signiﬁcant transient activity among individuals of lower SES. Therefore women at most
risk may not be in a community long enough to receive the full beneﬁts of the
intervention. Lastly, while evidence exists that women who receive various types of
intervention are able to achieve behavior change, many women are not able to change
their behavior because the barriers to practicing protective behaviors have not been
sufﬁciently addressed. Though many of these factors are beyond the control of the
interventionists, researchers and service providers must provide practical options for
women to engage in protective behaviors. For instance, learning effective, culturally
appropriate condom negotiation skills may be a healthy strategy that women can use to
engage in protective behaviors. The largest barrier to a woman’s ability to engage in
protective behavior may be her sex partner since the behavior change necessary for
preventing sexual transmission requires the cooperation of another person. Interventions
are necessary for the creation of an environment that supports prevention norms among
both men and women (DiClemente, 2000).

A recent meta-analysis examining the effectiveness of US based HIV prevention

interventions speciﬁcally targeting 36 women, found that overall, interventions impacting

27

the sexual and relational context of HIV risk had limited long term effects (Mize,
Robinson, Bockting, & Scheltema, 2002). The successes and limitations of the above
mentioned interventions provide further support for the notion that behavior change
efforts must now rapidly move to “second generation” approaches that not only
understand the predictors of self-protective behaviors, but also have an appreciation for
the contexts in which these behaviors occur. As the infection rates increase among
African American women successful theoretically based interventions need to become
more rigorous with implementation to a wider audience.

A wide range of interdisciplinary traditional and contemporary theories have
played a signiﬁcant role in the development and implementation of HIV interventions
with limited success across populations. The limitations of these approaches have led to
the maturation of previous theories, along with the development of new ones. The current
theoretical approaches have been useful in furthering the understanding of HIV risk
behaviors. However, despite the utility of current models, much of the variance in
behavior change remains unaccounted for as evidenced by the limited success of HIV
interventions for African American women. Innovative theories that build on the
strengths of established theories are beneﬁcial in moving the arena of behavior change
interventions into the future. Contemporary theories and models must acknowledge that
many women are constrained in negotiating safer sex because of gender-based
imbalances in relationship power (Arnaro, 1995; De Bruyn, 1992; Ehrhardt &
Wasserheit, 1991; England, 1997; Feimlee, 1994; Gomez & Marin, 1996; Wingood,
Hunter-Gamble, & DiClemente, 1993). The success of any given HIV risk-reduction

intervention is its ability to acknowledge and incorporate some of the issues that surround

28

engaging in protective behavior. Understanding the ability or otherwise stated “power”
that an individual has to initiate the desired behavior within the contexts of a relationship
is critical.
Interpersonal Power

The central premise of a gender-speciﬁc approach to examining HIV prevention
is a strong focus on power differentials in relationships (Amaro, 1995). Power is a
complex multidimensional construct that has been conceptualized and operationalized in
a multitude of ways and most recently been used in order to understand women’s risk for
HIV infection (Amaro, 1995). Interpersonal power has been deﬁned as the ability to
inﬂuence one’s partner (Cromwell & Olson, 1975). Greater power is held by the member
of the couple who maintains control over decision-making in the relationship, has control
over both their own and their partner's actions, is less dependent on the relationship,
possesses more resources, and is perceived to have alternatives to the current relationship
(Pullerwitz et al., 2000). Research demonstrates that women who subscribe to traditional
gender roles and are more dependent on their partner’s have less interpersonal power in
relationships (Amaro, 1995). Asserting one’s power can conﬂict with what is
traditionally expected from women in interpersonal relationships if gender role norms
and institutional rules deﬁne the behavior as inappropriate for women (Jenkins, 1994a;
Stewart & Chester, 1982). Much of the research literature about power is based on
assumptions that are not inclusive of the experiences of African American women.
Examination of interpersonal power and how it inﬂuences HIV protective behavior can

only be appropriately applied to Aﬁican American women if it is translated conceptually

29

 

into the social roles and normative behaviors prescribed for women within their cultural
frameworks.

Much of the previous HIV/AIDS research has assumed that individuals have total
control over their own behaviors, without regard for the contextual factors, such as power
differentials and gender roles that may heighten women’s HIV risk. In a qualitative study
of HIV -related risks perception, Timmons and Sowell (1999) interviewed Aﬁican
American (n=19) women between the ages of 18 to 44. The number one risk identiﬁed by
participants was the practices of sexual partners labeled, “A man will be a man.” Most of
the participants in the sample reported that men are unable to be monogamous resulting
in feelings of an overall sense of powerlessness or lack of control over men’s behavior.

The ﬁndings of Timmons and Sowell (1999) support the View that the desire to be
in a relationship often overrides the desire and often promotes women relinquishing their
power in relationships to protect oneself against HIV. The women in this study felt an
overall sense of powerlessness represented by a lack of control over men’s behavior
(T irnmons & Sowell, 1999). These attitudes may lead to a more passive position on HIV
protection because outcomes are attributed to the “blessings” or “lessons” of a higher
power. To date, few published studies have examined these beliefs in the context of HIV
preventative behavior among African American women. The impact of African American
women’s unequal social status, further perpetuated by low socioeconomic status, places
them at severe disadvantage in negotiating sexual encounters and in seeking and utilizing
education and health services (Chen, Sepulveda, Amor, & Segal, 1991, p. 1999). In order

to understand interpersonal power within the contexts of African American women’s

30

lives, there are three important aspects of cultural context that need to be taken into
account. These include: gender roles, sex ratio, and partner dependency.

One theory that has attempted to take an integrative approach to account for the
contextual factors that contribute to interpersonal power and the role it plays in HIV
preventative behaviors, particularly among ethnic minority women, is Wingood and
DiClemente’s (1998) expanded version of Connell’s (1987) theory of gender and power.
Wingood and DiClemente expanded Connell’s theory to develop a public health model
that includes exposures, risk factors, and biological factors that adversely affect the health
of women in relation to HIV risk. This theory was used as a framework to guide the
proposed study. This theory suggests that women's lack of protective behavior is
inﬂuenced by socioeconomic factors, power imbalances within relationships, and gender-
speciﬁc gender roles inﬂuenced by culture. The theory of gender and power (TGP) takes
a multi-level, multidimensional approach to examining many of the factors that place
African American women at risk for HIV transmission. The current research will built
this theory in order to gain further understanding the processes through which
interpersonal power inﬂuences HIV protective behavior.

Developing an Integrated Model of Gender and Power

Until recently, research has excluded Black women as participants in research on
diseases that pose the largest threat to Black women’s heath (Klonoff, Landrine, & Lang,
1997, NIH, 2000). In recent years, Black women’s health issues have gained a larger
amount of attention (Klonoff et al., 1997). Understanding the relationship between
interpersonal power and HIV protective behaviors is relevant across all dyadic

relationships; however, understanding the cultural factors that inﬂuence interpersonal

31

power within speciﬁc groups is imperative. In addition to the traditional models of
behavior change, other inﬂuential factors must be taken into consideration and integrated
into existing models when examining the relationship between interpersonal power and
HIV protective behavior. The purpose of this study is to propose an integrated model of
behavior change that identiﬁes and examines the circumstances surrounding HIV
protective behavior among African American women. The theory of gender and power
provides the framework for examining the context for HIV prevention among ethnic
minority women. However the current study was designed to introduce and test a new
integrated conceptual model of women's gender roles, power in relationships, and HIV
protective behaviors. This model further integrates traditional behavior modiﬁcation
theories which allows for the deeper examination of the circumstances in which these
relationship negotiations take place. A multidimensional, integrated analysis is necessary
to understand the factors that contribute to interpersonal power and overall protective
behaviors among African American women.

Previous studies that target Aﬁican American women have provided the
foundation for the development of more complex models by identifying important
predictors of risky sexual behavior among African American women. However, some of
these studies continue to support the prevailing stereotypes about African American
women’s sexuality, without understanding how and why ecological factors place this
group at increased risk for HIV transmission. Few studies have examined how speciﬁc
factors like gender roles, partner dependency, and sex ratio imbalance predict
interpersonal power and how these relationships place this particular group at increased

risk for HIV transmission.

32

 

While Aﬁican American women share many common contexts and experiences,
it is important to acknowledge the heterogeneity of this group. This study focused on the
factors that predict interpersonal power for low-income Aﬁican American women. The
development of group speciﬁc models is beneﬁcial in understanding protective behaviors
within this population. This current study examined: (1) the relationship between
interpersonal power and HIV protective behavior among low income Aﬁican women, (2)
the inﬂuence of risk perception on the relationship between interpersonal power and HIV
protective behavior, (3) the role of sexual self-efficacy as a mediator of the relationship
between interpersonal power and HIV protective behavior, and (4) the culturally relevant
predictors of interpersonal power and perceived risk. In analyzing the variables that lead
to protective behaviors among low-income African American women, the following

model was proposed.

33

 

Figure 1: Proposed Protective Behavior Model

 

Fatalism

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Gender
Roles
Partner I power rotective
Ogrendency . Behavror
Sex-Ratio
Imbalance
Sexual
Self-efﬁcacy

 

 

 

Predictors of Interpersonal Power

As described earlier the TGP suggests that interpersonal power in relationships is
a key predictor of HIV /AIDS protective behaviors. Three culturally relevant predictors of
interpersonal power was examined in this study: partner dependency, gender role, and

perceptions of sex-ratio imbalance within the African American community.

34

Partner Dependency

Diseases in general pose a disproportionate threat to those who are economically
disadvantaged (Carey et al., 1997; Krieger & Williams, 2001). The HIV/AIDS epidemic
among Aﬁican Americans highlights the problems related to low socioeconomic status,
including lack of education, inadequate ethnic Aﬁican American personnel in medical
and public health ﬁelds, racism and its inﬂuence on access to the necessary resources to
prevent HIV transmission (Williams, 2003). While lower socioeconomic status may
inﬂuence access to resources, it may also inﬂuence how individuals behave within the
conﬁnes of a relationship.

Despite the growing proportion of heterosexual HIV exposure among African
American women due to male infected partners, there has been little focus on how the
factors within a dyadic relationship play a role in HIV risk reduction behavior. Unsafe
sex may be linked to emotional and economic dependence on men, further complicating
the issue of self-protective behavior. Numerous studies indicate that women are
psychologically, economically, and socially the more dependent partner in heterosexual
dyads (W ingood & DiClemente, 2000). In some instances the male partner brings more
assets (e.g., money, status, security) to the relationship and the female partner becomes
dependent on these resources. For others, relationships are viewed as a means to
individual achievement (Amaro, 1995). Many of the women most at risk for HIV
transmission depend on their male partner for economic security (J emmott et al., 1995).
Women who are economically dependent on their partners generally have less
interpersonal power, including control and decision making in relationships, which

compromises their ability to negotiate protective behaviors with their partners. Some

35

economically dependent women may not have the desire to engage in protective
behaviors if it jeopardizes the stability of the relationship.

Paradoxically, in some instances, African American women have historically
been the “breadwinner” which places these women in a peculiar predicament of having to
uphold the male status by compromising the true scope of their power and allowing their
mate to dominate them in reaction to his diminished power in society (Wingood, Hunter-
Gamble, & DiClemente, 1993). Therefore, while some women may exhibit greater
ﬁnancial self-sufﬁciency, they have had to temper this with satisfying dictated gender
role based power imbalances. The relationship between Aﬁican American women’s
economic dependency or lack thereof, and interpersonal power, is one that has not
sufﬁciently been examined in the research literature. The existing literature on Black
relationships supports the assertion that both economic dependence and economic
independence may inhibit interpersonal relationship power among African American
women, a curvilinear relationship (Staples, 1993). Black women have historically had to
be more instrumental in terms of having to work outside of the home to provide
economic security for themselves and their families, "they must also maintain traditional
beliefs about the female role in order to sustain meaningful relationships within their
domestic network; especially with men" (Binion, 1990, p. 505).

Gender Roles

Gender roles were found to be an inﬂuential factor in the examination of
sociocultural factors that contribute to Aﬁican American women’s susceptibility to HIV
transmission. Gender roles are a factor that inﬂuence an individual’s attitude, opinions,

and world-view, including appropriate sexual conduct (Bern, 1974; Fullilove et al., 1990).

36

Traditional gender role characteristics among women include passivity, docility,
dependency, lack of initiative, and an inability to act (Miller, 1986; Amaro, 1995). Like
women in general, African American women are expected to subscribe to culturally
scripted gender norms that guide relationships and in turn, sexual behavior (Simon &
Gagnon, 1986). Historical perceptions of Black women that contribute to the acceptance
or rejection of contemporary gender roles have included the three prototypes of Jezebel
(the seductive temptress), Sapphire (who has the ability to dominate poor, defenseless
men), and the stereotype of Aunt Jemima or Mammy. Mammy was the ideal slave, obese,
domesticated, and asexual (Wyatt, 1997 p. 31). The Jezebel or Sapphire persona typiﬁes
the image of the She Devil, who characterizes most of the negative characteristics
attributed to Aﬁican women before and during slavery. These images are emulated in the
lifestyles of women who are labeled as “loose” and manipulate men in order to improve
their life circumstances. This image is also most commonly used in the political rhetoric
about Black teen mothers and welfare recipients. In order to counter these negative
images, some African American women may feel the need to adopt more traditional
gender roles, so as not to be viewed negatively. Gender roles provide women with the
scripts that determine what behaviors are appropriate within the context of sexual
relationships. These norms produce the laws, taboos, and prohibitions that deﬁne
normalcy, restrain sexuality, and localize the cultural norm for femininity within
relationships (Wingood & DiClemente, 1998). The prevailing gender roles for Aﬁican
American women dictate that they should be traditionally feminine in intimate
relationships and maintain intimate relationships at the expense of their own needs

(Golden, 1996). In the context of HIV transmission, gender norms provide scripts shaped

37

by sociohistorical contexts that may present an obstacle to the adoption of HIV sexual
risk-reduction practices that encourages women to behave in “nontraditional,” assertive
ways that are in direct opposition to her culturally dictated gender norms (Howard et al.,
1986). Previous research on gender roles and sexual risk behaviors suggests a link
between traditional gender roles and decreased interpersonal power dictated by norms
and risky behavior (Amaro & Gomemann, 1992; Howard, Blurnstein & Schwartz, 1986).
Sex Ratio Imbalance

In addition to gender roles and partner dependency, another cultural factor that
has been demonstrated to inﬂuence Aﬁican American women’s interpersonal power and
in turn their risk for HIV transmission, is sex-ratio imbalance within the Aﬁican
American community (O’Leary & Wingood, 2000; Wingood & DiClemente, 1995). The
concept of the structure of cathexis in the theory of gender and power, refers to the
structure of social norms and affective attachments. It includes the emotional and sexual
attachments women have with men. In the Aﬁican American community, the sex-ratio
imbalance between Aﬁican American women may hinder women's ability to form
meaningful emotional and sexual attachments with men. The decreasing number of
eligible partners with whom to establish a relationship may increase Aﬁican American
women's susceptibility to HIV infection by placing Aﬁican American women in a
position where they must choose to tolerate objectionable behavior and in turn
compromise their interpersonal power or remain alone (Mays & Cochran, 1988; Wingood
& DiClemente, 1992). Traditional models and theories used in HIV prevention
interventions have failed to take into account that violence, racism, incarceration, and

lack of economic opportunity reduce the pool of potential Aﬁican American male

38

partners, increase the value of having a mate, and contribute to male dominance in
interpersonal relationships (Dicks, 1994; Quinn, 1993; Shervington, 1993).

As a result, many Aﬁican American women perceive that they have little control
over the sexual behavior of their partners, and limited opportunity to introduce condoms
into the relationship (Weeks, Schensul, Williams, Singer, & Grier, 1995; Zierler, 1994).
Additionally, men may view their options as limitless, resulting in less pressure to
develop commitments, greater power within relationships, and the perception that they
are not mandated to practice safer sex if they so choose, placing themselves and their sex
partners at risk for HIV. Margillo and Irnahori (1998) conducted a study on condom use
among low-income African American women. Personal qualitative interviews revealed
that the women in their sample felt that men could not be trusted. However, by virtue of
their decreasing numbers, condom use among this sample was inconsistent. Men were
thought to hold relatively greater power in relationships by having more alternatives in
sexual relationships in comparison with Aﬁican American women. This perceived sex-
ratio imbalance demonstrates how viewing behavior (e.g., safer sex) in relation to the
particular sociocultural and historical setting in which it occurs, is reﬂective of an
ecological approach to understanding diverse issues. While it is imperative to study
individuals’ contexts and perceptions, there remain some pro-existing theories, that when
combined with this ecological perspective, increase the understanding of various
phenomena.

Perceived Partner Reaction
In order to understand the aforementioned factors’ inﬂuence on HIV protective

behavior, the context in which these behaviors occur must be taken into account. A

39

partner’s reaction to an individual’s initiation of protective behaviors plays a role in the
ability to engage in HIV precautionary behaviors (St. Lawrence, Eldridge, Reitrnarr,
Little, Shelby, & Brasﬁeld, 1998). In general, sexual behavior is shaped by prescribed
gender roles, whereby in most societies, the lower status is ascribed to women (Amaro &
Raj, 2000). Negotiation of condom use takes place within the context of relationships and
more broadly within the contexts of social norms that prescribe expected sexual behavior
in which women are to be passive and men are supposed to “take the lead.” Within the
contexts of a relationship, condom use is seen as a barometer of distance and intimacy
and indicates what type of relationship an individual is in (Estrada & Quintero, 1999).
Women may not prioritize HIV protective behavior, because for some women
motivations for emotional connection, demonstration of trust, and/or desired pregnancy
outweigh HIV infection risk.

With the decreasing number of potential African American partners, due to
violence, incarceration, and lack of economic opportunity, there is an increased value of
having a mate, and contributing to male dominance in relationships (St. Lawrence et al.,
1998). With the recognition that gender-based inequalities are a major force driving the
epidemic, some researchers feel that the development of prevention methods over which
women have some control are imperative. In contrast to this view, research demonstrates
that male partners have a strong inﬂuence on initiating or hindering HIV protective
behavior strategies with both male and female condoms (Shervington, 1993). In a study
of partner inﬂuences on noncondom use among Aﬁican American women, Wingood and
DiClemente (1998) demonstrated that noncondom use was strongly associated with a

woman’s perception that asking one’s partner to use a condom may imply inﬁdelity or

40

may compromise the stability of the relationship. In addition, women in this study who
did use condoms were almost three times more likely to feel insulted if their partner
suggested that condoms may be used. A woman’s HIV risk may be strongly inﬂuenced
by the dyadic nature of her relationship. Therefore, models developed to understand the
process of HIV protective behavior among Aﬁican American women must be used in
conjunction with a gender/relationship relevant approach, including taking partners’
reactions towards engaging in preventive methods into account. New models that are
developed for diverse populations can beneﬁt from building on the strengths of
traditional theories and constructs.
Traditional Constructs of Behavior Change

Sexual Self-Efficacy

In addition to examining the cultural variables that play a role in HIV protective
behavior, there remain several well-established traditional models of cognitive behavior
change that are reliable predictors in HIV prevention. For instance, asserting the power to
protect oneself in a relationship requires certain risk reduction skills and conﬁdence in
one’s skills. The difﬁculty women have in negotiating safer sex with male partners is in
part due to the perception of having little control over condom use in a sexual
relationship. There is a marked difference between possessing skills and being able to use
them under difﬁcult circumstances (Bandura, 1994). Possessing the conﬁdence to assert
oneself in a given situation enables an individual to exercise control over their behavior
and in short their social environment (Bandura, 1977). This conﬁdence requires a certain
amount of power, or the actual ability to make and enact decisions, speciﬁcally within a

relationship. Bandura calls this self-efﬁcacy or the level of conﬁdence in one’s ability to

41

effect change in a speciﬁc practice. A number of studies on perceived conﬁdence in one’s
ability to practice safer sex even when barriers are present have been conducted
(Bradford & Beck, 1991; O’Leary et al., 1992; Wulfer & Wan, 1993).

Self-efﬁcacy is a variable that describes an individual’s perception of their ability
to initiate changes in self-destructive behavior inﬂuenced by the extent to which an
individual perceives himself/herself as having control in certain situations (Bandura,
1977; 1990). Wingood and DiClemente (2000) have characterized self-efﬁcacy as a part
of the sexual division of power; however, while power in general is the ability to make
decisions and the amount of control an individual has in a relationship, sexual self-
efﬁcacy has been demonstrated to mediate the relationship between interpersonal power
and HIV protective behaviors (Shroder, Hobfall, Jackson, & Lavin, 2001). More
speciﬁcally, interpersonal power predicts sexual-self-efﬁcacy which in turn predicts HIV
protective behavior. Promotion of self-efﬁcacy has been the basis for condom promotion
interventions and has been demonstrated to be an excellent predictor for condom use
among Aﬁican American women (J emmott & J emmott, 1992). Self-efﬁcacy, speciﬁc to
sexual behaviors, is treated as a global, cross-situational construct in some interventions.
Self-efﬁcacy is actually a context speciﬁc concept and must be enacted in the situations
in which they occur (Bandura, 1977). In addition, the level of challenge or impediments
to “successful performance” must also be examined. For instance, gender-based power
differentials may inﬂuence a woman’s ability to enact sexual self-efﬁcacy (e. g. negotiate
condom use). Findings from a study on Aﬁican American women and condom use by St.
Lawrence et a1. (1998) demonstrates that women in exclusive relationships, stable

circumstances, and with greater economic and employment resources, reported less

42

frequent condom use, but less frequent exposure to high-risk partners. In a study of the
proximal and distal predictors of AIDS risk among Aﬁican American and White women,
Shroder et al. (2001) found that in comparison to White women, sexual self-efﬁcacy
beliefs and attitudes were strong predictors of safer sex among only the African
American women in their sample.

The presence of physical, sexual, emotional or subtler forms of sexual
coerciveness may complicate the implementation of self-protective behaviors, despite
level of sexual self-efﬁcacy (Gomez & Marin, 1996). In a study conducted by Murphy
and colleagues (2001), a multidimensional examination of self-efﬁcacy in the context of
safer sex was investigated. Their ﬁndings demonstrate that self-efficacy is a good
predictor of safer behavior when situation and level of difﬁculty or challenges present are
accounted for. These ﬁndings suggest that research that examines self-efﬁcacy must ﬁrst
take into account the contextual difﬁculties an individual is faced with, in order to enact
efﬁcacious behavior. If an individual does not perceive themselves to be at risk for
contracting HIV, it does not matter how much interpersonal power they possess. There is
no motivation to enact the necessary chain of event that lead to protective behavior
becomes pointless.

