Andrea Carlson Gielen

The intersections of HIV and violence: directions for future research and interventions.

The purpose of this paper is to review the available literature on the intersections between HIV and violence and present an agenda for future research to guide policy and programs. This paper aims to answer four questions: (1) How does forced sex affect womens risk for HIV infection? (2) How do violence and threats of violence affect womens ability to negotiate condom use? (3) Is the risk of violence greater for women living with HIV infection than for noninfected women? (4) What are the implications of the existing evidence for the direction of future research and interventions? Together this collection of 29 studies from the US and from sub-Saharan Africa provides evidence for several different links between the epidemics of HIV and violence. However, there are a number of methodological limitations that can be overcome with future studies. First, additional prospective studies are needed to describe the ways which violence victimization may increase womens risk for HIV and how being HIV positive affects violence risk. Future studies need to describe mens perspective on both HIV risk and violence in