Perception of Risk

Perceived risk is typically examined as a unidimensional cognitive representative
of likelihood, without regard for the multidimensionality of this construct. The risk that
an individual will contract HIV via sexual intercourse depends on the likelihood that a
sexual partner is infected (determined by the prevalence of HIV within a population

segment in a given community) (Kelly, 1995). In comparison, an individual’s perception

43

of risk is subjective, based on beliefs people hold about the particular risk situation

(W einstein, 1988). Previous research indicates that perceived HIV risk is a primary
motivator for the initiation of HIV precautionary behaviors (CDC, 2000; Gerrard et al.,
1996) however, perceived risk or optimistic bias is dependent on both internal and
external factors. Moreover, traditional cognitive behavioral theories have been unable to
identify a direct link between perceived risk and the initiation of protective behaviors,
suggesting other mitigating factors that constitute this relationship. To date, no published
studies have examined the interaction between perceived risk and interpersonal power in
predicting HIV protective behaviors. According to traditional theories of behavior
change, by identifying certain practices (e. g. needle sharing) as conducive to the
transmission of HIV, speciﬁc groups with these and other risky behaviors are prompted
to recognize their heightened probability of HIV infection (Estrada & Quintero, 2000).
This presumption assumes that the threat of HIV infection supercedes other problems
(Wyatt, 1994). This perspective drastically oversimpliﬁes an individual’s perceived risk
status because it does not account for the multiplicity of risk construction. While previous
theories and models have incorporated perception of risk into their behavior change
models, the factors that lead to the construction of personal felt risk have gone largely
ignored.

With the growing disproportionate incidence rates of HIV among African
American women, researchers have begun to address risk perception from a racial and
gender relations perspective (Amaro, 1995; Carovano, 1991; Kane, 1990; Kline, & Oken,
1992; Sobo 1995; Weeks et al., 2000). For instance, in terms of power differentials in

dyadic relationships, disempowerrnent is less consequential if women have accurate low

HIV risk perceptions and, in turn, low motivation to practice safer sex due to involvement
in monogamous relationships (Bowleg et al., 2000). Consequently, the women who in
fact need to reduce their chances of contracting HIV may not actually perceive
themselves to be at risk (Wyatt et al., 1997). There are a number of factors that may
inﬂuence the accuracy of risk perceptions. The health belief model purports that
perceived risk is inﬂuenced by an individual’s evaluation of their likelihood of
contracting a disease or illness. Factors like HIV knowledge, optimistic bias, and fatalism
may increase an individual’s perception that they are at risk for contracting a disease. In a
study of 671 Aﬁican American women conducted by Sikeema, Kelly, Anderson, Winett,
Soloman et al. (1996), one third of the women were perceived by the researchers to be at
high risk for HIV infection, yet they reported weak behavioral intentions to reduce risk.
In addition, women in coupled relationships were least likely to use condoms consistently
due to feeling that they were in a monogamous relationship, further supporting the claim
that relationship status may decrease the perception of risk. Perhaps most inﬂuential is
the view proposed by Cochran and Mays (1993) that ethnic minority women evaluate
their risk in terms of the risk to their speciﬁc group, not some generalized notion of risk.
In a study conducted by Hobfall and colleagues (1993), with a sample of Aﬁican
American and White women, both groups tended to underestimate their personal risk
compared to the risk within their community. However this resulted in increased
optimistic bias only among the Aﬁican American women in their sample. Based on
traditional models of behavior change, the aforementioned studies indicate that
perception of risk alone does not contribute to engaging in protective behaviors. There

are various mitigating factors including relationship status and accuracy of perceived risk.

45

Perceived risk is a traditional construct in behavior change theory, and has demonstrated
to operate similarly across populations; however, the factors that inﬂuence the perception
of risk are unique to various populations. Understanding the contextual factors that
inﬂuence risk perception can improve the development of risk reduction models. The
general health literature suggests that perceived HIV risk is not determined by a single
underlying construction. Instead, the multiplicity of factors may inﬂuence individual’s
risk perception (Estrada & Quintero, 1999). These may include optimistic bias, fatalism,
and HIV knowledge.
Construction of Perceived Risk

Optimistic bias. Group membership and adherence to the norms and values of that
group play a critical role in the way people think and behave when it comes to health and
preventive practices. A common practice by most prevention programs has been to
construct the idea of “high” risk versus “low” risk groups. These labels tend to reify
already stigmatized members of society (e. g. homosexuals, IDUs). In doing so, a
conceptual buffer is provided which allows “others” (e. g. heterosexuals, non-IDUs) to
distance themselves from feeling vulnerable to HIV infection. Therefore, if an individual
is not a member of a “high” risk group, they do not feel the need to enact protective
behaviors (Estrada & Quintero, 1999), when in fact their behaviors, or the behaviors of
their partners may actually be conducive to the transmission of HIV. The HIV literature
purports that one of the major contributing factors to the growing HIV epidemic in the
Aﬁican American community is the original view of HIV as a White gay male disease.
The tendency to make downward comparisons is one cause of optimistic bias, which may

make optimism especially prevalent among Aﬁican Americans in terms of HIV risk

46

(Shroder et al., 2001). From the beginning of the epidemic to the present, Aﬁican
Americans did not associate their risky behaviors with the White gay community and
therefore, did not feel that they were at risk. Weinstein and colleagues (1999, 1996, 1980)
show that people make comparative risk assessments in an egocentric manner, paying
little attention to the risk status of others when asked to determine their own relative risk.
This ideology continues to be a barrier in HIV prevention in the African American
community. According to Johnson (1993: p. 54), there is an “omission of speciﬁc
information regarding the relationship between ethnicity and high risk sexual behavior
related to HIV infection.” Therefore, it is difﬁcult to determine the attitudes that African
Americans have in regard to engaging in risky sexual behaviors.

Many individuals are not willing to conclude that their behavior may actually
contribute to their probability of contracting a disease or being injured. This personal
fable is further perpetuated by reportedly high levels of spirituality among Aﬁican
American women. The African American community has a well-documented history of
using religious/spiritual beliefs as a coping mechanism (J agers, 2000). Studies have
shown both positive and negative associations between religion and health beliefs and
behaviors (Franklin & Schlundt, 2004). Belief in a higher power in some, but not all
instances, is associated with higher levels of optimism (e. g. following the bible,
adherence to religious rules and doctrine). These beliefs involve the tendency to
overestimate one’s probability of experiencing positive life events (Elkind, 1967). For
example, in the area of health, research has demonstrated that more than half of surveyed
individuals perceive that they are less likely than others to be afﬂicted with such health

outcomes as drug addiction, cancer, tooth decay, and auto injury. Overestimation of

47

experiencing positive life events is known in the health arena as optimistic bias

(W einstein, 1987). Optimism is described as a general yet favorable attitude or
expectation toward future events irrespective of one's perceived ability to efﬁcaciously
engage in goal-oriented situations or control outcomes. Optimistic bias is also the
tendency to view oneself as invulnerable (or less likely than others) to experiencing
negative life events and has been linked with spirituality or belief in a higher power. It is
also the belief that other people, but not one’s self, will develop a disease, or experience
other negative effects (Brannon & F eist, 2003). Diseases that are related to behavior risk
factors, or diseases that show an increased perceived controllability, increase the
optimistic bias in the perception of risk for that disease (Taylor, 1989; Weinstein, 1982,
1984,1987)

Optimistic bias has mostly been examined in treatment adherence or substance
use, however, there is a small but growing body of literature indicating that it may play a
role in HIV risk reducing behaviors (Timmons & Sowell, 1999). Kunda (1990) suggests
that engaging in behaviors with the knowledge that it may lead to a controllable disease
constitutes a threat to one’s intelligence, perhaps leading to cognitive dissonance. In order
to preserve self-esteem, one is more motivated to assess his/her risk for the possible
harmful outcomes of this behavior as being low.

F atalism. When a disease is extremely threatening or precautionary measures are
either unavailable or perceived to be difﬁcult to implement or sustain, the typical reaction
is to ignore or distort the threat, rather than to change one’s behavior. In these
circumstances, religious/spiritual beliefs may inﬂuence individuals’ motivation to engage

in protective behavior. Religious/spiritual beliefs can affect the amount of control people '

48

feel that they have over their lives and how things will affect them in the future (J agers,
2000). As noted, Aﬁican American women report high levels of spirituality and
religiosity and rely heavily on a sense of spirituality which has demonstrated to be a
coping mechanism and aids in resiliency, perseverance and destiny (J agers, 2000). As a
result, there is evidence that Aﬁican American women feel their lives are guided by a
higher power and their circumstances are beyond their control (Powe, 1996). While high
levels of religiosity/spirituality can foster feelings of optimism when dealing with certain
situations, it may also have the effect of believing an individual has no control over the
outcome of a situation. A phrase frequently used, but not unique to, the Aﬁican American
community “this situation is in God’s hands.” Powe (1996) asserts that "in addition to
poverty, oppressive forces such as the long history of slavery, segregation,
discrimination, substandard health care, and the subsequent perceptions of
meaninglessness, hopelessness, and social despair provide the environment for the
emergence of fatalism" among African Americans (Powe, 1996; p. 18). Not surprisingly,
people with more fatalistic attitudes have demonstrated to be less likely to take advantage
of preventive services (Conrad, Brown, & Conrad, 1996; Powe, 1995, 1996).

In a cross-cultural study of cancer fatalism, Conrad et al. (1996) found African
Americans and women to be more fatalistic than European Americans and men. Women,
particularly Aﬁican American women, in the study were less likely to seek mammograms
if they were afraid of cancer, believing that any time one has cancer it will be fatal and
result in death. Not only was their willingness to seek mammograms inhibited, but their
willingness to seek out information or even think about cancer was also diminished

(Champion et al., 1998).

49

HIV knowledge. There remains some ambiguity about the relationship between
knowledge of HIV risk factors and actual behavior modiﬁcation to engage in protective
behaviors. However, most models and theories used in HIV risk reduction identify
knowledge as an important component of their programs (Carey et al., 1997). According
to the protection motivation theory (Rogers, 1975), information about a health hazard
stimulates a cognitive appraisal of the vulnerability to the negative event and is said to act
as a motivator to protect oneself. Accurate knowledge about preventive behaviors and
awareness of the need to practice them is critical for behavior change to occur. According
to the information-motivation-behavioral skills (1MB) model, Fisher and Fisher (1992)
argue that a person is more likely to adopt HIV -risk-reduction strategies (e.g., condom
use) if he or she is well-informed about HIV transmission and prevention, motivated to
reduce his or her risk, and capable of demonstrating the necessary self-management and
interpersonal skills needed to avoid risk behavior. Health educators acknowledge that
cognitive and attitudinal changes take place from HIV/AIDS education, but these changes
alone do not necessarily result in changes in behavior that lower the risk of infection.

Studies have shown that the accuracy of knowledge about HIV and AIDS may be
effective in changing risky sexual behaviors among White gay males (McCusker,
Stoddard, Mayer, et al., 1988). There are various factors that inﬂuence the perception,
receipt and overall acceptance of accurate HIV knowledge and it has been indicated that
the relationship between HIV knowledge and HIV protective behavior demonstrated
among White gay males, may not be applicable to African American populations

(Johnson, 1987: p. 53).

50

There is a tremendous variability in the level of knowledge that Aﬁican
Americans have about HIV (Johnson, 1983: p. 47). In comparison ti other ethnic groups,
African Americans report lower rates of accurate HIV knowledge (U CSF, CAPS, 2000).
Many African-Americans have a history of distrust of government programs and health
institutions. Remnants of the Tuskegee Experiment continue to fuel the lack of comfort
and trust African Americans have with the medical system (Bowmen, Hickman, &
Power, 1997). Some African-Americans believe that the effects of AIDS on the
community are the results of deliberate efforts and omission of responsibility by the US
government as demonstrated in the Tuskegee Experiment. Distrust of formal institutions
including those that provide HIV information, can lead to incorrect or lack of knowledge
which has been identiﬁed as a major contributing factor to the sexual HIV risk among
African American women (Cochran & Mays, 1993; St. Lawrence, 1993). Reagan and
colleagues (1999) assert that disseminating information about behavior change will be
ineffective if barriers, misunderstanding, and fear exist between health care professionals
and clients. They maintain, "even if well-informed specialists successfully transfer
information, (to the individuals at risk) a positive behavioral change may not result
because other variables also motivate behavior." Also signiﬁcant are the Aﬁican
American community's misconceptions and myths about HIV/AIDS and the
unavailability of HIV/AIDS statistical data to most Aﬁican Americans, resulting in the
group's underestimation of the problem (Williams, 2003). Additionally, some HIV
prevention programs serve only to reinforce the misconceptions already in place in the
community. For example, strong negative views and attitudes held by many Aﬁ'ican

Americans about homosexuality and the perceptions of HIV/AIDS as a "gay" disease

51

may have hindered efforts to positively engage African American communities in
meaningful HIV/AIDS prevention (Carey et al., 2000). Furthermore, the beliefs that
illness is a form of punishment by God, and attitudes that HIV is a consequence of sinful
behavior, also affect ways in which some Aﬁican Americans respond to HIV/AIDS
prevention efforts (Williams 2003).

Using an ecological approach and taking the aforementioned factors into account,
knowledge alone does not account for behavior change without examination of the
context within which certain behaviors occur. In a study of Aﬁican American men and
women, research has demonstrated that having HIV/AIDS knowledge seldom results in
regular condom use (Johnson, et al., 1992). Taking into account gender differences in
knowledge, Carroll (1991) found that greater knowledge of HIV was related with safer
sex practices among men, but not women college students. Males in this research who
were more knowledgeable about HIV/AIDS reported less intercourse and said they were
more likely to use condoms, suggesting that power may play a mediating role in the
relationship between knowledge and behaviors. HIV knowledge and misinformation can
lead to the misperception or under identiﬁcation of risk, which will inﬂuence an
individual’s motivation to enact HIV protective behaviors.

HIV Protective Behavior

In order to understand HIV protective behavior, the variable and the contexts in
which that behavior occurs must be identiﬁed. While previous research has made strived
in identifying some noteworthy predictors of HIV protective behavior among Aﬁican
American women, the complex processes through which these behaviors occur warrant

ﬁrrther understanding in the development of models. As demonstrated, knowledge does

52

not automatically translate to HIV protective behaviors; however, it does play a key role
in the ability to properly protect oneself. Whether having sex with an infected partner will
result in contracting HIV infection is substantially determined by the nature of the sexual
practice and its efﬁciency for transmitting HIV (Kelly, 1995). The most certain way for
persons to avoid sexually contracting HIV infection is by refraining from sex under any
circumstance where a partner might be infected, whether this is achieved by abstinence or
by having sex only in the context of a mutually-monogamous relationship with an
assuredly uninfected partner. Although abstinence until establishing a monogamous
relationship constitutes the most certain protection against HIV, it is not the pattern that
characterizes the sexual behavior of most young adults in the United States. There has
been little evidence of change in the age of sexual activity onset or in the numbers of
sexual partners of American adolescents and young adults since the start of the HIV
epidemic, except for overall reductions in multiple partner rates among gay men in some
AIDS epicenters (Martin, 1987). Given this reality, consistent condom use during
intercourse or the adoption of other safer sex practices is widely encouraged among
persons who are sexually active outside assuredly monogamous relationships with
uninfected partners. Although condoms reduce the risk of HIV transmission during
vaginal intercourse by approximately 90% (Trussel, Sturgen, Strickler, & Dominick,
1994), condom use among inner-city Aﬁican American women remains relatively low

(J emmott & J emmott, 1991; Kelly et al. 1994). Individuals who lack accurate HIV
knowledge have devised a host of methods to protect themselves against HIV, including
genital washing, douching, use of sperrnacides, and knowledge of non-primary

relationships to name a few. It is critical to understand individuals’ subjective perceptions

53

and the construction of personal meanings as determinants of HIV protective behavior.
While some individuals who practice these behaviors may avoid becoming infected, in
the presence of HIV these behaviors are rendered ineffective. The contexts in which
individuals live helps to promote or inhibit speciﬁc behaviors. The current study was
designed to identify and examine the attitudes and beliefs that are predictors of actual and
perceived HIV/AIDS protective behaviors among lower income African American
women.
Summary

The purpose of this study was to prepose a model which examines the
relationship between contextual interpersonal power and HIV protective behaviors
Aﬁican American women. With the growing HIV incidence rates among Aﬁican
American women, data on transmission suggests that prevention efforts with African
American women should focus on prevention of transmission through heterosexual
intercourse within the contexts of dyadic relationships. The effects of gender-related
factors such as interpersonal power on women's abilities to engage in HIV protective
behavior is a critical component to developing effective HIV prevention interventions
speciﬁc for African American women most at risk. Therefore the nature of sexual
negotiation in male-female relationships is an important domain for examining the
behaviors that place Aﬁican American women at risk for HIV (Bowleg, Lucas, &
Tschann, 2004; CDC, 2002). This study builds on previous prevention and intervention
research with the goal of contributing an integrated perspective to the HIV literature.
Previous research demonstrates that successful interventions targeting Aﬁican American

women are typically grounded in theory. Effective theory is developed through empirical

54

investigations that locate sexual behavior within a context of gender relations and
considers the role of cultural factors which facilitate or inhibit Aﬁican American women
from engaging in HIV protective behaviors.

Rising HIV incidence and prevalence rates suggest that gaining a deeper
understanding of the epidemic in the Aﬁican American community is an urgent priority.
Although we are entering the third decade of the HIV pandemic, there is yet no HIV cure
or vaccine. At this time, the principal means for deterring the ﬁrrther spread of HIV
remains behavioral risk prevention. Thus, developing and implementing theory and
models that focus on behavioral prevention are of utmost importance. Although the scope
of the epidemic has reached into most segments of society, its disparity continues to be
striking and this trend has continued and worsened. Previous research and traditional
theories and models have provided a foundation and groundwork for understanding HIV
risky behaviors; however, new integrative approaches that take the strengths and
limitations of previous work into account are necessary to meet the challenges that HIV
presents to the health and well-being of Aﬁican American women. Like the virus, the
behavioral and social aspects of HIV are constantly changing, making HIV prevention
research an ongoing process.

Contributions of the Proposed Study

This study utilizes aspects of the theory of gender and power along with
traditional models of behavior change (e. g. health belief model) to examine the well-
substantiated relationship between interpersonal power and HIV protective behaviors of
Aﬁican American women. The theory of gender and power provides the framework for

examining the relationship between interpersonal power and protective behaviors, while

55

taking into account the cultural factors that predict interpersonal power. Previous studies
have targeted low-income Aﬁican American women; however, few studies have
examined how speciﬁc factors like gender roles, partner dependency and sex ratio
imbalance predict interpersonal power and how these relationships place this particular
group at increased risk for HIV transmission. Consequently, while the relationship
between interpersonal power and HIV protective behavior is critical to understand in
dyadic relationships in general, the factors that predict interpersonal power for low-
income African American women will be unique for this group. Therefore, the
development of group speciﬁc models is useful in understanding risk behaviors within
this population.

Traditional theories of behavior change serve an important purpose in the
development of culturally relevant HIV prevention models. Traditional models (e. g., like
the health belief model) focus on perceived risk as a determinant of protective behaviors.
While there is a wealth of support for the relationship between interpersonal power and
HIV protective behaviors, there are no published studies to date that examine a
multidimensional model, which examines how perceived risk moderates this relationship.
Additionally, while perceived risk has been examined as a predictor of HIV protective
behaviors, to date there are no published studies which examine the cultural factors that
predict perceived risk (6. g. access to HIV knowledge, trust, optimistic bias, and fatalism).
In conclusion, various aspects of the proposed model have been identiﬁed in the literature
as important predictors in HIV prevention. However, to this author’s knowledge, there
are no published studies that include the aforementioned factors into one

multidimensional model speciﬁc to low-income Aﬁican American women. While it is

56

imperative to examine the factors that contribute to HIV protective behaviors, researchers

must understand the complex processes which lead to the desired outcomes.

Research Questions

1. Will the proposed model of HIV protective behavior ﬁt for low-income Aﬁican
American women?

2. How do African American women protect themselves against HIV?

Speciﬁc Hypotheses

Hypothesis 1. Three cultural factors will have a direct effect on interpersonal power.

Hypothesis 2.

Hypothesis 3.

Hypothesis 4.

These include: gender roles, partner dependency, and sex-ratio imbalance.

la. Individuals who subscribe to more “feminine” gender roles will have
less interpersonal power.

lb. Individuals who are more ﬁnancially dependent on their partner will
have less interpersonal power in their relationships.

1c. Individuals who perceive there to be fewer available partners will have
less interpersonal power in relationships

Higher levels of interpersonal power will predict higher levels of
protective behaviors.

Sexual self-efﬁcacy will mediate the relationship between power and
protective behaviors.

Perceived risk will moderate the relationship between interpersonal power
and protective behaviors. Speciﬁcally, the relationship between
interpersonal power and protective behaviors will only exist in the
presence of perceived risk.

Hypothesis 5. Three culturally relevant factors will have a direct effect on perceived risk.

These include optimistic bias, fatalism, and HIV knowledge.

5a. Optimistic bias will be negatively correlated with perception of HIV
risk.

5b. Fatalism will be negatively correlated with perception of HIV risk.

57

5c. HIV knowledge will be positively correlated with perception of HIV
risk.

58

METHOD
Participants

Epidemiological data from the Center for Disease Control and Prevention (CDC,
2004) report that the HIV /AIDS epidemic disproportionately affects women, people of
color, and individuals of lower socioeconomic status; therefore, the participants for this
study were purposively selected to represent this larger population of interest.

Two hundred and sixty (n=260) women were either approached or contacted the
research team to express interest in participating in the study. Only 5% (n=9) of the
individuals who were approached and recruited for the study reported not being interested
in participating. Two hundred and ﬁfty-one Black/African American women were
screened (according to the study criteria) for potential participation (refer to Table 1 for a
complete list of recruitment rates). After being screened, it was determined that a total of
thirty-two (n=3 2) women were ineligible by one or more of the eligibility criteria, and
211 two women were eligible and invited to complete a survey.

Selection criteria for inclusion in the study included (1) self-identiﬁcation as an
African American woman, (2) at least 18 years of age, (3) must have currently been in a
heterosexual relationship in which sexual activities occurred, or have been in such a
relationship within 3 months prior to completing the survey, and (4) individuals who
earned a salary of 3 $30,000 or less a year.1

Exclusion criteria for the study included: (1) participants who were aware of their
HIV seropositive status, (2) participants who were pregnant or in the process of trying to
conceivez, and (3) participants who were married’, because individuals who are married

are expected to represent less variance in terms of HIV risk perception and behaviors due

59

to marriage’s implicit connotation of ﬁdelity, which (if mutual) should not place
individuals at risk for sexual transmission.
Procedure

Prior to the initiation of data collection, community gatekeepers, leaders, key
informants, executive directors, and staff who provide services to Aﬁican American
women or who were somehow connected with the target population were identiﬁed in
Lansing, Grand Rapids, Flint, Saginaw, and Detroit. Information packets containing
material about the author, the purpose of the study, and the beneﬁts to the community and
participating organizations were mailed, and followed up by meetings with the study’s
principal investigator. To encourage participation, organizations and various individuals
were asked to give input into the survey design and informed that they would receive a
technical report and community/ staff presentation at the conclusion of the study.
Pilot Data Collection

Pilot data collection was conducted in order to test the feasibility and validity of
the proposed survey instrument. Piloting the instrument was a small-scale rehearsal for a
larger scale data collection and followed a written protocol. The purpose of the pilot data
collection was to learn more about the data acquisition process prior to investing large
amounts of time and resources. A sample of convenience from a participating
organization in Lansing was utilized. Data were collected from ﬁve members of the target
population in order to examine whether the proposed methods and instruments were

inappropriate or too complicated.

 

1 Financial criteria is consistent with receiving government assistance in accordance with the criteria set
forth by the US Census of the Bureau.

2 the desire to become pregnant is associated with not practicing “safer sex”

3 unless separated for more than three months

60

The pilot data collection allowed for the data collectors to practice the sampling
techniques and recruitment strategies, identifying potential problems with the survey
instrument (e.g., word confusion) and the overall comfort level of the target population
with the survey items. After completing the survey, participants were asked to identify
any confusing sections of the survey and discuss their level of comfort with the survey
items. This was done in an attempt to determine if there were any factors that needed to
be addressed prior to the beginning of data collection. If necessary, after completion of
the ﬁrst phase of pilot data collection, the protocol would have been critiqued and
revised. No major changes to the ﬁnal protocol and/or survey were made based on the
pilot data. The pilot data participants were included in the ﬁnal sample.

Recruitment. Due to the sensitive nature of the current study, issues of
conﬁdentiality and participant safety were taken into account in the recruitment strategies
and procedures. Participants were recruited in three ways: 1) through social service
agencies (e.g., W1C, Work First), 2) community organizations and settings (e.g., Black
Child and Farrrily Institute) and 3) the snowball or social network technique.

1) Social Service Agencies: There were a number of identiﬁed service agencies
that targeted a substantial number of Aﬁican Americans. Data were collected ﬁ'om
Lansing, Flint, Grand Rapids, and Saginaw (refer to Table 1 for a complete list of
participating organizations). A total of 164 participants were recruited on site at social
service agencies. Two approaches were used in these settings.

First, potential participants were informed of the research study either by staff or
by seeing posters about the study and its inclusion criteria. Individuals who were

interested in participating in the study had the option of volunteering for the study by

61

calling and making an appointment to complete a survey, or showing up at the designated
data collection sites on the speciﬁed days. Potential participants who called the project
ofﬁce gave verbal consent to be screened over the phone. Those individuals who showed
up at data collection sites on the designated days went through the informed consent
procedure (detailed explanation by research assistant and then signing a consent form)
and the screening criteria in person.

Second, the research staff was present at the agency and approached potential
participants who were waiting for or leaving an appointment, and invited them to
participate in the study. The majority of participants were recruited in this manner.
Participants who agreed to be screened for the study in person went into a separate room
for the consent and screening procedures and, if eligible, began survey administration.
Those participants who were ineligible were thanked for their time, provided with an HIV
resource guide, and entered into a drawing for a DVD player. For those individuals who
were eligible but waiting for service appointments, research assistants and service
providers determined if there was enough time to complete the survey prior to an
individual’s appointment or if the survey should be completed after an individual’s
appointment. In some instances, survey administration began and was interrupted by
appointments. All but one participant completed their survey alter the conclusion of their
appointment. In other scenarios where participants did not have enough time to begin the
survey, research assistants coordinated alternate times to complete survey administration.

2) Community Organizations and Settings: There were a number of organizations
that provided direct services to African Americans; however, they were geared towards

serving the African American community either as referral organizations, organized

62

clubs, or neighborhood centers. A total of 22 participants were recruited ﬁ'om
organization and community settings. These institutions had a variety of programs that
they offered on a regular basis including: classes (e.g., parenting, nutrition, self-help,
computing, career planning), health awareness campaigns, and regular community social
meetings. Recruitment in these settings took place in two ways similar to the methods
utilized with the social service organizations.

First, outreach workers provided potential participants with brochures about the
study and potential participants had the option of calling to inquire about the study. After
contacting the research team and obtaining verbal consent, potential participants gave
verbal consent to be screened over the telephone. If participants were eligible to
participate in the study, they were invited to make an appointment to complete the survey
in person.

Second, there were designated days on which onsite recruitment and data
collection took place at these organizations (e.g., Baker Donora Community Center).
These designated days took place during regular meetings or “specia ” events (e.g., health
programs, Head Start end of the year program) where an announcement was made and
potential participants stayed after the meeting to complete the survey, or community
members were informed of regular designated data collection days where research
assistants were available to administer the survey.

3) Snowball technique: potential participants were recruited from other known
potential participants in a technique known as the “snowball effect” (also referred to as
network sampling). This technique allowed participants to make referrals and actually act

as recruiters to members of their network, who were assumed to share some of the

63

demographic characteristics of that individual. Participants were given ﬂyers to distribute
to the individuals in their social network. A total of 25 women were recruited via the
snowball technique. Similar to the other recruitment strategies, potential participants
could call to make an appointment to complete the survey, at which time they gave verbal
consent to be screened over the phone. If participants were eligible to participate in the
study, they were invited to make an appointment to complete the survey in person.
Research Assistant Training

This research study was conducted by an ethnically diverse group of seven
undergraduate and one graduate research assistants. Due to the sensitive nature of this
study, all of the research assistants were required to complete a three-week interviewer
training module developed by the author. The purpose of the training was to teach the
research assistants to be empathic and effective data collectors. During the ﬁrst week of
the training sessions, research assistants received basic HIV knowledge from an HIV
prevention specialist ﬁom the Lansing Area AIDS Network (LAAN) and an introduction
to the sensitive issues surrounding this research topic. The research assistants were
encouraged to explore their own issues around HIV. In addition, research assistants also
explored and were encouraged to challenge their own preconceived notions around
working with this particular population. During the second week of training, the research
assistants received a lecture on basic interviewer training skills (e.g., appropriate attire,
body language, tone, how to approach potential participants). During the third week of
training, the research assistants’ basic HIV knowledge was assessed and the entire survey
administration procedure was role played and audio-taped in order for the research

assistant to critique their own interview. Two research assistants required additional

64

training after the completion of the three-week module. This additional training entailed
additional role-playing. By the fourth week, all research assistants were trained and
administering surveys.
Survey Administration

Trained research assistants gave participants a detailed explanation of the
informed consent form and procedure. After obtaining a signed consent form, participants
were given a copy of the consent form for their records. Research assistants then
conducted the screening criteria in a structured interview format. Individuals who were
eligible to complete the survey were asked to identify their present or previous most
signiﬁcant, primary partner. A primary partner was identiﬁed as an individual with whom
the participant had had sexual intercourse (on more than two occasions) within the past
three months, and whom they felt “closest” to (however they subjectively deﬁned close).
This individual’s initials were then referred to in questions pertaining to “primary”
partners throughout the remainder of the survey. In order to standardize the survey
administration process, all surveys were administered in a structured interview format.
Participants were instructed to answer all of the questions to the best of their ability.
Additionally, participants were reminded that they had the option to not answer a
question or discontinue the survey at any time if they so chose.

There were no participants who opted to discontinue taking the survey or who
refused to answer any questions. After completing the survey, research assistants
administered a debrieﬁng protocol. During the debrieﬁng, participants were given a

resource guide/ fact sheet about HIV prevention and referral services (Appendix D). The

65

resource guide included organizations that provided services related to some of the topics
in the survey including HIV testing and counseling.

Participant Incentives. Aﬁican Americans are considered a “difﬁcult to reach”
population. Methodological studies on Aﬁican American participation in research studies
recommend the use of community gatekeepers, incentives, and result reporting as
methods to successfully engage this population in research studies (Bickrnan & Rog,
1998). This study utilized all three techniques. The majority of published HIV prevention
research use some form of participant incentive. Individuals who participated in this
study were compensated $10.00 cash. Individuals who chose to participate in the study,
but were ineligible for inclusion in the study, were entered into a drawing to receive one
of two DVD players. The American Psychological Association’s Ethical Principles of
Psychologists Code of Conduct research guidelines section 8.06, recommends the
following guidelines for offering inducements for research participation (a) psychologists
“make reasonable efforts to avoid offering excessive or inappropriate ﬁnancial or other
inducements for research participation when such inducements are likely to coerce
participation.” These incentives satisfactorily met these guidelines.

Confidentiality All research assistants involved with the project signed
conﬁdentiality agreements. Information containing participant names (e.g., consent
forms, participant payment forms) were separated ﬁom participants’ surveys and access
was limited to the principal investigator and relevant project staff. All data were kept in a
locked ﬁle cabinet in a locked ofﬁce. Participants completed the survey in a conﬁdential
setting due to the fact that conﬁdentiality typically decreases the rate of socially desirable

responses to sensitive questions (Sudman & Bradbum, 1982).

66

Study Sample

Participants ranged in age from 18 to 57 years with an average age of 30.38 years
(SD = 9.34) and reported having an average of 2.85 (SD = 1.75) children. More than one
third of the participants (3 6%, n= 70) lived with their primary partner at the time of the
survey. The average number of individuals living in the participants’ household,
including the participant, was 3.69 (SD = 1.85).

Participants were predominantly low-income and unemployed. Eighty-six percent
(n=164) of participants reported being eligible for public assistance. Twenty-eight
percent (n=55) of participants reported being employed. Among the employed
participants, 14% (n=27) had a full-time job and 14% (n=28) had a part-time job.
Seventy-two percent (n=141) of participants reported that they were unemployed. In lieu
of employment, the participants reported being a “student,” “homemaker,” or “other.”
Forty-three percent (n=84) of participants reported sharing or pooling their ﬁnances with
their primary partner. The reported yearly incomes for the participants ranged from $0 to
$30,000 per year with a mean of $5,619 (SD = $7,900). The number of years of education
for participants ranged from 7 to 17 years with a mean of 12.51 years (SD = 1.95).
Consistent with the study’s eligibility criteria, 82% (n=161) of participants were in a
current sexual relationship and 18% (n=3 5) of the participants reported that they were not
currently in a sexual relationship, but had been in one in the past three months prior to
taking the survey (refer to Tables 2 and 3).

Measures
Eligible study participants completed a 20—minute, 45-item Women ’s Health and

Relationship Survey. The survey was compiled by the principal investigator and included

67

a battery of published, modiﬁed, and newly developed measures. These measures
included: demographics, gender roles, perceived sex ratio imbalances, partner
dependency, interpersonal power in relationships, perception of HIV risk, fatalism,
optimistic bias, sexual self-efficacy, HIV knowledge, and HIV protective behaviors. In
order to determine whether individuals’ HIV protective behaviors differed as a function
of primary versus non-primary partners, the survey assessed HIV protective behaviors
with present/past primary and non-primary sexual partners (refer to Appendix C for the
complete survey instrument).
Demographic Measure

Demographic information on participants’ age, relationship status (present vs.
past) and length, salary, HIV status, religion, and desire to conceive were assessed
(Appendix C, items 1-13,15-19, 38-45). These items were developed and compiled by the
principal investigator and based closely on previous HIV surveys.
Exploratory Factor Analysis

The majority of the scales utilized in this study were developed for this study,
modiﬁed from existing scales, or did not have published data on their psychometrics for
this particular population. Therefore, exploratory factor analysis was conducted on all of
the scales used in the current study.

Interpersonal Power

Interpersonal power in relationships has typically been measured using two

dimensions: decision-making and control in relationships. For the purposes of this study,

interpersonal power was initially investigated by examining both dimensions.

68

A modiﬁed version of the Sexual Relationship Power Scale (SRPS) (Pulerwitz,
Gortrnacker, DeJong. 2000) was used to assess: a) decision making, and b) control in
relationships. The original version of the SRPS is a 23-item scale containing two
subscales that can be used separately or combined, depending upon the research
requirements. Cronbach’s alpha for the overall published scale was .84. The Relationship
Control subscale consisted of 15 items and the Decision-Making Dominance subscale
had a total of 7 items. The Cronbach alphas of the two published subscales were .86 and
.62, respectively.

The original control subscale of the SRPS was measured on a 4-point Likert scale,
ranging ﬁom “1 = Strongly Disagree” to “4 = Strongly Agree.” The original decision-
making subscale was measured on a 3-point Likert scale ranging from, “1 = Your
Partner,” “2 = Both of You Equally,” or “3 = You.” Both the control and decision-
making subscales were modiﬁed to be measured on a 5-point Likert scale ranging from
“1 = My partner completely” to “5 = Me completely.” These modiﬁcations were
conducted in order to obtain more variability, increase analytical parsimony, and simplify
survey administration. The modiﬁed version consisted of ﬁve control items (Appendix C,
Items 23 a-c) and three decision-making items (see Appendix C, items 23a-c).

Psychometric analyses were conducted to explore the internal consistency and
underlying structure of the interpersonal power scale. These analyses included
exploratory principal factor analysis and internal consistency reliability. The results of the
exploratory principal factor analysis on the combination of control and decision-making

items using the varimax method yielded a two-factor solution.

69

The ﬁrst factor contained four items which measured both decision making and
control (a =.61) and the second factor contained four items which measured decision
making (a =.48). Because factors one and two yielded low internal consistency and both
contained decision-making and control items, these subscales were combined and
Cronbach’s alpha reliability was conducted in order to identify a subset of items with the
largest coefﬁcient alpha. The newly formed scale consisted of items 223, 22C, 22D, 22E,
23A, and 23C which loaded highly on the domain most related to interpersonal control.
The new subscale was named relationship control and had a coefﬁcient alpha of .64 for
the current study. After reverse coding several items, mean scores were calculated with
higher scores indicating higher levels of interpersonal power (refer to Appendix E for a
complete description of the psychometric properties of the scale).

Relationship Commitment

A three-item scale was developed speciﬁcally for the purposes of this study to
assess the level of commitment in an intimate relationship (Appendix C, Items 23D-F).
Relationship commitment was measured on a 5 point Likert scale ranging from “1 = My
partner completely” to “5 = Me completely.”

Psychometric analyses were conducted to explore the internal consistency and
underlying structure of the relationship commitment scale. The exploratory principal
factor analysis using the varimax method yielded a one-factor solution which supported a
unidimensional scale. All three items (23D, 23B, and 23F) loaded highly on one factor.
The coefﬁcient alpha for the relationship commitment scale for the current study was a
=.80. Mean scores were calculated with higher scores indicating higher levels of

commitment by the participant and lower levels of commitment by her partner.

70

HIV Protective Behavior

HIV protective behavior was examined as a two-dimensional construct, which
included: a) objective HIV protective behavior (e.g., frequency of condom use across
various sexual behaviors) and b) self-identiﬁed HIV protective behavior, where
individuals generated responses about how they protected themselves against HIV.
Objective HIV Protective Behaviors

Primary Partner. The objective three-item HIV protective behavior scale was
developed speciﬁcally for the purposes of this study to assess individuals’ HIV protective
behavior with their primary. The response items were scored on a 4 point Likert scale
ranging from “1: None of the time” to “4 = All of the time.” There was an additional
option for individuals who did not engage in the described activities (Appendix C, Items
24A-C).

Second Partner. An identical three-item HIV protective behavior scale that was
used with the primary partner was modiﬁed to assess individuals’ protective behavior
with a potential second partner. The response items were scored on a 4 point Likert scale
ranging from “1=None of the time” to “4=All of the time.” There was an additional
option for individuals who did not engage in the described activities (Appendix C, 29A-
C).

Sum scores were calculated and averaged across the sexual behaviors which
comprised two separate sexual behavior indices (e.g., oral, anal, vaginal sexual
intercourse) for the primary and second partner. The indices with higher scores indicated

higher levels of HIV protective behaviors. The index with the primary partner was used

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as the outcome variable in the structural equation model and all subsequent analyses used
to test the speciﬁc hypotheses with the outcome variable of HIV protective behavior.
Self-Identiﬁed HIV Protective Behaviors

Participants were asked to generate all of the behaviors that they engaged in to
protect themselves against HIV (Appendix C, item 31A-I). This item was developed
speciﬁcally for the purposes of this study to assess individuals’ perceptions of how they
protect themselves against HIV. This data was used to answer the second research
question of participants’ subjective HIV protective behaviors. Additionally, a
dichotomous variable was created among participants who did and did not generate
condom use as an HIV protective behavior. This new variable was used in additional
analyses as an alternate HIV protective outcome variable (refer to Table 5 for a complete
list of response endorsements).

Condom Self-Eﬂicacy

Condom self-efﬁcacy was examined using a subscale of the Sexual Self-Efﬁcacy
scale (Rosenthal et al., 1991). The original larger measure is a 20-item scale that assesses
participants’ perceptions regarding their efﬁcacy in various sexual situations. Participants
were provided with various scenarios and asked to rate their responses on a 5-point Likert
scale ranging from “1=Very Uncertain” to “5 = Very Certain.” The modiﬁed version of
the seven item subscale was measured on a 5-point Likert scale ranging from
“1=Strongly Disagree” to “5 = Strongly Agree.”

Psychometric analyses were conducted to explore the internal consistency and
underlying structure of the construct condom self-efﬁcacy. Cronbach alpha reliability and

exploratory principal factor analysis using the varimax method were conducted. The

72

analysis yielded a one-factor solution which conﬁrmed condom self-efﬁcacy as a
unidimensional scale; however, reliability analyses yielded a low coefﬁcient alpha of .38.
Item analysis showed that negatively-worded items had lower item-total correlations than
positively-worded items, consistent with the ﬁndings of Corwyn (2000) who found that
negatively worded items do not load with positively worded items (refer to Appendix E).
In order to increase the internal consistency of the measure, negatively worded items (3 2d
& 32c) were deleted from this scale (Appendix E). The ﬁnal scale was comprised of ﬁve
items (32A, 32B, 32C, 32F, 32G), which yielded a coefﬁcient alpha of .64 for the current
study. Mean scores were calculated with lower scores indicating lower levels of condom
self-efﬁcacy (Appendix C, item 32A, 32B, 32C, 32F, 32G).

Perceived HIV Risk

The Sexual Risks Scale - Perceived Susceptibility (SRSP) scale (DeHart &
Birkimer, 1997) was utilized to assess perception of HIV risk. This pro-existing ﬁve-item
measure was a subscale of the larger SRSP scale. The response stems were on a 5-point
Likert scale ranging from “1 = Strongly Agree” to “5 =Strongly Disagree.” The published
coefﬁcient alpha for the subscale was .84. The original subscale was utilized in the
current study.

Psychometric analyses were conducted to explore the internal consistency and
underlying structure of the construct perceived HIV risk. The exploratory principal factor
analysis using the varimax method yielded a one-factor solution which conﬁrmed a
unidimensional scale. The scale yielded a coefﬁcient alpha of .67 for the current study.
Alter reverse coding one item, mean scores were calculated higher scores indicating

higher levels of perceived HIV susceptibility. (Appendix C, item 34a-e).

73

F atalism

This seven-item scale was modiﬁed from an original scale developed by Colon
(2000) to assess disease fatalism. The original scale consisted of 5 items measured on a 5-
point Likert scale ranging from “1 =Strongly Agree” to “5 = Strongly Disagree,” and was
used to measure a generic sense of fatalism. The modiﬁed scale included items speciﬁc to
HIV fatalism and were measured on the same 5-point Likert scale.

Psychometric analyses were conducted to explore the internal consistency and
underlying structure of the construct fatalism. Exploratory factor analysis using the
varimax method yielded a two-factor solution. As a result, fatalism was measured as a
two dimensional scale, general and HIV fatalism.

General F atalism

Factor one included three items (e.g., items 35A, 358, 35C) regarding general
fatalism (a = .64). Mean scores were calculated with higher scores indicating higher
levels of general fatalism (Appendix C, items 35A,35B,35C).
HIV F atalism

Factor two included two items (e.g., items 35D, 35E) regarding HIV speciﬁc
fatalism (a = .20). Because of the low coefﬁcient alpha and in accordance with the
decision to delete negatively worded items (Corwyn, 2000), item 35c “There is not much
a person can do to avoid getting HIV,” was deleted which resulted in a one-item

(Appendix C, Item 35D) indicator of HIV fatalism.

74

Optimistic Bias

Optimistic bias was assessed by a modiﬁed version of Chapin’s (2000) ﬁve item
optimistic bias scale. The modiﬁed response scale was a 5-point Likert scale which
ranged from “1=Much Greater” to “5=Much Less.”

Psychometric analyses were conducted including reliability and exploratory
principal factor analysis using the varimax method and yielded a two-factor solution,
sexual optimistic bias and general optimistic bias.

Sexual Optimistic Bias

The ﬁrst factor consisted of three items (Appendix C items 36B,36C,36D)
regarding sexual optimistic bias ((1 = .69). Mean scores were calculated with higher
scores indicating higher levels of optimistic bias.

General Optimistic Bias

The second factor included two general optimistic bias items (items 36A, 36C)
which yielded a coefﬁcient alpha of (a = .16). Because of the low coefﬁcient alpha and
in accordance with the decision to delete negatively worded items, item 36a, “Compared
to other Aﬁican American women, my chances of experiencing a tragic event are...” was
deleted (Corwyn, 2000), which resulted in a single item indicator of general optimistic
bias (Appendix C, ltern 36A).

HIV Knowledge

HIV knowledge was assessed by the HIV/AIDS Knowledge Scale (Yancey,
Wang, Goodin, & Cockrell, 2003). This pre-existing 24-item HIV knowledge scale had
an original response scale of “true,” “false,” and “do not know.” The scale was developed

speciﬁcally for use with African American women aged 17-44 years. The published

75

reliability for the scale was .73. The response option of “do not know” was not used in
the modiﬁed version of the scale, in order to increase the item response rate. An HIV
knowledge score was calculated by summing the correct responses to the 24 items.
Higher scores indicated more accurate HIV knowledge (Appendix C, 37a-e).

In addition to the original items on the scale, three supplementary items were
created to assess participants’ knowledge of HIV/AIDS knowledge in the Aﬁican
American community (items 36L, 360, and 36t). Overall, participants answered 77% of
the questions pertaining to Aﬁican American transmission correctly. The coefﬁcient
alpha for the entire HIV knowledge scale was (a = .63) for this sample.

Gender Role Identity

Gender role identity is a multidimensional construct that is typically measured as
three factors: masculinity, femininity and androgyny. The original version of the Personal
Attributes Questionnaire (PAQ)- (Spence & Helrnreich, 1978) was utilized to assess
“traditional” feminine gender roles. This pre-existing 25-item scale assesses masculinity
and femininity in terms of respondents’ self-perceived possession of various traits that are
stereotypically believed to differentiate the sexes. The authors acknowledge that the PAQ
taps into limited aspects of sex roles: certain self-assertive or instrumental traits
traditionally associated with masculinity and certain interpersonal or expressive traits
traditionally associated with femininity. Although the PAQ should not be viewed as a
global measure of masculinity and femininity, it has been widely used in research with
diverse populations (Bowleg, 1998) to provide a rough classiﬁcation of participants in
terms of their gender-role identity. In responding to the PAQ, the participants chose an

answer that best represents the type of person they think they are. Each question

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consisted of two opposing characteristics, with the letters A-E in between them. The
letters form a scale between two extremes (scored from 1-5). Participants chose a letter
that described where they fall on the scale. For the purposes of this study, femininity was
the only construct of importance in the proposed model, therefore, masculinity and
androgyny were excluded from further analysis.

Psychometric analyses were conducted to explore the internal consistency and
underlying structure of the construct femininity. For the purposes of maintaining the
integrity of the existing scale, reliability analyses were conducted based on the scale
authors’ directions for scoring. To compute a score on the femininity subscale of the
PAQ, the numbers next to items 3, 7, 8, 9, 12, 15, 21, and 22, were summed. The
coefﬁcient alpha on the femininity subscale was .72 for the current study.

Perceived Sex Ratio Imbalance

Perceived sex-ratio imbalance is a ﬁve-item, unidimensional scale developed
speciﬁcally for the purposes of this study to assess the perception of sex ratio imbalances
of African American women to Aﬁican American men. The response stems were
measured on a S-point Likert scale that ranged from “1 =Strongly Agree” to “5 =
Strongly Disagree.”

Psychometric analyses were conducted to explore the internal consistency and
underlying structure of the construct sex ratio imbalance. Exploratory factor analysis
using the varimax method yielded a two-factor solution. Factor one consisted of three
items (33A, 33D, 33E) ((1 = .35) and factor two consisted of two items (33B, 33C) ((1 =
.24). Reliability analyses suggested that the items on factor one yielded the highest

reliability of .35, therefore items 338 “If I wanted to, I could ﬁnd a new partner,” and

77

33C “There are plenty of available partners for Aﬁican American women,” were deleted.
After reverse coding two items, mean scores were calculated a with higher scores
indicating higher levels of perceived sex ratio imbalance in the African American
community (Appendix C, Items 33A,33D,33E).

Partner Dependency

Partner Dependency was assessed by examining participant ﬁnancial
independence. Financial independence was a unidimensional construct that that was
developed speciﬁcally for the purposes of this study.

A seven-item scale was developed to assess partner ﬁnancial independence. The
response scale was measured on a 4 point Likert scale ranging from “1 = Strongly
Disagree” to “4= Strongly Agree.”

Psychometric analyses were conducted to explore the internal consistency and
underlying structure of the items. The exploratory principal factor analysis using the
varimax method yielded a three-factor solution. The ﬁrst factor consisted of items 20A,
ZOB,and 20C. The second factor consisted of items 21B, 21C, and 21D. The third factor
consisted of item 21A. Reliability analysis demonstrated that all of the items combined
yielded an alpha coefﬁcient of or = .24.

Reliability analyses were conducted on each factor which demonstrated that if
factor one excluded item 20C “I rely on the assistance from others (e.g., family/friends to
help me get by,” it would yield a higher coefﬁcient of .62 with the remaining two items
(20A and 208). (refer to Appendix E for a complete list of the psychometric properties of

this scale).These two items (20A & ZOB) were used to comprise the ﬁnal scale of

78

ﬁnancial independence. Mean scores were calculated with higher scores indicating higher
levels of ﬁnancial independence (Appendix C, Items20A, 20B).
Attitudes Toward Condom Use

Perceived partner and participant attitudes toward condom use were assessed by
using items from the Sexual Relationship Power (SRPS) Scale (Pulerwitz, Gortrnaker, &
Dejong, 2000). The original partner reaction items from the scale loaded onto control and
dominance dimensions in previous studies (refer to Appendix E). The original subscale of
partner and participant reactions was comprised of 13 items. The modiﬁed version
contains ﬁve parallel participant and partner items and one additional item pertaining to
the perception of one’s partner becoming violent if the participant introduced condoms.
The modiﬁed version of this scale was measured on the original 4-point Likert scale
ranging from “1=Strongly Disagree” to “4=Strongly Agree.”

Psychometric analyses were conducted to explore the internal consistency and
underlying structure of the construct, “attitudes toward condom use.” Exploratory
principal factor analysis using the varimax method yielded a three-factor solution,
however, factor analysis did not yield exclusive factors. The ﬁrst factor consisted of ﬁve
items (25C,25E,25F,25H,25G) regarding participant and perceived partner negative and
positive attitudes toward condom use (a: .27). The second factor consisted of four items
(25K, 251, 25J, 25H), three of which consisted of participant attitudes towards condom
use and one item which regarded perceived partner attitudes (a.= .51). The third factor
consisted of two items (25A & 25D) regarding enjoyment of sexual intercourse by the

participant and partner when condoms were used (a =.60).

79

Due to the poor performance of the total scales, items were separated into two
subscales, a) partner attitudes toward condom use, and b) participant attitudes toward
condom use, and an additional single item indicator of perceived violence.

Perceived Partner Attitudes Toward Condom Use

Reliability analysis yielded the highest coefﬁcient alpha for the following three
items including 25C, 25E, and 25F (a = .75). These items assessed perceived partner
positive attitudes toward condom use (Appendix B). Mean scores were calculated with
higher scores indicating more positive perceived partner attitudes toward condom use.
Participant Attitudes Toward Condom Use

Reliability analysis yielded the highest coefﬁcient alpha for the following three
items including, 25K, 251, 25G (a = .63). These items assessed positive participant
attitudes toward condom use (Appendix C). Mean scores were calculated with higher
scores indicating more positive attitudes toward condom use.

Violence

Item 25j regarding violence was used as a single item indicator based on face
validity and its lack of conceptual congruence combined with a low inter item correlation
with the other items comprising the other subscales scales (refer to Appendix E).

Data Preparation

Double date entry was performed by two research assistants who entered all of the
data into two separate SPSS version 12 databases. After data entry was completed, the
two databases were compared and frequencies were examined in order to determine any

discrepancies in data entry. Data discrepancies were checked and corrected against the

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original paper data. Preliminary examination of the data detected missing data and/or
outlier scores.
Data Analysis Strategy

Univariate and multivariate analysis techniques were employed to examine the
research questions posed in this study. Univariate analyses (e.g., descriptive statistics,
frequency distributions, histograms, and scatter plots) were utilized to conduct descriptive
analyses on the demographic data and overall scales. In order to test the hypothesized
relationships between variables (e.g., moderator effects), multiple linear regression
(MLR) was employed. To test the speciﬁcation of the proposed model, and mediation
effects (Mackinnon et al., 2002), the Structural Equation Modeling (SEM) program
AMOS 5 (Arbuckle & Wothke, 1999) was utilized in accordance with Anderson and
Gerbing's two-step approach (Anderson & Gerbing, 1988), in which the ﬁt of the
measurement model, with all constructs allowed to freely covary, provides a baseline for
testing the ﬁt of the hypothesized structural model.

RESULTS

Univariate Analysis

Univariate analyses were conducted on all descriptive data. Descriptive statistics
were also conducted on the independent and dependent variables in order to examine
skewness, kurtosis, outliers, and missing data (see Table 6).

Missing Data. Due to the interview format of the data collection, missing data
was very uncommon; there were approximately (n=4) or 2% cases with missing data on a
few items, generally due to human error. The statistical software AMOS is able to

address missing data by utilizing a full information maximum likelihood (F IML)

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algorithm; however, because the extent of missing data was so low, item mean
replacement methods were used in order to allow calculation of all ﬁt indices and
diagnostics.
Descriptives

Interpersonal Relationships

HIV infection most commonly occurs within the context of dyadic relationships
for African American women, signifying the importance of examining relationships in
HIV prevention. Eighty-two percent (n=161) of participants in this sample were currently
in a sexual relationship. The remaining 18% (n=3 5) had been in one or more relationships
in the past three months. Three percent (n=5) of the participants reported being married at
the time of the survey, but separated for more than three months. On average, participants
reported that they and their partners shared approximately equal levels of control and
decision-making power within their relationships (M = 3.39, SD = .65) on a scale of one
to ﬁve. With regard to relationships with male partners, the majority of participants
reported high levels of perceived sex ratio imbalance (more African American women
than Aﬁican American men) (M = 4.09, SD = .77) on a scale of one to ﬁve. However,
63% of participants “strongly agreed” that “they could ﬁnd a new partner if they wanted
to.”

Overall, the majority of participants reported approximately equal levels of
commitment to their relationship with their partners (M = 3.38, SD = 1.00) on a scale of
one to ﬁve. When asked in an open ended question to describe their relationship, the
majority of participants 68% (n=132) described their relationship as monogamous (7%,

n=12) or serious (61%, n=120), while approximately one third of the participants (32%,

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n=60) described their relationship as casual (23%, n=46), open (7%, n=14), or “other”
(2%, n=4).

Interpersonal relationships and HIV risky behaviors. When asked, “how do you
protect yourself against HIV,” 25% (n=55) of the participants indicated that they were in
a monogamous relationship. Despite the number of women who reported being in a
monogamous relationship, nearly half of the participants 47% (n=93) reported that their
primary partner had sexual relations with someone else during some point in their
relationship, and 20% (n=3 7) of the participants reported having sexual relations with
someone else other than their primary partner within the past three months. Of the
participants who reported having a second partner within the past three months, 13%
(n=26/3 7) of the participants reported being in a relationship with their primary partner
when this behavior occurred.

In terms of HIV protective behavior (measured as condom frequency with the
combined index of anal, vaginal, and oral intercourse), there were signiﬁcant differences
based on relationship status t(9l) = -1.95, p <.05. Participants who indicated that they
were in a monogamous relationship engaged in less condom use (M = 1.69, SD = .88) in
comparison with participants who reported being in a casual or open relationship (M:
2.02, SD = 1.02).

HIV risk and knowledge. The majority of participants (66%, n=120) reported that
their primary partner had previously been tested for HIV, and 88% (n=l72) of
participants reported that they had at least one previous HIV test. Seventy-one percent
(n=137) of the participants reported previously receiving some form of HIV education.

The majority (77%, n=151) of participants rated their HIV knowledge as average (31%,

83

n=61), good (30%, n=59), or excellent (16%, n=31). On average, participants reported a
low (M=] .77, SD = .81) perception of HIV susceptibility or risk on a scale of one to ﬁve.
In terms of perceived HIV risk, these results yielded trend level differences between
monogamous and non monogamous relationships t(194) = -1.66, p =.10. Participants
who indicated that they were in a monogamous relationship perceived slightly lower
levels of HIV risk (M= 1.61, SD = .68) in comparison with participants who did not
indicate being in a monogamous relationship (M= 1.83, SD = .84).

HIV knowledge was assessed by examining participants’ knowledge of general
HIV transmission and rates in the Aﬁican American community. On average, participants
answered approximately 82% of the general HIV knowledge items correctly and 77% of
the Aﬁican American community items correctly. Participants were most likely to answer
the following questions wrong, 1) all pregnant women infected with HIV will have babies
born with AIDS, 2) Coughing and sneezing do not spread HIV, and 3) African American
women are twice as likely as White women to get HIV, respectively (refer to Table 7 for a
complete list of response rates).

HIV Protective Behavior

Self-Identiﬁed HIV Protective Behaviors

One of the current study’s research questions was, “How do African American
women protect themselves against HIV? Participants were asked to generate the HIV
protective behaviors that they used to protect themselves against HIV. The majority of
participants 65% (n=127) identiﬁed condom use as the method they used to protect

themselves against HIV. The results demonstrated that the participants were more likely

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to choose effective strategies to protect themselves against HIV over ineffective
strategies (refer to Table 5).
Objective HI V protective behavior

Primary Partner

Forty-four percent (n=87) of participants reported using condoms in the past three
months “none of the time” when they engaged in vaginal intercourse with their primary
partner. F ifty—six percent (n=110) of the participants reported using either condoms or
other latex barriers “some of the time” (20%, n=3 9), “rrrost of the time” (17%, n=33), or
“all of the time” (18%, n=9) when engaging in vaginal intercourse with their primary
partner.
Second Partner

Of the participants (20%, n=3 9) reported having vaginal or oral intercourse with

a second partner. Out of this number, (19%, n=3 7 )4 reported having vaginal intercourse
with at least one other sexual partner other than their primary partner within
the past three months, 13% (n=5/3 7) reported using condoms with the second partner in
the past three months “none of the time.” While 87% (n=32/37) of the participants who
engaged in vaginal intercourse with a second partner within the past three months
reported using condoms or other latex barriers with the second partner “some of the time”
( 16%, n=6/37) “most of the time” (22%, n=8/37) and “all of the time” (49%, n=18/37)

when engaging in vaginal intercourse with a second partner.

85

Birth Control

Over half of the participants, 55% (n=107) were currently using some form of
birth control. Tubal ligation was the most common form of birth control reported (16%,
n=32), followed by Depoprevera (13%, n=26). Condoms (4%, n=7) were the ﬁfth most
common form of birth control used (refer to Table 4 for a complete list of birth control
methods). There were no signiﬁcant differences in the frequency of condom use among
participants who reported using birth control other than condoms (M= 1.88, SD = 1.01)
and those who did not (M= 1.90, SD = 1.00), t(l 87) = .25, p =.61.

When participants were asked about their perceptions about their partner’s
attitudes toward condom use, the majority of participants (59%, n=115) reported that
their partner “never” reﬁrsed to use some form of protection. Forty percent (n=79) of the
participants reported that their partner refused to use some form of protection “some of
the time” (19%, n=3 7), “most of the time” (5%, n=9), or “always” (17%, n=33).

When asked if the participants, themselves “refused to use any form of
protection?” the majority of participants (70%, n=137) reported that they “never” refused
to use any form of protection. Thirty percent of the participants reported that they refused
to use some form of protection “some of the time” (17%, n=34), “most of the time” (3%,
n=5) or “always” (10%, n=20). When asked who was more likely to initiate condom use,
the majority of participants (57%, n=112) reported that they (the participant) were more
likely to initiate condom use, followed by both (the participant and their primary partner)
(17%, n=33), their partner only (12%, n=24), and neither (6%, n=12). On average,

participants reported high levels 4.57 (SD = .64) of condom self-efﬁcacy on a scale of

86

one to ﬁve. Ten percent (n=] 9) of participants reported that their partner would become
violent if they (the participant) initiated condom use.
Intercorrelations of the Independent and Dependent Variables

Interpersonal Relationship Control

Among the hypothesized predictors of interpersonal relationship control, ﬁnancial
independence demonstrated to have the strongest correlation with relationship control,
however, this relationship was slightly above the cutoff for signiﬁcance (r= —.13, p =
.06). Relationship control was related to the combined index of oral, anal, and vaginal
intercourse with a primary partner (r= .1 l, p< .14), such that higher levels of relationship
control were related to a higher frequency of condom use. Although not signiﬁcant, this
relationship was approaching a trend.
Perceived HIV Risk

Both cultural and cognitive behavioral factors were related to perceived HIV risk.
Individuals who had higher levels of perceived HIV risk had lower levels of general
fatalism perceptions (r= -.30, p< .05), and lower levels of sexual optimistic bias (r= -. l 7,
p< .05). There was a trend level relationship between perceived HIV risk and engaging in
vaginal intercourse with the primary and second partners (r= .12, p = .09).
Condom Self-Eﬁ‘icacy

Condom self-efﬁcacy was related to a number of different variables including
with relationship commitment (r= .18, p< .05), HIV risk (r= -.14, p= .05), general
fatalism (r= -.13, p< .05), HIV knowledge (r= .15, p< .05), ﬁnancial independence (r=
.22, p< .05), participant attitudes toward condom use (r= .33, p< .05), and HIV

protective behavior (anal, vaginal, and oral) with the primary (r= .19, p< .05) and

87

secondary partner (r= .33, p< .05). There were also trend level relationships with
interpersonal relationship control (r= .12, p< .09) and relationship violence (r= -.12, p<
.08) (refer to Table 8 for a complete list of correlations).
Testing the Model

In order to examine the ﬁrst research question of whether the proposed model of
HIV protective behavior would ﬁt for low-income Aﬁican American women, structural
equation modeling (SEM) techniques were utilized, using maximum likelihood (ML) as
recommended by Hu and Bentler (1995). The ﬁrst step in SEM is speciﬁcation of a
model and essentially conﬁrming a hypothesized model. As currently recommended by
the literature (Hu & Bender, 1998, 1999), model ﬁt was assessed through the following
indices and thresholds: standardized root meanresidual (SRMR) of .08 or smaller, root
mean-square error of approximation (RMSEA) of .06 or smaller, and incremental ﬁt
index (IFI) of .95 or greater. Model chi square values were also assessed, and the
likelihood ratio (LR) chi-square was used to compare the ﬁt of the measurement and
structural models. These ﬁt indices guided the modiﬁcation of the measurement model in
order to specify and improve the model ﬁt. Individual path coefﬁcients were examined in
order to test the speciﬁc hypotheses about relationships among variables in the proposed
model . Indirect and direct effects were examined by path coefﬁcients in the SEM.
Multiple linear regression (MLR) techniques were utilized to examine the hypothesized
moderated relationship.

The proposed model was examined in two steps: validating the measurement
model and ﬁtting the structural model (Anderson & Gerbing, 1988). The validation of the

measurement model was accomplished primarily through conﬁrmatory factor analysis

88

(principal axis factoring), ﬁrst on the core model (Figure 2) with the constructs that were
purported to have a direct effect on the outcome variable, then with the larger model,
including the indirect effects on the outcome variable (Figure 3). Conﬁrrnatory factor
analysis (CFA) was used to conﬁrm that the indicators sorted themselves into factors
corresponding to how the author linked the indicators to the latent variables. CFA models
in SEM are used to assess the role of measurement error in the model. Structural
Equation Modeling (SEM) goodness-of-ﬁt tests were examined to determine if the
pattern of variances and covariances in the data were consistent with a structural (path)
model speciﬁed by the author. Once the measurement model was validated, the structural
model was examined.

Transformations. Several variables had signiﬁcant negative or high kurtosis and
skew which pose model ﬁt and estimation problems for the measurement model in SEM.
If skew and kurtosis values were over the absolute value of three, transformations were
conducted. In some instances, when skew improved, kurtosis became worse or the
opposite would occur. Therefore, some values maintained a relatively high kurtotic value
(refer to Tables 6 and 9). These log transformations were applied to particular items and
scales to better meet the assumption of multivariate normality for SEM. Among the
variables that were included in the ﬁnal model, skew and kurtosis did not exceed the

absolute value of three.

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Figure 2 Core Measurement Model

   

  

Financial
Independence

  
 
 

      
   
  

Relationship
Control

Sex w/ Primary
Partner

  

  
   

Sex Ratio
Imbalance

Testing the Core Model

The initial core measurement model for only the independent variables that were
purported to have a direct and empirical evidence of an indirect effect on HIV protective
behavior was estimated. Kline (1998) recommends the two step approach of estimating a
measurement model ﬁrst to determine if the ﬁt of the measurement model is found
acceptable, then to proceed to the second step of testing the structural model by
comparing its ﬁt with other structural models and the initial measurement model. The
results of the CF A indicated a moderately good overall ﬁt to the data [172(180, N=196) =
214.87, p = .04, IFI =.93, RMSEA =.O3, SRMR = .06]. However, tests of univariate and
multivariate normality indicated problematic distributions on several item-level
indicators, and examination of item loadings showed that several were not signiﬁcant.

The next step was to modify the measurement model.

90

The goal of model modiﬁcation is to develop parsimonious, good —ﬁtting models
with unimportant parameters deleted (Tabachnick & Fidell, 2001). The parameter
estimates and modiﬁcation indices output in AMOS were useful in evaluating
unnecessary parameters. The following analyses were framed within an exploratory,
rather than conﬁrmatory mode although conﬁrmatory factor analytic procedures were
used for the respeciﬁcation and reestimation of the model, known as “speciﬁcation
searches” (MacCallum, 1986).

Parameter estimates and modiﬁcation indices suggested several other
modiﬁcations. First, item 14C did not signiﬁcantly load onto its latent construct of
femininity and was therefore excluded from further analyses. The resulting coefﬁcient
alpha for the new seven-item scale was V =.7 6. Second, two of the three indicators (20A,
ZOB) for the latent construct Financial Independence had a large negative skew and
kurtosis. Log transformations to improve distribution were successfully conducted on
these two items. Third, based on model speciﬁcation problems (e. g., low inter item
correlations with the other variables and single item indicators), the construct Sex Ratio
Imbalance was excluded from further analyses due to model speciﬁcation problems.
Principal axis factor analyses yielded low reliability for Sex Ratio Imbalance, and as
such, none of the three indicators loaded signiﬁcantly onto the latent construct.
Additionally, the overall construct did not signiﬁcantly contribute to the overall
prediction of the model, which provided further support for the decision to exclude this
variable from subsequent analyses.

Lastly, two error terms ﬁ'om the femininity construct (140 “ aware of others

feelings” and 14U “understanding of others”) were allowed to covary because these two

91

items were conceptually more similar to each other than to other items and appeared to
share measurement error (Hoyle, 1991). Random measurement error is generally assumed
to be independent of other variables, and the strength of various relationships can be
misestimated if correlated errors are not reﬂected in the model. A liklihood ratio chi
square difference test was conducted. The LR Chi square difference test is the most
commonly used method for comparing the ﬁt of two nested models. The results yielded
96 degrees of freedom and a chi-square of 114.23, which was signiﬁcant at p < .05. This
indicated that the structural model did not ﬁt the data as well as the CFA, which allowed
all constructs to freely covary; this suggested that better-ﬁtting models might exist.
Testing the Core Structural Model

After conducting all of the aforementioned modiﬁcations, the modiﬁed
measurement model was estimated. The results demonstrated that the model provided an
excellent ﬁt to the data [1T(84, N=196) = 100.64, p =.10, IFI :96, RMSEA =.03, SRMR
= .05]. All measurement parameters were signiﬁcant and in the expected direction (refer
to Table 13).

Figure 3

92

Final Structural Model

  
  

(I; ’/ / A u >\' \‘jfﬁ-K if \ I \ \~ ,>~"-\.~_
/____ , ﬂ, .. 1/ x r “ax—x
I gr _ .. ...\ .‘g '
-7»? -’ \ W \
’ ' " ' ' ' Sexual "
, / , @001" OWIDISUC BIOS I Optimistic Bias I I HIV Knowledge j
.-/l ,5/ “-\___,.~-" e , J c _,-
,/ f7? ’
I 17;: l
«martial... m...
r. .‘k l . ' /————- ‘x-x \ HIV RISK ,A.\ ._ —-_
, f L Re sh' ‘ —"""" K
. ;‘ Iation Ip L v _ ,._. ._V_-__’ ." Sexwl ‘\
\ ‘4 LN //"\\ Control I, Primry Partner /'
Femininity ,I
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I
Self-Efﬁcacy

The next step in data analysis was to conduct a CFA on the entire measurement
model (Figure 3). The entire measurement model extended the modiﬁed core
measurement model by including the variables that were purported to have an indirect
effect on the outcome variable of HIV protective behaviors. The initial entire
measurement model was estimated in a conﬁrmatory factor analysis. [172(395, N=196) =
423.26, p =.00, IFI ==.98, RMSEA =.02, SRMR = .06]. Table 14 reports the goodness-of-
ﬁt statistics for the latent variable models.

Parameter estimates and modiﬁcation indices suggested several modiﬁcations.
The constructs of sex ratio imbalance, HIV fatalism, and general optimistic bias had

distribution problems and did not have signiﬁcant regression weights and did not

93

correlate with other constructs in the model. These three constructs were excluded ﬁom
further analysis. Additionally, six error terms were ﬁ'eed and allowed to covary because
the items were theoretically similar and highly correlated (refer to Appendix C);
therefore, their error terms were allowed to covary within, but not across constructs
(Hoyle, 1991). Modiﬁcations were made to the latent construct of condom self-efﬁcacy.
Five indicators originally comprised this construct. However, Item 32A, “1 can buy
condoms or dental dams without feeling embarrassed,” and item 328, “I can carry
condoms or other latex barriers around with me in case I have sex,” were excluded from
further analyses due to a lack of correlation with the outcome variable HIV protective
behaviors compared with the other three items, large kurtosis and violations of external
parallelism. It is essential that the items relate identically or, at least are similar to
theoretically linked covariates (Cheong & Raudenbush, 2000). In addition, these items
represented a conceptually different aspect of behavior related to condom acquisition and
access, in contrast to the remaining three items which speciﬁcally addressed condom use
behavior. The remaining scale consisted of three items (32C, 32F, 32G) with a coefﬁcient
alpha of (n= .51), which, although it yielding a lower coefficient alpha than the original
alpha of (n= .64) obtained for this sample, represents a conceptually consistent measure
of condom self-efﬁcacy. Measurement loadings for all items were significant. The
modiﬁed model provided an excellent ﬁt [172(395, N=196) = 423.37, p =.16, IFI =.98,
RMSEA =.02, Standardized RMR = .07].
Estimating the Structural Model
Based on the CFA, the structural model was estimated and the results yielded a

model that was a good ﬁt to the data [1f(412, N=196) = 462.94, p =.04, IFI =.96,

94

RMSEA =.03, SRMR = .07]. The correlations among the exogenous variables were
calculated (refer to Table 6). The magnitude of the direct and indirect effects in the model
and the proportion of variance explained in the frequency of HIV protective behavior was
examined (refer to Tables 11 and 12). The change in ﬁt between successively estimated
models was assessed through the use of a likelihood ratio (LR) chi-square difference
tests. The results yielded 17 degrees of freedom and a chi-square of 39.63, which was
signiﬁcant at p = .002. This indicated that the structural model did not ﬁt the data as well
as the CFA, which allowed all constructs to ﬁ'eely covary; this suggested that better-
ﬁtting models might exist. However, the proposed model met the criteria for excellent ﬁt
on all indices and had a small model chi-square that was signiﬁcant at p = .04. Therefore,
the parameter estimates generated ﬁ'om the ﬁnal model were used to examine the speciﬁc
hypothesized relationships at a .05 signiﬁcance level.

Results of the Hypotheses Testing

HYPOTHESIS: Three cultural factors: gender roles, ﬁnancial independence, and sex
ratio imbalance, will have a direct effect on interpersonal power.

In order to test the effects of the cultural variables on interpersonal control, the
direct and indirect estimates of the structural equation model were examined. The results
demonstrated that femininity and ﬁnancial independence did not have signiﬁcant direct
effects on interpersonal control (refer to Table 11), and the construct sex ratio imbalance
was excluded from analyses in the early phase of data analysis due to measurement
problems in the SEM model.

Traditional feminine roles did not have a direct effect on interpersonal control.
The standardized regression weight was .00 (2 =01, p :99). Financial independence did

not have a direct effect on interpersonal control. The standardized coefﬁcient was -.04 (z

95

= -.44, p =.66). Although non signiﬁcant, contrary to the hypothesized direction,
individuals who reported higher levels of ﬁnancial independence had lower levels of
interpersonal control in their relationship as expected. As noted, the construct of sex ratio
imbalance was excluded from further analysis in the structural equation model due to
measurement problems; therefore, the relationship between perceived sex ratio imbalance
and interpersonal control was not examined.

HYPOTHESIS: Higher levels of interpersonal power will predict higher levels of
protective behaviors.

In order to test the second hypothesis of a direct relationship between
interpersonal control and HIV protective behavior, the direct and indirect estimates of the
structural equation model were examined. The results demonstrated that there was no
direct relationship between interpersonal control and HIV protective behavior (3= .08, p
= .67) (refer to Table 11).

Most of the conceptual and some of the empirical research on women and HIV
have strongly supported a relationship between interpersonal power and HIV protective
behavior. The construct of HIV protective behavior was examined as condom ﬁequency
as done in most HIV prevention studies, however, in order to place condom use within an
HIV speciﬁc context, an additional analysis with a newly created dichotomous variable
was utilized.

Logistic Regression

A logistic regression was conducted in order to determine whether interpersonal

relationship control would predict condom use speciﬁcally for HIV protective behavior.

The dichotomous variable created by the self generated responses to the item, “how do

96

you protect yourself against HIV?” was used as the outcome variable (e.g., condom use
yes/no). The effect of relationship control while controlling for perceived HIV risk was
examined. The results of the logistic regression indicated that relationship control was
signiﬁcantly associated with condom use as an HIV protective behavior (Wald = 6.14, p
< .05). In this model, women with higher interpersonal relationship control were nearly
twice as likely to report condom use for HIV protection than women with lower
relationship control (OR = 1.85).

Table 15

Summary of Logistic Regression Analysis for Interpersonal Relationship Control

Predicting Condom Use as an HIV Protective Behavior (n=I9Q
Condom Use for HIV Protection

 

 

 

Predictor B SE B Odds p value
Ratio
Block 1
HIV Risk -.07 .19 .92 .70
Block 2
Relationship Control .62** .25 1.85 .01
Constant -1.32
1" 7.45 .02
Df 2

 

HYPOTHESIS: Sexual self-efﬁcacy will mediate the relationship between power and
HIV protective behaviors.

To test the third hypothesis of whether condom self-efﬁcacy mediated the
relationship between interpersonal control and HIV protective behavior, the indirect

effects of the structural equation model were examined (MacKinnon, Lockwood,

97

Hofﬁnan, West, & Sheets, 2002). Condom self-efﬁcacy did not demonstrate signiﬁcant
mediation of the relationship between interpersonal control and HIV protective behavior
(condom frequency with the index of oral, anal, and vaginal intercourse). The direct
effect of interpersonal control on condom self-efﬁcacy is (EI=.14,p=27), the direct effect
of condom-self-efﬁcacy on HIV protective behaviors is (3:23, p<.05), and the indirect
effect of interpersonal control on HIV protective behavior is (3:04, p= .14)
HYPOTHESIS: Three culturally relevant factors: optimistic bias, fatalism, and HIV
knowledge, will have a direct effect on perceived risk.

To test the hypothesis of whether three culturally relevant factors (optimistic bias,
fatalism, and HIV knowledge) have a direct effect on perceived HIV risk, the direct and
indirect effects of the structural equation model were examined. Two of the three
hypothesized relationships were supported.

As predicted, a direct, negative relationship was demonstrated between sexual
optimistic bias and perception of HIV risk. The standardized regression weight was
-.61(z= -3.40, p < .05). Individuals who reported higher levels of sexual optimistic bias
reported lower levels of perceived HIV risk. A direct, negative relationship was also
demonstrated between general fatalism and the perception of HIV risk .The standardized
regression weight was -.31 (z = -2.75, p < .05). Individuals with higher levels of general
fatalistic attitudes were more likely to report lower levels of perceived HIV risk. HIV
knowledge did not have a signiﬁcant direct effect on perceived HIV risk. The
standardized regression weight was .00 (z = .86, p = .39).

HYPOTHESIS: Perceived HIV risk will moderate the relationship between interpersonal

power and protective behaviors. Speciﬁcally, the relationship between interpersonal
power and protective behaviors will only exist in the presence of perceived risk.

98

To test the hypothesis of whether perceived HIV risk moderated the relationship
between interpersonal control and HIV protective behaviors, a multiple linear regression
(MLR) was conducted to test Baron and Kenny’s (1986) criteria for a moderating
variable. The results did not detect any signiﬁcant main effects, [E (2, 193) = 1.40; p =
.25] or interactions, [E (3, 193) = .18; p = .68]. Perceived HIV risk did not signiﬁcantly
moderate the relationship between relationship control and HIV protective behaviors
(refer to Table 16).

Table 16

Moderated hierarchical regression analysis: HIV risk as a moderator of the effect of
relationship control on condom frequency with oral, anal, and vaginal intercourse

(N=196).

 

 

Variable B SE B B p-value )R2 )F p-value

Block 1 - main effects .01 1.4 .25
.45

HIV Risk -.07 .09 -.06 .45
.19

Relationship Control 15 11 ~09 20
.00 .18 .68

Block 2 - main plus
interaction effect

.41

HIV Risk -.08 .09 -.06 .41
.19

Relationship Control "15 '12 '10 ~19
.68

Interaction "05 '13 '-03 .68

 

R2 = .00

Additional Analyses on Subsample
Additional MLR analyses were conducted in order to examine the role of
interpersonal power on a subsample of (n=69) participants for whom the proposed

relationships were hypothesized to be more relevant. This subsample consisted of

99

participants who reported perceiving some level of HIV risk, did not indicate being in a
monogamous relationship or using mono garny as an HIV protective behavior, and whose
partner had less favorable attitudes toward condom use. Interpersonal relationship control
did not signiﬁcantly predict HIV protective behavior after controlling for perceived HIV
risk (3:.18, p = .14). However, in this small sample the relationship approached a trend
level. A power test indicates that increased power to ﬁnd an effect of this size signiﬁcant
for a two-tailed p < .05, would require a sample size of 233. This ﬁnding suggests that
relationship control may be more relevant for a subsample of individuals who perceive
themselves to be at risk, are possibly confronted with resistance when negotiating
condom use (partner’s negative attitude), and do not use monogamy as an HIV protective
behavior (refer to Table 17).

Table 17

Relationship control as a predictor of H1 V protective behavior (condom frequency with
oral, anal, and vaginal intercourse), while controllingfor perceived risk (N =69).

 

 

 

Variable E SE B B p-value )R2 JP p-value
Block 1 — Control variable .03 1.74 .19
.19
HIV Risk -.19 .14 -.16 .37
Block 2 - plus .03 2.21 .14
Relationship control
.37
HIV Risk -.13 .15 -.ll .37
.14
Relationship Control '28 '19 '18 '14
R7 = .03

100

DISCUSSION

The purpose of this study was to propose an integrated model of HIV protective
behavior for low-income Aﬁican American women. Racial and ethnic minorities have
been disproportionately affected by HIV /AIDS since the beginning of the epidemic, and
now represent the majority of new AIDS cases (CDC, 2004). Though heterosexual
transmission has risen for all women, Aﬁican American women continue to account for
the vast majority of new HIV cases among women of all ethnicities. The changing face of
the epidemic continues to challenge researchers and service providers to develop new
methods and strategies for curbing the increasing rates among speciﬁc “high risk”
populations. A new line of HIV prevention research that accounts for the contextual
factors which place particular groups at increased risk for contracting HIV promises to
provide useful information that can inform prevention strategies for Aﬁican American
women.

The model combined traditional models of health behavior with contemporary
health models that include culturally relevant variables. More speciﬁcally, the proposed
model took a gender and culture speciﬁc approach to examining the relationship between
interpersonal relationship power and HIV protective behavior. As suggested by the
current research literature, the cultural context in which this relationship occurs was
explored.

As suggested by the theoretical literature, the speciﬁc cultural constructs that were
purported to inﬂuence interpersonal relationship power and perceived HIV risk were
investigated. In the proposed model, the hypothesized cultural predictors of interpersonal

power included: gender roles, ﬁnancial independence, and perceived sex ratio imbalance.

101

The cultural predictors of perceived risk included: fatalism, optimistic bias, and HIV
knowledge. The ﬁndings from this study demonstrated that the data were a good ﬁt for
the proposed model, suggesting that the theoretical model provided a reasonable
framework for examining HIV protective behavior for low income, Aﬁican American
women. However, some of the speciﬁc hypothesized relationships were not supported in
the proposed model.

The cultural constructs of optimistic bias and fatalism were signiﬁcant predictors
of HIV risk perceptions, while HIV knowledge was not. The importance of one’s
worldview over traditional cognitive behavioral factors inﬂuenced by culture has
considerable implications for intervention and warrants further investigation. The
proposed relationships between interpersonal relationship power, perceived HIV risk, and
HIV protective behaviors were not signiﬁcant in the model analysis. However,
subsequent additional analyses yielded support that the model and hypothesized
relationships may be more relevant under speciﬁc circumstances and for a speciﬁc subset
of the sample. The model ﬁndings in addition to the descriptive ﬁndings for the entire
sample will be discussed below.

The Proposed Integrated Model
Interpersonal Power and HIV Protective Behavior

The proposed integrated model in the current study goes beyond the
individualistic cognitive behavioral approaches to consider the role of culture and
relationship dynamics in the HIV protective behavior of low-income Aﬁican American
women. Gender based inequalities that result in power differentials within intimate

interpersonal relationships can place some women at an increased susceptibility for HIV

102

infection. More speciﬁcally, the gender speciﬁc HIV literature purports that women who
have certain levels of power, operationalized as control and decision-making, within their
intimate relationships are able to employ the necessary HIV precautionary behaviors
when warranted (Amaro & Gomemann, 1992; Gomez & Marin, 1993; Mantell et al,
1995; Timmons et al., 1998). This study examined an integrated model to test the
hypothesis that interpersonal relationship power, operationalized as control in
relationships, would predict HIV protective behavior, operationalized as condom use
ﬁequency. In the model, the relationship between interpersonal control and HIV
protective behaviors was not supported. In the structural equation model, the level of
relationship control reported by women did not signiﬁcantly predict their HIV protective
behavior. This ﬁnding is inconsistent with much of the theoretical literature on gender
related factors and HIV protective behaviors (Amaro, 1995; Amaro & Raj, 2000;
Wingood & DiClemente, 2000). However, this ﬁnding is not surprising in light of the
interpersonal relationship power literature, Amaro and Raj (2000) discuss the difﬁculty of
assessing relationship power and its relationship with HIV protective behavior.

There are a number of factors that may have inﬂuenced the relationship between
interpersonal power and HIV protective behavior in the current model, including the
difﬁculty of empirically examining the construct of power. Power has been
conceptualized and operationalized in a number of different ways, and the HIV
prevention ﬁeld has yet to reach a consensus on a deﬁnition. This study utilized a
deﬁnition of power from the social psychological literature, where power is

conceptualized as control and decision making, speciﬁcally at the interpersonal level.

103

The methodological challenges (low coefﬁcient alpha) of attempting to measure a
complex construct such as interpersonal power may have contributed to the inability to
detect a signiﬁcant relationship between power and HIV protective behavior. In addition,
the construct of power was examined only from the women’s perspective. While the
women’s perspective is critical for understanding the motivation behind particular HIV
protective behaviors, the study of dyadic relationship factors may need to consider the
other member of the dyad’s perspective on power within their relationship.

Additional analyses on the relationship between interpersonal relationship power

and HI V protective behaviors.

Because the model failed to support the well-substantiated relationship between
interpersonal relationship power and HIV protective behavior, two additional analyses
were conducted to ﬁrrther examine this relationship. The ﬁrst used a subset of the sample
for whom the relationship between interpersonal power and HIV protective behavior may
be more relevant. The second utilized a different outcome measure of HIV protective
behavior.

Consistent with the HIV prevention literature, the current study operationalized
the outcome variable of HIV protective behavior as the frequency of condom use. The
speciﬁc motivation behind this condom use or nonuse was not identiﬁed (e.g., birth
control, STD prevention, monogamous and unnecessary). Since condom use requires the
cooperation of both partners, it was important to account for the inﬂuence of partner
attitudes toward condom use. Therefore, a subset of the sample for whom interpersonal
relationship power would be more relevant to the use of condoms was identiﬁed. The

women in this subset reported not using monogamy as a form of HIV protective behavior

104

(implying that condom use was perhaps relevant), having a primary partner with negative
attitudes toward condom use (implying that she would have to use power to negotiate
with a resistant partner) and perceiving themselves to be at some level of risk for HIV
(implying that she had a motivation to engage in HIV protective behavior).

In the ﬁrst analysis, a multiple linear regression was utilized to examine the effect
of interpersonal relationship control on HIV protective behavior (condom frequency)
while controlling for perceived HIV risk on the subsample. Since the subsample was
selected because they did perceive themselves to be at risk, the interaction between power
and HIV risk was removed from the analysis. In this subset, interpersonal power was a
stronger predictor of HIV protective behavior. Given the small sample size, the
probability value of .14 is suggestive of a relationship between interpersonal relationship
control and HIV protective behavior.

In a second analysis a different outcome variable was used. One item on the
survey asked women to self-identify how they protected themselves against HIV. From
this item, a dichotomous (i.e., identiﬁed/did not identify condom use as an HIV
protective behavior they engaged in) outcome variable was created. Approximately one
quarter of the sample identiﬁed condom use as at least one strategy that they used to
protect themselves against HIV.

A logistic regression was conducted on the entire sample to examine the
relationship between interpersonal power and condom use as a self-identiﬁed HIV
protective behavior using this newly created dichotomous outcome variable. The ﬁndings
demonstrated that interpersonal relationship control was a signiﬁcant predictor of

condom use (p < .05). It is unclear why the relationship was signiﬁcant with this outcome

105

variable and not with the condom ﬁ‘equency outcome variable. It may be because
interpersonal control plays a more important role when condom use is speciﬁcally for the
purposes of HIV protective behavior. It may also be due to the fact that the outcome
variable used in the logistic regression required the women to independently generate
their own responses. This may have minimized a positive response bias to report that they
were using condoms to protect themselves.

This dichotomous outcome variable was not used in the model or subsequent
analyses because of the measurement problems it would introduce due to the violation of
multivariate normality in the structural equation model and the overall limitations of
dichotomous variables. The signiﬁcant result of the logistic regression ﬁrrther
demonstrates the complexity of the relationship between interpersonal power and HIV
protective behavior along with the need to understand the contextual conditions under
which this relationship occurs.

Cultural Contextual Factors in the Proposed Model

In addition to examining the relationship between interpersonal power, HIV
protective behavior and traditional cognitive behavioral health factors, this study also
examined the cultural factors that inﬂuence these relationships. Cultural variables that
were hypothesized to have a direct effect on perceived HIV risk and interpersonal
relationship control were included in the model. Most of the literature on these constructs
is conceptual rather than empirical. The cultural constructs that were hypothesized to
have a direct effect on perceived risk included: optimistic bias, fatalism, and HIV

knowledge. The cultural constructs that were hypothesized to have a direct effect on

106

interpersonal control included: traditional feminine gender roles, ﬁnancial independence,
and perceived sex ratio imbalance.
The Role of Perceived HIV Risk

Both traditional and contemporary health theories acknowledge the importance of
perceived risk in the role of precautionary health behaviors. This study hypothesized that
perceived HIV risk would moderate the relationship between interpersonal control and
HIV protective behaviors. This hypothesis was not directly supported in the model
analysis; however, additional analyses on the aforementioned subset of the sample (for
whom risk was present and therefore power was relevant), demonstrated that
interpersonal control became a stronger predictor of HIV protective behavior, as
demonstrated by the larger regression coefﬁcients. While perceived HIV risk
signiﬁcantly predicted HIV protective behaviors, as expected from previous analysis,
neither interpersonal control nor the interaction between perceived risk and interpersonal
control was signiﬁcant in the model.

Consistent with the research literature, the women in this study overall did not
perceive themselves as being at risk for HIV (Cochran & Mays, 1993; Estrada &
Quintero, 1999; Hobfall et al., 1993). The perception of risk has been examined in a
number of different health contexts; however, there has been relatively little empirical
examination of the cultural predictors of perceived risk within the context of HIV for
Aﬁican American women.

Cultural Predictors of Perceived Risk
This study examined three culturally relevant predictors of perceived HIV risk.

One predictor, HIV knowledge, was a traditional behavioral health predictor of perceived

107

risk. However, it was examined as a cultural predictor in this context due to the inﬂuence
that lack of access to health services (Cochran & Mays, 1993) and distrust of government
and mainstream institutions by low-income African American women have on HIV
knowledge (Klonoff & Landrine, 1997). Two additional cultural inﬂuences on perceived
risk suggested by the literature were included: fatalism and optimistic bias. The results
from this study are consistent with the literature on the cultural inﬂuences of risk. As
hypothesized, both sexual optimistic bias and a perceived sense of general fatalism had a
direct effect on an individual’s HIV risk perceptions in the model. Interestingly, HIV
knowledge did not have a direct effect on perceived risk in the model.

HIVKnowledge. The majority of women in this study reported previously
receiving some form of HIV education and were fairly knowledgeable about the
transmission of HIV. However, the women were slightly less knowledgeable about the
high rate of HIV transmission within the African American community. This lack of
knowledge about African American transmission rates may perhaps be related to an
underestimation of their own risk. Although HIV knowledge did not have a direct effect
on perceived risk, after accounting for the effects of other inﬂuencing factors (e.g., sexual
optimistic bias and fatalism), the correlation matrix demonstrated that general HIV
knowledge was signiﬁcantly related to perceived risk (r = .21 , p< .05). The women who
had higher levels of knowledge also had higher levels of perceived HIV risk. The lack of
a direct effect of HIV knowledge on perceived risk is indicative of other inﬂuential
factors more speciﬁc to African Americans.

Optimistic Bias and F atalism. Optimistic bias is the tendency to view oneself as

invulnerable (or less likely than others) to experiencing negative life events, while

108

fatalism has been characterized as viewing life events as being “out of one’s control.”
Both optimistic bias and fatalism have been linked with spirituality or belief in a higher
power. Although the speciﬁc level of religiosity or spirituality was not assessed, the
majority of women in this study reported having some type of religious afﬁliation.
Optimistic bias. Optimistic bias is characterized by the belief that other people,
but not one’s self, will develop a disease, or experience other negative effects (Brannon
& Feist, 2003). In the current study, psychometric analyses suggested that optimistic bias
was comprised of two dimensions, sexual Optimistic bias and a single item indicator of
general optimistic bias. The exploratory measurement model suggested that sexual
optimistic bias would be more parsimonious in the ﬁnal structural model. Therefore a
single item indicator of general optimistic bias was excluded from examination in the
ﬁnal structural model. The results of the model demonstrated that sexual optimistic bias
had a direct effect on perceived risk. Overall, the current sample had high levels of sexual
optimistic bias and low levels of perceived HIV risk. Otherwise stated, the women felt
that the consequences of sexual behavior would not happen to them and they were not at
risk for HIV. Some additional reinforcement for the high rates of sexual optimistic bias
may include the ﬁnding that the majority of women and virtually all of their primary
partners had tested negative for HIV. In addition, although the Aﬁican American
HIV/AIDS incidence (60%) and prevalence (58%) rates are comparable to that of the
national rates, Michigan does not receive the widespread prevention campaigns often
seen in other larger disease epicenters (e.g., New York, Los Angeles), which may also
contribute to the lowered knowledge of HIV within the African American community.

This may also contribute to an increased optimistic bias.

109

F atalism. The literature asserts that Aﬁican American women generally feel that
their lives are guided by a higher power and their life circumstances are beyond their
control (Powe, 1996). Psychometric analyses in the current study suggested that fatalism
was comprised of two dimensions, general fatalism and a single item indicator of HIV
fatalism. The exploratory measurement model suggested that general fatalism would be
more parsimonious in the ﬁnal structural model therefore; the single item indicator of
HIV fatalism was excluded from examination in the ﬁnal structural model. Overall, the
women in this study felt that various life events were out of their control.

Implications of Optimistic Bias, General F atalism, and HIV Knowledge

While conceptually different, the constructs of sexual optimistic bias and general
fatalism intertwined with one another to yield interesting ﬁndings about this sample. The
women in this study felt that general life events were out of their control. However, in
terms of sexual behavior and despite high levels of HIV knowledge, the women were
optimistic that they would not have to deal with the unwanted or negative consequences
of sexual behavior.

The Role of Interpersonal Relationship Power

Interpersonal relationship power was operationalized as control and decision-
making and measured as interpersonal relationship control. As previously noted, the well
substantiated relationship between interpersonal relationship power and HIV protective
behaviors was not supported in the model, but was signiﬁcant in the logistic regression
using an alternate outcome measure of HIV protective behavior. The lack of support for
this relationship in the model was perhaps due to a number of methodological issues

including measurement limitations. Researchers have argued that interpersonal power is

110

not examined within various cultural contexts (Amaro & Raj, 2000). However, there has
been little discourse on exactly what a cultural context of power for African American
women would entail. The ﬁndings from the proposed model did not support the
hypothesis of the three cultural predictors of interpersonal control. Traditional feminine
gender roles and ﬁnancial independence did not have signiﬁcant direct effects on
interpersonal control. There are several possible reasons for the lack of signiﬁcance
found among these cultural variables on interpersonal control.
Cultural predictors of Interpersonal Relationship Power

Financial independence. Overall, the women in this study reported high levels of
ﬁnancial independence. The construct of ﬁnancial independence predicting power in
relationships is not unique to African American women. However, historically Aﬁican
American women have generally been viewed as having higher levels of interpersonal
control within their relationships speciﬁcally due to their ﬁnancial contribution to the
household in comparison with their White and Latina counterparts (Bowleg, 1998). This
history of sharing ﬁnancial responsibilities or being the main breadwinner in a household
has had lasting implications (Hill, 2002). It has been suggested that lack of ﬁnancial
independence is particularly disempowering for Aﬁican women because of the
signiﬁcance of ﬁnances within these relationships, particularly for low-income women.
While the structural equation model did not yield any direct effects on interpersonal
control, the correlation matrix for the dependent and independent variables did
demonstrate a positive trend level ﬁnding between ﬁnancial independence and
relationship control (r= .13, p = .06). Women who had higher levels of ﬁnancial

independence had higher levels of interpersonal control in their relationships.

lll

F emininity. Another hypothesized cultural predictor of interpersonal relationship
control was traditional feminine gender roles. The women in this study reported overall
high levels of traditional feminine gender roles. However, research has demonstrated that
Eurocentric conceptualizations of gender roles may not be generalizable to low-income
Aﬁican American women (Hill, 2002). Prescribed cultural scripts dictate that Aﬁican
American women adhere to more traditional gender roles within the context of intimate
relationships. However, research has viewed African American women as taking on more
androgynous and masculine gender roles in society as the primary caretaker in her family
(Hill, 2002). Increased research is needed to understand the duality of women’s gender
roles and how they play out within the dynamics of intimate relationships and HIV
protective behaviors.

Sex ratio imbalance. Another hypothesized cultural predictor of interpersonal
relationship control was a perceived sex-ratio imbalance. One of the criteria for
participating in this study was the existence of a present or recent sexual relationship with
a male partner. Although all of the women included in the study met this criterion,
somewhat surprisingly, the consensus among the women was a high sex ratio imbalance
of Aﬁ'ican American women to Aﬁican American men. Despite this perceived sex ratio
imbalance, the majority of women felt conﬁdent about their ability to ﬁnd a partner if
they wanted to. The lack of variability and a very low coefﬁcient alpha (V=.35) for this
construct posed measurement problems in the model and was excluded from ﬁrrther
analysis in the model. In addition, the correlation matrix did not yield any relationships

between sex ratio imbalance and interpersonal control.

112

The role of violence. Researchers have found that violence within the context of
intimate relationships plays a signiﬁcant role in the HIV protective behavior of women in
general and requires speciﬁc and direct attention in the ﬁeld of HIV (Wu, El-Bassel,
Witte, Gilbert, & Chang, 2001). While the proposed model examined very general
notions of relationship power, the role of violence in relationships was acknowledged,
speciﬁcally in the descriptive data. In the current study, there were a relatively small
proportion of women (10%, n=1 9/ 196) who reported perceiving themselves as being at
risk for violence if they were to initiate condom use with their primary partner. Data on
intimate paMer violence show that Aﬁican American women experience intimate partner
violence at a rate 35% higher than that of White females, and about two times the rate of
women of other races (US Dept of Justice, 2002). Descriptive analysis in the current
study demonstrated trend level ﬁndings that the women who did perceive themselves as
being at risk for HIV were more likely to perceive their partner as becoming violent (r= -
.12, p= .08) if they initiated condom use and in turn were less likely to feel efﬁcacious
about condom use behaviors (r= -.16, p< .05). Due to the fact that male perpetuated
violence against women is the leading cause of injury to women in the US (US Dept of
Justice, 2002), violence against women has been considered to be a critical factor in the
ability of women to negotiate safer sex behaviors. The women in this study who
perceived their partner as becoming violent if they (the woman) initiated condom use,
were more likely to have negative attitudes toward condom use, making condom use a
less desirable option due to its perceived harmful consequences.

Intimate partner violence is representative of control in intimate relationships.

While violence was not speciﬁcally used as a proxy for control in the current study, the

113

data demonstrated a trend level correlation between perceived violence (r= -.12, p= .08)
and interpersonal relationship control. Male perpetuated violence within the context of
intimate relationships is one method that is used to control, keep women subordinate and
is viewed as a “manifestation of gender inequality” (Koss et al., 1994, p. 4) and warrants
further in depth investigation in the HIV ﬁeld.

The complexity of traditional behavioral constructs and their relationships within
speciﬁc cultural contexts was demonstrated in the proposed model. The descriptive
analysis of the data from the current study allowed for a more detailed description of the
target population for whom these relationships were modeled.

The Sample: Low-Income African American Women

A signiﬁcant proportion of the of HIV research literature on low-income African
American is comparative in nature with their White and Latina counterparts and fails to
empirically examine culture and gender speciﬁc models based on inherent cultural
antecedents. In addition, most of the published literature; on low-income Aﬁican
American women is based on outdated assumptions and treats this group as homogenous.
Very little is known about the within group differences in terms of dyadic relationships
and HIV protective behaviors. This sample of participants were purposively selected for
this study because they reﬂect a segment of the population who have been identiﬁed by
researchers and interventionists as being at increased risk for HIV, due to lower levels of
education, socioeconomic status, the practices of potential partners within their “sexual
partner pool,” and in turn, a marginalized status in the dominant society. This
marginalized status has been purported to result in a compromised sense of empowerment

in general and more speciﬁcally within intimate relationships (Timmons & Sowell,

114

1998). All of the women in the study were considered economically disadvantaged, or
low-income, but did not speciﬁcally ﬁt the presumed stereotypes for low-income
minority women.

Similar to other studies, the women in this sample were recruited primarily from
health or social service agencies from medium to large urban areas. The average level of
education was a little higher than typically reported in the research literature, however,
the rate of unemployment and income levels were comparable to other studies (Bowleg et
al., 2000; Dancy, Marcantonio, & Norr, 2000; Ehrhardt et al., 2002). Inconsistent with
previous studies, the women in this sample had relatively high levels of HIV knowledge
and were overall conﬁdent in their ability to engage in HIV protective behavior (Carey et
al., 1997; Landrine & Klonoff, 1997). Despite the fact that the majority of new HIV cases
occur within heterosexual relationships among African American women, little is known
about the male-female relationships within the Aﬁican American community.
Description of intimate relationships

As one of the criteria for participating in this study, all of the women were in a
current or recently ended, sexual relationship. The majority of women in this study had
children and nearly half of the women lived with their primary partner and shared or
pooled their ﬁnances with their primary partner. The majority of the women reported
being in a “monogamous” or “serious” relationship with approximately equal levels of
commitment to the relationship by the women and their partner. On average, the women
in this study reported being in egalitarian relationships, where they shared control and

decision making with their primary partners.

115

Despite low levels of perceived HIV risk, nearly half the women in this study
reported that their primary partner had sexual relations with someone else during some
point in their relationship. A smaller proportion of women reported having had sexual
relations with someone other than their primary partner in the past three months. In some
circumstances sexual relations with a second partner occurred while the women were in
relationships with a primary partner. The presence of multiple sexual parmers places
these women at increased risk for HIV.

HIV risky behaviors. Traditional health research assumes that perceived
susceptibility to any condition or disease is the primary motivation for the avoidance of
risky behavior and the initiation of precautionary behavior. Behavior is thought to be
directed toward the goal of sustaining or improving one’s health. However, this involves
a personal evaluation of the required behavior, and in turn one’s attitude toward their own
perceived susceptibility or risk. For the purposes of this study and in accordance with the
guidelines set forth by the Centers for Disease Control and Prevention as done in most
HIV prevention studies, HIV protective behaviors was deﬁned as consistent condom use.
Inconsistent condom use and/or sexual relations with multiple partners increases the risk
of HIV transmission and despite a relatively good level of knowledge about general HIV
transmission, and reportedly high levels of condom self-efﬁcacy, condom use remained
variable with primary partners and was slightly more consistent in the presence of a
second partner.

Condom use among African American women has demonstrated to be more often
commonly associated with STD/HIV protection rather than contraceptive use (Amaro et

al., 2002). Condom use was variable in this population. While the majority of women

116

endorsed condom use as the method they used to protect themselves against HIV, nearly
half of the women in this sample reported not using condoms in the past three months
with their primary partner. The other half of the women varied in the consistency of
condom use over the past three months with their primary partner. Less than one fourth of
the women reported always using condoms in the past three months.

The majority of the women in this study reported that neither they and their
partners “never” refused to use condoms implying that they mutually agreed whether or
not condoms were used. If condoms were used, the woman reported being the one who
was most likely to initiate the behavior, placing the onus of condom use and negotiation
on her. Interestingly, it was the partner’s, not the participant’s, attitude toward condom
use that was related to the outcome variable of HIV protective behaviors (condom use
ﬁequency), though not in the expected direction. Women in this study who perceived
their primary partner as having a negative attitude toward condom use were surprisingly
more likely to use condoms (r= -.16, p< .05). Perhaps this was because the women were
aware that their partner negatively evaluated condoms, which may decrease the
likelihood of him using condoms with a second partner, thereby placing her at increased
risk. This ﬁnding suggests that the women in the current study played a signiﬁcant role in
the decision of whether or not condoms were used.

It is important to note that studies have found that African American women who
use condoms consistently are more than seven times more likely to perceive themselves
as having high self efﬁcacy over using condoms and having greater control over their

partner’s use of condoms (Wingood & DiClemente, 1997). Higher rates of condom self-

117

efﬁcacy were signiﬁcantly related to higher rates of HIV protective behavior (r= .21,
p=.05) in the current study.

Condom self-efficacy. The hypothesis of condom self-efﬁcacy mediating the
relationship between interpersonal relationship control and HIV protective behaviors was
not supported in the model due to the earlier ﬁnding of interpersonal control failing to
predict HIV protective behavior. While the hypothesis of condom self-efﬁcacy as a
mediator in the model was not supported, there were a number of interesting
relationships.

First, condom self-efﬁcacy was signiﬁcantly related to relationship commitment
(r= .18, p< .05). The women in this study who felt more cormnitted to their relationship
in comparison with their partner, reported higher levels of conﬁdence in their ability to
engage in the behaviors related to condom use, condom self-efﬁcacy. Less commitment
by the women’s partner was perhaps associated with feelings of possible partner
inﬁdelity and may have motivated the women to feel more efﬁcacious in terms of
condom use. This ﬁnding is further supported by the signiﬁcant correlation between
relationship commitment and perceived HIV risk (r= .20, p< .05). The women in this
study who reported higher levels of relationship commitment than their partners,
perceived themselves to be at greater risk for HIV in comparison with the women who
reported that their partner was more committed to their relationship than they were.

The combination of individual and perception of partner related factors that are
associated with condom self-efﬁcacy further demonstrates the importance of looking at

the role of the partner in HIV protective behavior.

118

Relationship Status and HIV Protective Behavior

The HIV literature suggests that the perception of one’s relationship
(monogamous or not) is currently one of the most salient predictors of HIV protective
behavior among women of color in the research literature (Hobfall et. al., 1993; Kelly &
Kalichman, 1995; Logan et al., 2002; Sobo, 1993; Weeks et al., 1995). Research
demonstrates that relationship status or length can inhibit perceived HIV risk and
protective behaviors. The descriptive data from the current study demonstrate that the
women in this study perceived themselves to be at low risk for HIV infection, based on
their own and their paMer’s behavior. In some instances this ﬁnding may have been
accurate however, as noted, over half of the women in this sample reported that their
partner or they had sexual relations with someone else during some point in their
relationship.

Some literature suggests that condom use is stigmatized among African
Americans as a sign of casual relationships (Catania et a1, 1994; Carovano, 1991;
F ullilove et al., 1990). Consistent with the research literature, descriptive analyses of the
current study demonstrated a signiﬁcant ﬁnding that women who indicated being in a
casual or open relationship were more likely to use condoms (M=2.02, SD=1.04) in
comparison with the women who reported being in monogamous relationship (M=1.67,
SD =.88) t(91) = -1.95, p <.05. One possible explanation for this ﬁnding is that
monogamous women may not believe themselves to be at risk for HIV because they feel
a sense of security from having one sexual partner, and as demonstrated, may not feel the

need to use condoms because they do not perceive a valid threat.

119

As demonstrated by this and other study ﬁndings, there are a myriad of
individual, partner, cultural, and gender related factors that contribute to the decision of
whether or not to use condoms. It would be erroneous to assume that the motivation
behind this decision is the same for all members of a particular group therefore, an
increased understanding of particular at risk groups is critical in curtailing the HIV
epidemic.

Limitations of the Current Study

There are a number of methodological limitations of this study. A number of these
limitations reﬂect the new generation of gender speciﬁc HIV prevention research. The
increasing number of human sexuality studies have been initiated in response to the HIV
epidemic, yet methodological developments in the ﬁeld of sex research have been slow in
meeting the demands of these complex investigations (Cantania et al., 1990). Efforts to
study the HIV-related sexual behavior of minority populations are hampered by the fact
that most of the methodological work in sex research has been conducted with White,
middle-class college students and are unlikely to be generalizable to low-income Aﬁican
American women.

First, many of the measures used in this study had a low internal consistency.
However, this is not uncommon with HIV research and low-income populations with
limited education levels. Given the nature of sexuality research moderate coefﬁcient
alphas are acceptable in this particular domain due to the challenges of measuring such
complex constructs. However, they may still limit the ability to detect signiﬁcant

relationships.

120

Second, research has demonstrated that measures within the sexual domain may
invoke socially desirable responses, especially in self-report, face-to-face interviews
(Cantantia et al., 1990). The women in this study may have been reluctant to rate their
behaviors unfavorably or admit that they are indeed engaging in HIV risk behavior.

Third, instead of assessing actual partner behavior, women’s perceptions of their
partner’s behavior was assessed and may not provide true measures of parmﬂ
characteristics. However, these perceptions do serve as valuable indicators of participants
behaviors in relation to her perceptions about her partner. This was also evident for the
interpersonal relationship control construct. Relationship control occurs within a dyadic
relationship, yet only one person in the dyad’s perception was evaluated. A more accurate
appraisal of relationship control may include both individual’s perspectives.

Fourth, the ﬁndings from this study may be generalizable only to low-income
Aﬁican American women of a certain behavioral risk proﬁle and not applicable to
Aﬁican American women of other socioeconomic statuses or other behavioral risk
proﬁles (e.g., substance use, trading sex for money). While there is some overlap, the
factors examined in this study only pertain to heterosexual HIV transmission and do not
adequately address the factors related to substance use or trading sex for money.

Lastly, the majority of participants were somewhat homo genous in their
perception of HIV risk. Overall, the perception of HIV risk was low. Given this low level
of perceived risk, issues of negotiating HIV protective behavior become less relevant.
The proposed model and hypothesized relationships may have been more applicable,

given a more diverse sample in terms of HIV risk perception.

121

Strengths of the Current Study

This is the ﬁrst known study to empirically model the suggested culture and
gender speciﬁc variables related to HIV protective behaViOr for low-income Aﬁican
American women, as guided by the current theoretical literature. Although there is
support for the inclusion of these variables in the literature, there are very few studies that
have empirically examined these complex relationships. The current study’s ﬁndings
support the inﬂuential role of culturally relevant factors on traditional behavior
constructs, speciﬁcally for perceived HIV risk, which is the basis of most behavior
change models.

There remains a need for more empirical research on low-income African
American women. This group has been identiﬁed as a “difﬁcult to reach” population and
much of what is known about the cultural context of Aﬁican American women in terms
of HIV behavior is conceptual. This study was able to recruit a moderate sized sample of
Aﬁican American women who reﬂect the characteristics of the population that is
experiencing increasing incidence rates of HIV in Michigan and throughout the United
States. Research often examines this group as homogenous in terms of risk and
behaviors, however, this study identiﬁes speciﬁc subgroups who require distinct
attention. The current study highlights the importance of developing more gender and
culture speciﬁc models to understand the array of complex relationships identiﬁed by the
research literature. In addition, it points to the importance of examining the inﬂuence of
partner related factors on these relationships, including the role of violence in
relationships. This study contributes to the research literature on low-income Aﬁican

American women by providing descriptive information about their perceptions,

122

behaviors, and attitudes, which support and add new perspectives to the current literature.

Furthermore, some of the hypothesized cultural predictors of traditional cognitive

behavioral constructs demonstrated to be just as important or stronger in the overall

model as the conventional well substantiated predictors. These ﬁndings provide further

merit for the importance of culture when examining risk-reducing behaviors.
Implications for Interventions

The results of this study yield several important implications that may inform HIV
risk reduction interventions for low-income African American women. First, theoretical
models pertaining to HIV protective behaviors must be speciﬁc to the circumstances of
the women’s relationships. Although identiﬁed as one of the fastest growing risk groups,
all low-income Aﬁican American women are not at risk for contracting HIV. While
prevention messages have stated that reducing the number of sexual partners may be an
effective method of lowering one’s risk of HIV infection, only a quarter of the women in
this study reported mutual monogamy as a method they used to protect themselves
against HIV. The majority of women in this study reported condom use as the method
they used to protect themselves against HIV, yet their self-reports of their actual condom
use was variable indicating that the women know how to protect themselves, but are
choosing not to do so in the presence of a valid risk.

This particular proposed model in the current study may not be applicable to
women who are in mutual monogamous heterosexual relationships with a seronegative
partner in which both partners are abstaining from HIV risk behaviors. Instead, this
model is more applicable to women who perceive themselves as being at risk for HIV

infection. This current study identiﬁed at least four subgroups of women that are not

123

explicitly identiﬁed or distinguished in the research literature on low-income African
American women. These groups include: 1) women who accurately perceive themselves
to be at low risk for HIV and for whom power is less consequential, 2) women who
inaccurately perceive themselves to be at low risk for HIV and for whom power is
inconsequential because they do not see the need to use it, 3) women who accurately
perceive themselves to be at high risk for HIV and are too disempowered to employ HIV
protective behavior, and 4) women who perceive themselves to be at high risk for HIV
and have the power to employ HIV protective behaviors. By clearly identifying which
group is being targeted at a speciﬁc point in time, speciﬁc strategies may be deemed
more effective.

While low-income Aﬁican American women are disproportionately
overrepresented in the HIV/AIDS epidemic, it is imperative to understand which group
the women who are being targeted for risk reduction services, generally ﬁt into with the
understanding that women could easily move from one group to another in a given time
period, given a change in relationship status. The three-month effect of most HIV
interventions indicates that some interventions need to be as dynamic as the changing
contexts of some, not all, members of the target populations. Interventions must be
individually tailored for the speciﬁc groups and current circumstances accordingly.

Second, perceived HIV risk tends to be low in this population. Given the
prevalence of HIV in this population, it appears that the overall perceptions of Aﬁican
American’s risk may be underestimated or inaccurate. If one does not perceive there to be
a valid risk present, they are unlikely to engage in precautionary behaviors. Accurate

knowledge is at the core of most if not all risk reduction HIV interventions. If knowledge

124

is theoretically supposed to increase an individual’s accuracy of assessing their risk, the
ﬁnding of cultural factors predicting perceived risk over HIV knowledge is intriguing.
Consistent with the critiques of the traditional health models, knowledge alone is not
enough to motivate individuals to engage in health protective behaviors and cultural
cognitive factors must receive more than the cursory “culturally competent” attention to
improve accurate risk assessment.

Lastly, while perceived violence prompted by condom initiation was reported by a
small segment of the sample, the prevalence of violence within these relationships is still
unknown. There remain signiﬁcant and trend level relationships between violence and
HIV related behaviors including condom self-efﬁcacy, parmer and participant attitudes
toward condom use, and perceived risk. The deterrent of precautionary behavior,
including the perception of violence, must be properly accounted for in the development
of HIV risk reduction interventions that stress condom negotiation within the contexts of
intimate relationships. Failure to account for the role of violence will fail to target those
factors that may place women at increased risk for infection.

Future Directions

This study’s ﬁndings support the need to develop and empirically examine culture
and gender speciﬁc models of HIV protective behavior with all groups, while, tailoring
the research questions to the boundaries of that group. Most of the cultural relationships
examined in this current study have never been empirically modeled in an HIV protection
model for low-income Aﬁican American women, and have mostly conceptual support for
their investigation. In order to further understand some of the conceptual relationships in

a relatively understudied population like low-income Aﬁican American women,

125

qualitative research techniques are suggested. These techniques can better inform the
necessary quantitative methods and the operationalization of constructs such as
interpersonal power, which will in turn engender the development of more rigorous group
speciﬁc models. While this study was speciﬁcally developed for the purposes of
examining the experiences of African American women, the proposed model lends
support for the development of models that address within and between group
differences.

In the future, this study will be replicated with the inclusion of partners to truly
examine the dyadic nature of relationships which are the context of HIV infection for
most Aﬁ'ican American women. Future investigations can utilize the ﬁndings of
traditional research, however, researchers must continue to examine these relationships
within their speciﬁc ecological cultural contexts and not assume homogeneity within
groups.

CONCLUSIONS

This study provides further descriptive information on the HIV related behaviors,
attitudes, and perceptions of low-income Aﬁican American women in addition to testing
a new model of HIV protective behavior for low-income, African American women.
While only some of the speciﬁc hypotheses were supported in the model, further analyses
(e.g., correlation and regression) suggest that the model is worthy of further investigation
with relevant populations and that the hypothesized relationships between variables may
need to be further conceptualized. The relationship between perceived risk and HIV
protective behaviors can be misunderstood without a cultural context and understanding

of the motivation and resources to engage in protective behaviors once actual risk is

126

perceived. There has been a lack of success of HIV interventions in the African American
community, evidenced by the increasing rates of HIV infection, while rates have
decreased in other populations. This lack of success may be the direct result of lack of
interventions that are speciﬁcally tailored for the unique needs of this group.

The sample in the current study differed somewhat from the samples collected in
other studies of low-income Aﬁican American women. This sample had slightly higher
levels of education, HIV knowledge, and relationship power than reported in related
studies (Carey et al., 1997; Dancey et al., 2000; Murphy et al., 2001; Sterk, Klein, &
Elifson, 2003 ;Timmons & Sowell, 1998). Unlike other studies, the majority of women in
this sample perceived themselves as possessing the necessary knowledge and skills to
protect themselves against HIV, yet did not feel that they were at risk. The majority of the
women did not have the need to use interpersonal power to protect themselves against
HIV because they did not feel that there was a risk present. It is those women who
perceived themselves to be at risk for contracting HIV, had less interpersonal control in
their relationships, and were more likely to experience a violent reaction from their
partner if they initiated condom use, who are of most interest and need to be speciﬁcally
targeted for HIV interventions.

The existing HIV risk reduction models have been largely based on individual
cognitive behavioral approaches while ignoring the dynamics of intimate relationships
(Amaro & Raj, 2000). While the proposed model indirectly examined partner related
factors on the women’s attitudes and behaviors (e.g., perceived risk, condom selfe
efﬁcacy), more speciﬁc perceived partner related factors were further examined in the

additional descriptive analyses and yielded a wealth of rich data about this population.

127

These data provide important new insights into low-income African American women’s
risk for HIV infection, in particular, the speciﬁc barriers to consistent condom use and the
factors that are relevant to women’s interpersonal relationships.

Among economically disadvantaged Aﬁican American women, HIV is simply
one more risk with which to be concerned (Mays & Cochran, 1988). The behavioral
response to HIV is contingent on one’s perception of the disease’s danger relative to the
hierarchy of other risks present and the existence of resources available to act
accordingly. Competition for low-income women’s attention may include more
immediate survival needs such as housing, children, personal safety, ﬁnancial stability,
and competition for male companionship when a sex ratio imbalance is perceived.
Additionally, low—income Aﬁican American may still View HIV/AIDS as a gay White
male disease rather than a threat to their own communities (Cochran & Mays, 1993).

While interpersonal relationship power and perceived risk are global constructs,
the inﬂuence of Aﬁican American cultural antecedents on both of these constructs is
important. As noted, the signiﬁcant predictors, optimistic bias and fatalism are related to
religiosity or spirituality in the Aﬁican American community and have been historically
used as coping mechanisms to deal with the difﬁculties of a marginalized status in
mainstream society (J aggers, 2000). This high levels of optimism found in this
community are consistent with the desire of most individuals, who aspire to increase or
sustain their well-being. This aspiration is what makes interventions to decrease the

transmission of HIV possible.

128

APPENDICES

129

APPENDIX A

 

 

Table 1
Recruitment Strategies
Location On-site Community Snow- Number of Participant
Recruitment Organizations balling screened Rejection
Service ineligible Rate
Organizations participants
Lansing‘ (n=l9) (n=10) (n=9) (n=9)
Print2 (n=120) (n=9) (n=24) (n=6)
Saginaw3 (n=25) (n=7) (n=7) (n=3)
Grand4 (n=12)
Rapids
TOTALS (N =1 64) (n=22) (n=25) (n=40) (n=9)

 

 

1 Baker Donora Community Center
Lansing Community

2 Genesee County Health Department, Women Infant and Children (WIC)
Work First Program-Flint

3 Janes Street Health Clinic Women Infant and Children (W 1C)

4 Grand Valley State Health Conference

130

Table 2
Demographic characteristics of participants

 

 

 

 

Data Collection Age Education Yearly Income
Sites
Sub samples
Lansing 20% (n=39) M = 29.91 M = 13.92 M = $8,584
SD = 9.50 S_D = 2.33 SD =$9,062
Saginaw 15% (n=29) M = 34.67 M = 12.14 M = $4,337
S_D = 11.38 S12 = 1.20 SD =$6,045
Flint 65% (n=128) M = 29.56 M = 12.16, M = $5,005
SQ = 8.57 S_D = 1.60 S_D =$7,73O
Entire Sample 100% (N=196) M=30.38 M=12.51 M=$5,619
_D 19.34 _D i 1.95 SD : $7,900
Yes No Mean
*Married 3% (n=5) 97% (n=191)
Live w/ partner 36% (n=70) 64% (n=126)
Share/pool ﬁnances 43% (n=84) 57% (n=112)
w/ partner
Eligibility for 86% (n=169) 14% (n=27)
Public Assistance
Have Children 86% (n=169) 14% (n=27) M = 2.85
SD 11.75
Religious 72% (n=141) 27% (n=53)
Afﬁliation
”Avg # of people M = 3.69
living in the home SD 1 1.85
Length of time with M = 4.39 (years)
partner SD : 4.59
Full-Time Part-Tirne Home Student Not Other
Work Work maker working

 

Employment Status 14%(n=27) 28 (14%) 140%) 26 (13%) 72 (37%) 25 (13%)

 

*Separated for at least 3 months
“Including the participant

131

Table 3

RelationshiEDescriptives

 

 

 

 

 

 

 

 

Monﬁamous Serious Casual Open
Participants’ 7% (n=12) 61% (n=120) 23% (n=46) 7% (n=14)
description of their
relationship
YES NO
Current sexual 82% (n=161) *18% (n=35)
relationship
Current birth control 55% (n=107) 45% (n=89)
use
Previous HIV 70% (n=137) 30% (n=58)
education received
Previous HIV Test 88% (n=l 72) 12% (n=24)
Partner Previous HIV 66% (n=129) 10% (n=20)
test
Positive Negative Don’t Know
Results of Partner’s .5% (n=1) 64% (n=126) 1% (n=2)
test
YES NO MEAN
Sexual relations w/ a 20% (n=39) 80% (n=156) M =1 .58
second partner during S_ i 1.45
the last 3 months
Male Female
Gender of 19% (n=37) 2% (n=3)
Second
partner
YES NO Don’t Know
Sexual 13% (n=26) 7% (n=14) ------------
relations w/
second
partner while
in a
relationship
w/ primary
partner
YES NO Don’t Know
Partner’s sexual 47% (n=93) 42% (n=82) 11% (n=21)
relations outside of
the relationship
Male Female Don’t Know
Gender of partner’s mm 93% (n=95) 7% (n=7)
secondary partner
Participant Partner Both Neither
Who is most likely to 56% (n=110) 12% (n=24) 17% (n=33) 6% (n=12)

initiate condom use?

 

*Were in a sexual relationship w/in the past 3 months of taking the survey

132

Table 4

Types of Birth Control Used

 

 

 

Count
Condoms 4% (n=7)
Depo (Shot) 13% (n=26)
Patch 5% (n=10)
IUD/Norplant 2% (n=3)
nglufontraceptrves 7% (n=14)
Hysterectomy 2% (n=4)
Tubul Ligation 16% (n=32)
Sterile .5%(n=1)

Table 5

Please list all the ways that you protect yourself from getting HIV/ AIDS?

 

Count

 

Condoms

Practice Mutual
Monogamy

Regularly get an HIV test

Douche/wash after sexual
intercourse

Know your partner is
negative

Take birth control
Partner pulls out before
ejaculation

Practice oral/anal
intercourse

65% (n=127)
25% (n=49)
13% (n=25)
10% (n=19)

10% (n=19)
5% (n=10)
4% (n=7)

.5% (n=1)

 

133

Table 6

Psychometric properties of ﬁnal measures: Means, standard deviations, and range

 

 

Measure Dimensions M SD Possible Cronbach Skew Kurtosis
Range Alpha
Gender Roles
Femininity 4.24 .57 1-5 .74 1.18 2.43
Partner Dependency
Financial
Independence 1.15 .22 1-4 .62 -2.05 4.37
Interpersonal Power
Control 3.39 .65 1-5 .64 -.57 1.64
RCIat'9DSh‘p 3.37 1.00 14 .80 -.10 -.17
Commrtment
Attitudes towards Condoms
Positive
Partner 2.38 .59 1-4 .75 .74 -.O6
Attitudes
Positive
Participant 2.79 .49 1-4 .67 -1.09 2.27
Attitudes

Protective Behaviors
Frequency of Condom Use

 

W/ 9mm” 1.92 1.00 1.3 N/A I I
partner
W/ sewn“ 2.73 1.06 1.3 MA I I
partner
W/ a" 1.97 .99 1.3 N/A I I
partners
Condom Self-Efﬁcacy 1.71 .36 1-5 .64 1.41 1.28
Sex Ratio Imbalance 4.09 .77 1-5 .35 -.90 1.09
HIV Perceived Risk 1.77 .81 1-5 .67 .94 .12
Fatalism
General
Fatalism 3.87 1.01 1-5 .64 -.83 -.05
HIV Fatalism 1.31 .82 1-5 S. Item SI SI
Optimistic Bias
General
Optimistic 2.27 1.07 1-5 S. Item SI SI
Bias
Sexual
Optimistic 3.21 .62 1-5 .69 —.23 .28
Bias
I-IIV General Knowledge .82 .12 0-1 .63 .33 6.65
HIV Aﬁ‘ca“ Amman .77 .26 0.1 .63 .89 -.07
knowledge
I Condom frequency index
SISingle Item Indicator

134

Table 7

HIV Knowledge Frequency of Correct Responses

 

HIV KNOWLEDGE ITEMS

Correct
(N=1 96)

 

Having sex with more than one partner can increase a
person's chance of being infected with HIV.

A person will NOT get HIV if she or he is taking
antibiotics.

Using Vaseline or baby oil with condoms lowers the
chance of getting HIV.

A person can get HIV by sitting in a hot tub or a
swimming pool with a person who has HIV.

There is a vaccine that can stop adults from getting HIV.

Showering or washing one's genitals/private parts, after
sex keeps a person from getting HIV.

A person can get HIV from oral sex.
A woman can get HIV if she has anal sex with a man

A woman cannot get HIV if she has sex during her period

A natural skin condom works better against HIV than does
a latex condom.

The leading cause of HIV infection among African-
American women is heterosexual contact, followed by
injection drug use.

Pulling out the penis before a man climaxes /cums keeps a
woman for getting HIV during sex

African Americans accounted for over half of the new HIV
diagnoses reported in the United States

A person can get HIV by sharing a glass of water with
someone who has HIV

People who have been infected with HIV quickly show
serious signs of being infected

Taking a test for HIV one week after having sex will tell a
person if she or he has HIV

There is a female condom that can help decrease a
woman's chance of getting HIV

People are likely to get HIV by deep kissing, putting their
tongue in their partner's mouth, if their partner has HIV.
Aﬁican American women are twice as likely as White
women to get HIV.

Coughing and sneezing Do Not spread HIV

All pregnant women infected with HIV will have babies
born with AIDS

99% (n=194)
97% (n=191)
96% (n=189)
94% (n=184)
91% (n=179)
90% (n=176)
90% (n= 176)
89%(n=175)
89%(n=175)
89% (n=175)

89% (n=175)

88% (n=173)
81% (n=159)
79% (n=155)
76% (n=148)
72% (n=142)
69% (n=135)
62% (n=122)
61% (n=120)
59% (n=115)
46% (n=9l)

 

135

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137

Table 9

Skew and Kurtosis values for log transformed variables

 

 

 

 

 

 

 

 

Pre- Transformation Post Transformations
Kurtosis Skew (SE) Kurtosis (SE)
Condom Self— 6.52 1.28 .90
Efﬁcacy
Violence 1 1.40 3.13 8.49
HIV Fatalism 11.58 2.41 5.169
Financial 4.37 -l .48 1.72
Independence
Femininity 2.42 -.26 -.24
Individual Item Transformations
Financial 10.866 2.518 5.610
Independence 20A
Financial 1.591 1.144 .399
Independence 20B
Table 10
Correlations Among Exogenous and Error Terms Variables in the SEM Model
. Estimated
Exogenous Variables Correlations
Femininity <--> Financial_1ndependence -.O8 1
Sexual_0ptimistic Bias <--> Genera1_Fatalism .181
*Financial_lndependence <--> Genera1_Fatalism -.272
Sexual_0ptimistic Bias <--> Financial_1ndependence -.140
Femininity <--> General_Fatalism . 145
Sexual_0ptimistic Bias <--> Femininity .003
‘HIVKNOWZ <--> General_Fatalism -.392
HIVKNOW2 <--> Sexual_0ptimistic Bias -.l47
HIVKNOW2 <--> Financial_1ndependence -.O43
*HIVKNOWZ <--> Femininity -.207
Error Terms
‘Efemo (error terms) <--> Efemu (error terms) .298
ERCd (error terms) <--> ERCe (error terms) .187
ERCc (error terms) <--> ERCd (error terms) -. 141
*Eriskb (error terms) <--> En'skc (error terms) .456
Eriskc (error terms) <--> Eriske (error terms) -. 142

 

"Correlation is signiﬁcant at the 0.05 level (2-tailed)

138

Table 11

Standardized Indirect Eﬂects of SEM Model

 

 

22:23:“? mv m Essa“, E???
S33; .00 .00 .00 .oo
{Dmﬂme .00 .00 -.01 .00
Femininity .00 .00 .oo .00
Exam Bias .00 .00 .oo .04
HKNIVOW .00 .00 .00 .00
3:33me .00 .oo .00 +.04
git; .00 .00 .00 .00
Egg: self' .00 .00 .oo .oo

 

"Correlation is signiﬁcant at the 0.05 level (2-tailed)
+ = .14 "Correlation is signiﬁcant at the 0.05 level (2-tailed).

139

Table 12

Standardized Direct Eﬂects

 

 

23:23:“? mv Risk Emmy 35$

Partner

3:33; .00 -.31** .00 .00
gmémc -.04 .00 .00 .00
Femininity .00 .00 .00 .00
ﬁﬂsm Bias .000 .00 .00 .00
ﬂow .00 .07 .00 .00
23:33:18”? .00 .00 .00 -.06
g; .00 .00 .00 .25
5352;: self' .00 -.31 .00 .00

 

"Correlation is signiﬁcant at the 0.05 level (2-tailed)

140

Table 13

Unstandardized and Standardized,Measurement Coeﬂicients 3 (N = 196)

 

 

Items Variables B El S.E. C.R. P

QUES14G femininity 1.000 .558

QUE314H femininity .740 .441 .155 4.778 ***
QUES14I femininity .668 .567 .117 5.716 ***
QUESI4L femininity 1.081 .720 .166 6.508 m
QUESI‘“) femininity .659 .455 .136 4.848 m
QUESl4U femininity .758 .549 .136 5.572 ***
QUESl‘W femininity 1.014 .640 .165 6.150 m
QUE20B44 Financial_1ndependence 1.000 .471

QUE20A44 Financial_1ndependence 1.690 .941 .794 2.127 .033
QUESSZZB Relationship_Control .494 .360 .134 3.695 ***
QUES22C Relationship_Control .558 .396 .144 3.878 tau
QUES22D Relationship_Control .664 .420 .176 3.775 ***
QUES22E Relationship_Control .747 .528 .162 4.623 ***
QUES23A Relationship_Control .783 .518 .165 4.762 ***
QUE823C Relationship_Control 1.000 .639

QUES32G Condom_Self-Efﬁcacy 1.000 .584

QUES32F Condom_Self-Efﬁcacy 1.070 .537 .345 3.103 .002
QUES32G Condom_Self-Efﬁcacy .770 .410 .250 3.076 .002
QUES34A HIV_Risk 1.000 .497

QUES34B HIV__Risk .391 .402 .093 4.196 ***
QUES34C HIV_Risk .493 .487 .105 4.708 ***
QUES34D HIV_Risk 1.198 .728 .203 5.900 m
QUES34E HIV_Risk 1.032 .631 .187 5.521 ***
QUES35A General_Fatalism 1.000 .521

QUESBSB General_Fatalism 1.462 .690 .277 5.275 ***
QUES35C General_Fatalism 1.435 .635 .276 5.204 ***
QUES36B Sexual_0ptimistic Bias 1.000 .314

QUES36D Sexual_0ptimistic Bias 2.384 .888 .568 4.195 ***
QUES36B Sexual_0ptimistic Bias 2.275 .861 .542 4.200 ***

 

141

Table 13 continued

Unstandardized and Standardized Structural Coefﬁcients

 

 

 

 

 

 

 

 

 

Variables Variables B 3 S.E. C.R. P
Fma‘w‘a‘ Relationship Control -1.236 -.04 2.757 -.448 .654
Independence -
femininity Relationship_Control -.007 -.01 .119 -.059 .953
Relationship Control condom self’ .096 .14 .084 1.133 .257
Efﬁcacy
General Fatalism HIV Risk -.401 -.31 .146 -2.752 .006
HIVKNOW2 HIV Risk .437 .07 .510 .857 .392
sexualgg‘m‘m HIV Risk -1250 -.61 .368 -3.395 ***
C°nd°m-Self' SEXWPR_A .463 .23 .217 2.133 .033
Efﬁcacy
HIV Risk SEXWPR_A -.068 -.06 .099 -.684 .494
Relationship Control SEXWPR_A .082 .06 .120 .683 .495
Note: 322(395) = 463.94, p < .05; SRMR = .07; IF I = .96; RMSEA = .03
Table 14
Measurement and Structural Model Comparison Table
Model 12 DP SRMR RMSEA IFI
Core Measurement
Model 214.87 84 .06 .03 .93
Core Structmal Model 100.64 180 .05 .03 .96
P
LR Chi Sqaure Diff 114 23 96 P < 05
Test ' '
Final Measurement
Model 423.37 395 .06 .02 .98
Final Structural Model 463.94 412 .06 .03 .96
P
LR Chi Sqaure Diﬁ‘ 17
Test 39.63 p=ns

 

142

APPENDIX B

Consent Form

HEALTH and RELATIONSHIPS STUDY

Purpose of the Study: You are being asked to participate in a study that
examines the inﬂuence of culture on relationships and the affect they have on
women’s health protective behaviors.

Procedures: You will be asked to complete a 60-minute questionnaire, which
asks questions about your cultural beliefs, present and previous relationship(s),
and your sexual behavior.

Compensation: You will be given $10.00 for completing the questionnaire.

Risks: There are no physical, legal or economic risks to participating in the
study. It is possible that you might experience uncomfortable or adverse feelings
from completing a questionnaire that asks questions about sensitive issues
regarding personal beliefs, experiences, relationships and sexuality.

Beneﬁts: This study will increase our understanding of the health practices of
African American women, help to identify factors that increase protective
behaviors among African American women, and possibly assist in the
development of interventions to decrease the number of new HIV infections in
this population. By participating you will be contributing to the understanding of
women, relationships and healthy behaviors.

Confidentiality: ”Your privacy will be protected to the maximum extent allowable
by law.” The survey is completely conﬁdential. You will not be asked to put your
name on a questionnaire and no one, including the researcher, will be able to
associate your responses or other data with your name. Only the researchers
and research staff will have access to data, except in rare circumstances in
which a researcher may be compelled to break the conﬁdentiality of subjects
(e.g., in response to a subpoena or at the request of University Committee on
Research Involving Human Subjects (UCRIHS), no absolute guarantees to
privacy are possible.

143

Withdrawal: Participation in this study is voluntary. You have the right to
discontinue participation in the study at any time. There are no penalties to

you if you choose not to participate in this study or if you choose to withdraw or
discontinue your participation

“If you have any questions about this study, please contact the investigator-
Sinead Younge, (517) 353-9965, youngesi@msu.edu. If you have questions or
concerns regarding your rights as a study participant, or are dissatisﬁed at any
time with any aspect of this study, you may contact — anonymously, if you wish —
Peter Vasilenko, Ph.D., Chair of the University Committee on Research Involving
Human Subjects (UCRIHS) by phone: (517) 355-2180, fax: (517) 432-4503, e-
mail: ucrihs@msu.edu, or regular mail: 202 Olds Hall, East Lansing, MI 48824. "

Your signature below indicates your voluntary agreement to participate in this
study.

 

 

Participant’s Signature Date

144

 

APPENDIX C

 

Before we start I want to make sure that you know that all of the information that you provide is conﬁdential
(your name will not be attached to it and no one but members of the MSU research team will see the
answers that you provide). This study is not afﬁliated with

HEALTH AND RELATIONSHIPS QUESTIONNAIRE

service providers. No one here or at any other place where you receive services will see your answers.

1.

2.

10.

11.

12.

123.

What ethnic or racial group do you feel you most closely identify with?

 

What is your date of birth? / / *Ineligible if born after _/86

Are you married? IQNO IQYes *Ineligible if they are currently married

During the past 3 months (e.g., August, 2004) have you been involved in a sexual relationship with a
male partner? By this I mean someone who you have had sexual intercourse with (with penetration), on
more than two occasions. We Wes

*Ineligible if they have not been in a sexual relationship in the past 3 months
Are you currently trying to become pregnant? 'teNo IQYes

*Ineligible if they are trying to become pregnant.

Have you ever been tested for HIV, the virus that causes AIDS?
IQNO if no skip to question #9 “tanes

If yes, when was your last HIV test? Month Year

What was the result of your last (i.e., most recent) HIV test?

 

IQPositive ~tQNegative tel don’t know *Inellgible if they are HIV positive
What is you yearly income? *lneltgible if more than $40,000 per year
Do you have any children? IQNO 1y es, How many? What are their ages?

Including yourself, how many individuals live in your household?

 

To the best of your knowledge, are you eligible for any public assistance? (e.g. Ingham county health
plan, WIC, food stamps)?

IQNO TQYes
Are you receiving any public assistance (e.g., food stamps, AFDC, Medicaid, etc.)?

”teNo IaYes (please specify)

 

********#**********************$****#End of screening#***#*************************#*

145

(current service provider) or any other

INELIGIBLE: “Thank you for your time and cooperation. At this time you do not ﬁt the
selection criteria for participation in this study. If you would like more information about
health and Aﬁican American women, we have some contact information that we would
be happy to provide you with. Thank you again and have a great day!”

ELIGIBLE: “Thank you for your time and cooperation. You ﬁt the selection criteria for
participation in the study. If you would like to continue, there is a questionnaire that takes
approximately 45 minutes to complete. Aﬁer completing the questionnaire you will
receive $10.00 cash for your participation.

* “If you are not able to participate at this time but would like to at a later date, we can
schedule a future appointment.”

13. Many of the questions I will be asking you will be about your relationship with the
person who was your main sexual partner in the last 3 months. If you had a sexual
relationship with more than one person during the past 3 months, this would be the
person who you felt more involved with or committed to than anyone else. Please tell me
the initials of that person

Are you currently in a sexual relationship with ? 9 No 9 Yes

If no, when did you stop seeing him?

 

146

 

PART 1: Anour You

The items below ask you about what kind of person you think you are. Each item consists of a pair of terms,
with the letters A-E in between. For example:

 

L Notatallgoodatsports [AJB IC ID IE [Vayﬂodatsports I

 

For each of the pairs of words below, please choose the letter which describes where you fall on the scale. In
the example above, if you think that you are not at all good at sports, you would choose A. If you think that
you are pretty good at sports, you might choose D. If you are only medium, you might choose C and so on.

14. Using the scale below, please circle the letter that best describes what kind of person you think you are for
each of the items. Please circle only one letter for each item.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

a. Not at all aggressive A B C D E Very aggressive

b. Not at all independent A B C D E Very independent

c. Not at all emotional A B C D E Very emotional

d. Veﬂsubmissive A B C D E Very dominant

e. Not at all excitable in a MAJOR crisis A B C D E Very excitable in a
MAJOR crisis

f. Very passive A B C D E Very active

3. Not at all able to devote my self A B C D E Able to devote my self

completely to other people cormﬂetely to other people

h. Very rough A B C D E Very gentle

i. Not at all helpful to others A B C D E Very helpful to others

j. Don’t like to compete with other people A B C D E Very much like to
comﬁte with other people

k. Know a lot about the home A B C D E Know a lot about the
world

i. Not at all kind A B C D E Very kind

m. Don’t care about what other people say or A B C D E Care very much what

think about me other people say or think

about me

n. Feeligs not easily hurt A B C D E Feelings_easily hurt

0. Not at all aware of others’ feelings A B C D E Very aware of others’
feelings

p. Can make decisions easily A B C D E Has difﬁculty making
decisions

q. Give up vet)l easily A B C D E Never give up easily

r. Never cry A B C D E Cry very easily

3 Not at all self-conﬁdent A B C D E Very self-conﬁdent

t. F eel very inferior A B C D E Feel very superior

it. Not at all understanding of others A B C D E Very understanding of
others

v. Very cold in relations with others A B C D E Very warm in relations
with others

w. Very little need for security A B C D E Very strong need for
security

x. Falls apart under pressure A B C D E Stand up well under
pressure

 

 

 

 

 

 

 

 

 

 

147

21. Now, I’d like to ask you a few questions about how your relationship with (main paraler’s initials)
works. Using the scale below, please describe how much you agree with the
following statements:

I 1 l 2 I

3
Snon Disa ee Somewhat Disa SomewhatA StIon A ee

 

22. Now, I’d like to ask you a few questions about how your relationship with (main partner’s initials)

a. partner not any my 1 2 3

my partner, am not to get

 

statement that best describes your answer:

 

 

 

 

 

 

 

 

23.
1 2 3 4 5
Your Partner Your Partner Both of You equally You You
Completely Somewhat Somewhat Completely

 

 

is going

 

148

PART 3: About Your Sexual Behavior

In this section, I would like to ask you some questions about your sexual relationship with (insert main
partner’s initials) . Some people may ﬁnd the questions to be of a sensitive nature,
therefore you may complete this section on your own if you so desire. My purpose in asking these
questions is to learn about women’s sexual relationships. Please remember, all information that you provide
is anonymous and conﬁdential (that is no one but members of the MSU research team will see the
answers that you provide).

24. How often did any of the following behaviors occur with (main partner ’s initials),
within the past 3 months. Using the scale below, please circle the correct response.

 

 

 

 

 

 

 

1 2 3 4
None of the Some of the time Most of the time All of the
time Time

 

 

24a. Thinking about your relationship with , who is most likely to initiate condom use?

25. Now, I’d like to ask you some questions about how you and (insert main partner’s initials)
feel about condom use. Circle the appropriate answer:

 

 

 

 

 

 

 

1 2 3 4
Strongly Somewhat disagree Somewhat Agree Strongly Agree
Disagee

 

56X

my partner to use a

partner to use a

me to use a

my partner me to use a

 

26. Do you think (insert main partner’s initials) has had sexual activities with another person
at any time during your relationship?

9N0 9 Yes 9 I don’t know

149

26a. If yes was this individual (please check all that apply)
9 Male 9Female 9 Don’t Know
27. Within the past 3 months, have my bad sexual relations with someone other than your main partner?

9N0 (If no please skip to question #31) 9 Yes (how many people arcluding your main parater?)

 

28. If yes, was this individual(s)
9 Male 9 Female 9 Both Males and Females

"If you haven’t had sex with someone other than your main partner in the past 3 months skip to
question #31“

29. Thinking about any and/or all other individual(s) who you have had sexual relations with in the past 3
months, excluding ( ) your main partner, how often did any of the following behaviors occur,
within the past 3 months? NOTE: We are interested in knowing about individual(s) other than (main

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

partner ’3 initials ). Using the scale below, please circle the correct response.
1 2 3 4
None of the Some of the time Most of the time All of the
time Time
a. Had oral sex with a condom or dental dam. l 2 3 4 Didn’t have oral
sex
b. Had vaginal sex with a condom or other latex 1 2 3 4 Didn’t have
barrier vaginal sex
c. Had anal sex with a condom or other latex barrier l 2 3 4 Didn’t have anal
sex
d. My partner refused to use any form of protection 1 2 3 4
e. I refused to use any form of protection. 1 2 3 4
30. Were you in a relationship with when any of the above behaviors occurred?
(main partner ’s initials)
9N0 9 Yes

SKIPPED QUEST IONED END HERE BEGIN WITH NUMBER 31

150

 

31. Please list all the ways that M protect yourself ﬁ'om getting HIV/AIDS? Check all that apply
9 Regularly use latex barriers (e. g. condoms, dental dams) 9 Take birth control (e. g., pill, shot, etc)

9 Practice Oral/Anal intercourse 9 Know your partner is negative
9 Practice Mutual Monogamy 9 Regularly get an HIV test
9 Douche/W ash after sexual intercourse 9 Other

 

9 Partner pulls out before ejaculation

 

32. Thinking about your behaviors related to sexual practices, please answer how much you agree or
disagree with the statements below.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

l 2 3 4 5
Strongly Disagree Disa Neither Agree or Agree Strongly Agree
gree Disagree
a I can buy condoms or dental dams without feeling embarrassed. 1 2 3 4 5
b. I can carry condoms or other latex barriers around with me in case I have sex. 1 2 3 4 5
c. I can discuss using condoms or other latex barriers with someone that I may 1 2 3 4 5
have sex with.
d. I cannot put a condom on a mnis that is erect or hard. 1 2 3 4 5
e. I cannot discuss HIV/AIDS precautions with a doctor or nurse. 1 2 3 4 5
f. I can discuss with a partner the use of condoms for HIV/AIDS protection 1 2 3 4 5
when I’m already using other types of birth control (e.g., the pill, Depo-
Provera, etc.)
(1. I can ask a potential partner to put-off or postpone sex if we don’t have 1 2 3 4 5
condoms or latex barriers available at the time.

 

 

 

 

 

 

 

 

PART 4: Attitudes and Beliefs

Now, I would like to ask you some questions about your opinions and belie/3 in diﬁ’erent situations. There is
no right or wrong answer. We would like to know how you feel. Using the following scales, please circle the
answer that you most agree with.

33. The following questions ask about your opinions, please circle the answer that best describes how you
feel.

 

 

 

 

 

 

 

 

 

 

1 2 3 4 5
Strongly Disagree Neither Agree or Agree Strongly
Disagree Diwee Agree
a. The number of eligible Aﬁican American women outnumbers the l 2 3 4 5

number of eliggle African American men.

If I wanted to, I could ﬁnd a new partner.

There are plenty of available partners for Aﬁican American women.
It is difﬁcult to ﬁnd a suitable partner.

Aﬁican American men have many options for available partners.

 

 

 

 

CANDID-l
«hath-Ii
UIUIUIU!

999.c-
I'd-III.—
NNNN

 

 

 

 

 

 

 

 

 

151

 

34.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1 2 3 4 5
Strongly Disagree Neither Agree or Disagree Agree Strongly
Disagee Agree

a. My sexual experiences do not put me at risk for contracting HIV /AIDS. 1 2 3 4 5
b. There is a possibility that I may have HIV. 1 2 3 4 5
c. I may have had sex with someone who has HIV 1 2 3 4 5
d. I am at risk for HIV/AIDS 1 2 3 4 5
e. My sexual partner(s) behavior may place me at risk for HIV/AIDS 1 2 3 4 5
35.
l 2 3 4 5

Deﬁnitely Mostly Not Sure Mostly False Deﬁnitely

True True False
a. People die when it is their time and there is not much that can be done 2 3 4 5

about it.

. We must live for the present, who knows what the future may bring. 2 3 4 5
c. It is not always wise to plan too far ahead because many things turn out to 2 3 4 5
be the way they are for better or worse anyway.
d. If I practice certain behaviors, I can protect myself against HIV 2 3 4 5
c. There is not much a person can do to avoid getting HIV 2 3 4 5
36.
l 2 3 4 5
Much Slightly About the Slightly Less Much Less
Greater Greater Same
a. Compared to other Aﬁican American women, my chances 2 3 4 5

ofexperiencing A tragic event are............ .

b. Compared to other African American women, my chances of 2 3 4 5
accidentally becoming pregnant are. . . ..
c. Compared to other Aﬁican American women, my chances of 2 3 4 5

Experiencing positive life events are .........

d. Compared to other Aﬁican American women, my chances of 2 3 4 5

Contracting a sexually transmitted disease are ............

e. Compared to other Aﬁican American women, my chances of 2 3 4 5

Contracting HIV are ..................

 

 

 

 

152

 

 

 

 

 

 

 

 

PART 5: About HIV

37. Now, I would like to ask you some questions about HIV, the virus that causes AIDS. Please
indicate whether you believe the statement is True or False.

 

 

 

a. Coughing and sneezing DO NOT spread I-IIV. T

b. A person can get HIV by sharing a glass of water with someone who has T F
HIV.

c. Pulling out the penis before a man climaxes/cums keeps a woman from F

getting HIV during sex.
d. ' A woman can get HIV if she has anal sex with a man.

 

 

 

 

e. Showering or washing one’s genitals/private parts, after sex keeps a F
person from getting HIV.

f. All pregnant women infected with HIV will have babies born with F
AIDS.

g. People who have been infected with HIV quickly show serious signs of F
being infected.

 

h. There is a vaccine that can stop adults from getting HIV.
i. People are likely to get HIV by deep kissing, putting their tongue in their
partner’s mouth, if their partner has PHV.

 

 

 

 

t-l tit-l t-lI-l t-l t-l t-lF-l t-i
51'11

 

J A woman cannot get HIV if she has sex during her period. F

k. There is a female condom that can help decrease a woman’s chance of F
getting HIV.

1. African Americans accounted for over half of the new HIV diagnoses F
reported in the United States.

m. A natural skin condom works better against HIV than does a latex F
condom.

 

n. A person will NOTJet HIV if she or he is taking antibiotics.
o. The leading cause of HIV infection among African-American women is
heterosexual contact, followed by injection drug use.

 

'1'1'11

 

 

 

 

 

 

 

 

 

 

 

T
T
T
p. Having sex with more than one partner can increase a person’s chance of T F
being infected with HIV.
q. Taking a test for HIV one week after having sex will tell a person if she T F
, or he has HIV.
‘ r. A person can get HIV by sitting in a hot tub or a swimming pool with a T F
person who has HIV.
s. A person can get HIV from oral sex. T F
t. African American women are twice as likely as White women to get T F
HIV.
11. Using Vaseline or baby oil with condoms lowers the chance of getting T F
HIV.

 

PART 6: BACKGROUND INFORMATION
38. Have you previously received any HIV education/ information?

9 No 9 Yes
When? (e.g., 2 years ago)
@lease specify)

 

 

153

 

39. How would you rate your HIV knowledge?
Poor Fair Average Good Excellent
9 9 9 9 9

40. Has your main partner been tested for HIV, the virus that causes AIDS?
9 No 9 Yes 9 I don’t know
40a. If yes, what was the result of your main partner’s HIV test?
9 I don’t know 9 Negative 9 Positive 9 N/A

40b. If you do not know if your partner was tested, what is your best guess of your main
partner’s most recent HIV status?

9 Negative 9 Positive 9 N/A

41. Are you currently using any kind of birth control? 9N0 9 Yes If yes, which kind do you
use?:

 

42. Which of the following best describes your work situation (Please check all that apply)?

9 I work full-time 9 I am retired

9 I work part-time 9 I work full-time taking care of my home and/or
children

9 I do not work 9 I am a full-time student (college, university etc.)
9 Other

 

43. What type of work do you do?

 

44. Do you have a religious affiliation/orientation? (e.g., Baptist, Methodist, Agnostic, etc.)

9 No 9 Yes, If yes please specify

 

45. What is the highest grade you have completed in school?

154

 

 

APPENDIX D
HIV Resource Guide

Facts about HIV

The HIV virus is found in blood, semen, vaginal fluids tit breast milk.

HIV is transmitted through sexual intercourse, intravenous drug use, blood-
to-blood contact, by birth from mother to child and by breast-feeding.

HIV is AIQI an airborne virus and cannot be caught by being in the same
room as an infected person or even by casual contact, e.g. a hugging an
infected person or shaking his or her hand.

HIV is the virus that causes AIDS, but not every person that is HIV
positive will contract the AIDS disease.

Condoms help prevent the transmission of during sexual intercourse.

Statistics on HIV

The World Health Organization estimates that about 9076 of HIV infections
are heterosexually transmissions.

The Center for Disease Control estimates that among women with HIV 75%
were infected through heterosexual intercourse and 25% through injection
drug use. Of these women 64% are African American.

African American women are 13% of the female population in this country,
but were 63% of the new AIDS cases in 1999.

About 800,000 to 900,000 people in the US have the HIV infection and 1/ 3
(250,000 to 300,000) of them are unaware that they are infected.

Know Your Status: Resources

Today HIV is most commonly tested by taking a sample of saliva. However, it can also be tested
though a special blood test.

There are many places in the Saginaw area that provide free, anonymous, and
confidential HIV testing and counseling

The Hearth Home, Health Delivery, Inc.

732 Hoyt Avenue (located behind St. Mary's Medical Center)

Saginaw (989) 753-9011

Saginaw County Health Department 1600 N. Michigan Avenue

Saginaw (989) 758-3880

Michigan AIDS Hotline (800) 872-AIDS

CDC National AIDS Clearinghouse (800) 458-5231

155

 

 

 

APPENDIX E
PSYCHOMETRICS OF FINAL SCALES

GENDER ROLE SCALE-PAQ

 

 

 

 

 

 

F emininity
#14 ITEMS Means SD ”9’" To?”
Correlatzons
Not at all able to devote my self
g. completely to other people 4.19 1.13 .48
h. Very rough 4.06 1.06 .37
i. Not at all helpful to others 4.66 .74 .48
1. Not at all kind 4.37 .95 .61
0. Not at all aware of others’ feelings 4.23 .926 .45
u. Not at all understanding of others 4.39 .87 .51
v. Very cold in relations with others 4.11 1.00 .53
Means SD Range of Scores Possible Cronbach
Range Alpha
4.24 .57 1.50-5 1-5 .76
DELETED ITEMS
[0. Not at all emotional 3.84 1.15 .07 |

 

156

 

Relationship Control Scale

 

 

 

 

 

#22 ITEMS Mean SD 1”” ["7"
Correlations
22b Who has more to say about what you
22c Who has more to say about when you V.
see one another? 3.14 1.06 .27
22d Who has more say about when you
talk about serious things? 3-28 1-19 ~33
22e Who has more say in making
important decisions in your 349 1.06 .45
relationship?
23a Who has more control of what your
relationship is like? 3-32 1 -14 -40
23c Who has more control of where your
relationship is going in the future? 347 1.18 .48
Means SD Range of Scores Possible Cronbach Alpha
Range
.65 1-5 1-5 .64

Deleted items based on factor analysis and reliability testing.

 

23e.
23f.

Who tries harder to make your relationship work

Who cares more about the relationship

157

 

 

Inter Item

 

#2232/ ITEMS Means SD Correlat-
ions
22a Who has more to say about whose ﬁ'iends you
22b Who has more to say about what you do
22c Who has more say in making important
decisions in your relationship? 3.49 1.06 _37
230 Who has more control of where your
relationship is going in the future? 347 1&7 . 35
220 Who has more to say about when you see one
22d Who has more say about when you talk about
serious things? 3.28 1 . 19 .34
23a Who has more control of what your
relationship is like? 3 ~32 1 ~14 -32
23b Who gets their way when you and your
3.87 1.32 .21

partner disagree?

"' 77

 

 

158

 

Relationship Commitment Scale

 

 

 

 

#22/ Inter Item
23 ITEMS Means SD Correlat-
ions
23d Who is more committed to your
relationship? 3 .34 l . 1 8 .27
236 Who tries harder to make your relationship
23f Who cares more about the relationship? 3.32 1.03 .21 ;
Possible Cronbach
Means SD Range of Scores Range Alpha _
3.37 1.00 1-5 1-4 .80 ~

 

159

 

Condom Self-Eﬂicacy

 

 

 

 

 

#32 ITEMS Means SD Item To?“
Correlations
I can buy condoms or dental dams
323 without feeling embarrassed 4.71 _91 395
I can carry condoms or other latex
32b barriers around with me in case I 4.39 1.22 .427
have sex
I can ask a potential partner to put-
off or postpone sex if we don't have
32g condoms or latex barriers available 4,63 .88 .302
at the time.
DELETED ITEMS
Item
Total Reverse
#32 ITEMS Means SD Corre la ti Coded
ans
I can discuss using condoms or
32c other latex barriers with someone 4.62 .96 .549
that I may have sex with.
32d I cannot put a condom on a penis 2.00 1.38 _.03 R
that IS erect or hard,
32a. 1 cam“)? d‘scui’s HIV/AIDS 1.37 .10 .03 R
precautlons wrth a doctor or nurse.
I can discuss with a partner the use
of condoms for HIV/AIDS
32f protection when I'm already using 4.51 1.02 .32

other types of birth control (e. g. the
pill, Depo-Provera,etc,

160

,2».-

 

 

Perceived HIV Risk

 

Item Total

 

 

 

 

#34 ITEMS Means SD Correlat- Reverse
. Coded
Ions
My sexual experiences do not put
34a me at risk for contracting 2.52 1.63 .40 R
HIV/AIDS
34b There IS a pOSSIblllty that I may 1.33 .79 .43 lr
have HIV.
I may have had sex with someone
34c who has HIV 1.32 .82 .433
34d 1 am at risk for HIV/AIDS 1.81 1.33 .55 i '
My sexual partner(s) behavior may
34c place me at risk for HIV/Aids 1'90 1'33 '45
Means SD Range ofScores Possible Range Cronbach Alpha
1.77 .81 1-4.20 1-5 .67

 

161

 

F atalism

 

 

 

 

 

 

General Fatalism
M Item Total
#35 ITEMS ":0 SD Correlatio
ns
People die when it is their time and there is
35a not much that can be done about it. 4.21 1.20 .394
We must live for the present, who knows
It is not always wise to plan too far ahead
because many things turn out to be the way
3 so they are for better or worse anyway 3 '45 1°42 '466
Scale Possible Cronbach
Means SD Range of Scores Range Alpha
3.87 1.01 1-5 1-5 .64
HIV Fatalism
Item Total
#35 ITEMS Means SD Correlatio
ns
35d If I practice certain behav10rs, I can protect 1.31 .84 -.05

myself against HIV

 

Deleted item due to negative wording.

 

3 5e There is not much a person can do to avoid

getting HIV 4'39

 

1.23

 

 

162

 

 

Optimistic Bias

Sexual Behavior Optimistic Bias Scale

 

 

 

 

 

 

#36 ITEMS Means SD Item To.”
Correlations
Compared to other African American women,
36b my chances of accidentally becoming 3.77 1.27 .306
pregnant are...
Compared to other African American women,
36d my chances of contracting a sexually 3.95 1.07 .622
transmitted disease are...
366 Compared to other African Amencan women, 4.16 1.05 . 63 8
my chances of contractlng a HIV are...
Scale Possible Cronbach
Mean SD Range of Scores Range Alpha
3.21 .62 1.33-5 1-5 .69
General Optimistic Bias ITEM 36C
#36 ITEMS Means SD Item To?“
Correlations
Compared to other Aﬁican American women,
36c my chances of experiencing positive life event 2.27 1.07 .638

are .........

 

Deleted item due to negative wording

 

7 36a. Compared to other African American women, my chances

of experiencing A tragic event are.

163

Financial Independence

 

 

 

 

 

 

 

#20 ITEMS Means SD ”9’" T0,”,
Correlations
20a I am able to take care of myself ﬁnanc1a11y 3.73 . 68 .45
whether or not I am in a relationship
20b In general, I am able to handle my monthly 3.47 .79 .45
ﬁnanc1al expenses by myself
Scale Possible Cronbach
Mean SD Range of Scores Range Alpha
1.15 .22 1-4 1-4 .62
Deleted Item
Item Total
#20 ITEMS Means SD Correlatio
ns
200 I rely on the assrstance of others to help me 399 1.03 .14

get by

 

164

Partner Attitudes Toward Condom Use Scale

 

 

Item Total Reverse

#25 ITEMS Means SD Correlations Coded
25c IfIaSked mypa’me’t" “sea 1.80 1.18 .22(.12) R

condom, he would get angry

IfI ask my partner to use a

condom, he would think that
256 I‘m having sex with other 2.18 1.34 .31 (-.05) R

people.

25f IfI asked my partner to use a

condom, he would agree 3‘16 1°14 "37 (‘59)

 

 

Scale Possible Cronbach
Mean SD Range of Scores Range Alpha
2.38 .59 1-4 1-4 .75

 

Participant Attitudes Toward Condom Use Scale

 

Inter Item Reverse
#25 ITEMS Means SD correlatio
ns Coded

 

If my partner asked me to use a
25h condom, I would think that he 2.04 1.26 .32 (-.35) R
is having sex with other people

If my partner asked me to use a

251 condom, I would agree

3.56 .92 -.24 (-.03)

If my partner asked me to use a
25k condom , I would think that he 3.36 1.00 -.07 (.04)

 

 

is trying to protect our health
Possib
Scale Cronbach
Mean SD Range of Scores le Alpha
Range
2.79 .49 1-4 1-4 .67

 

165

DELTED Attitudes toward condom use items

 

Inter
Item Reverse

 

 

 

 

#25 ITEMS Means SD correla Coded
tions
253 Using a condom makes sex less 227 1.19 .35 R
enjoyable for me.
If I asked my partner to use a
25b condom. he would think that I am 2.95 1.23 -.23
trying to protect our health
Using a condom makes sex less
25d enjoyable for my partner. 2'43 1'18 '36 R
25g Imy partner asked me to usea 1.44 .90 .31 R
condom, I would get angry
Single Item Violence Indicator
#25 ITEMS Means SD I'm” I’f’"
correlations
25j IfIaskmypartnerto usea 1.19 .65 .07

condom he would get violent

 

166

Sex Ratio Imbalance Scale

 

 

Inter Reverse
#33 ITEMS Means SD ”6’" . caded
correlatr
ons
The number of eligible Aﬁican
American women outnumber the
33a number of eligible Aﬁican 4'16 1'20 '05
American men.
33b IfI wanted to, I could ﬁnd a new 4.19 1.30 .26 R
partner.
There are plenty of available
33c partners for African American 3.64 1.42 .10 R
women.
33d It is difﬁcult to ﬁnd a suitable 4.04 1.24 .15
partner.
African American men have many
33c options for available partners. 4.06 1.16 .30

 

167

HIV Knowledge Scale

 

 

 

a. Coughing and sneezing DO NOT spread HIV. Reverse
Coded

b. A person can get HIV by sharing a glass of water with someone R
who has HIV.

c. Pulling out the penis before a man climaxes/cums keeps a woman R
from getting HIV during sex.

d. A woman can get HIV if she has anal sex with a man.

e. Showering or washing one’s genitals/private parts, after sex keeps R
a person from getting HIV.

f. All pregnant women infected with HIV will have babies born with R
AIDS.

g. People who have been infected with HIV quickly Show serious R
signs of being infected.

h. There is a vaccine that can stop adults from getting HIV. R

i. People are likely to get HIV by deep kissing, putting their tongue R
in their partner’s mouth, if their partner has HIV.

j. A woman cannot get HIV if she has sex during her period. R

k. There is a female condom that can help decrease a woman’s
chance of getting HIV.

m. A natural Skin condom works better against HIV than does a latex R
condom.

n. A person will NOT get HIV if she or he is taking antibiotics. R

p. Having sex with more than one partner can increase a person’s
chance of being infected with HIV.

q. Taking a test for HIV one week after having sex will tell a person R
if she or he has HIV.

r. A person can get HIV by sitting in a hot tub or a swimming pool R
with a person who has HIV.

3. A person can get HIV from oral sex.

11 Using Vaseline or baby oil with condoms lowers the chance of R
getting HIV.

AFRICAN AMERICAN ITEMS

1. Aﬁican Americans accounted for over half of the new HIV diagnoses
reported in the United States.

0. The leading cause of HIV infection among African-American women is

t.

heterosexual contact, followed by injection drug use.

African American women are twice as likely as White women to get HIV.

168

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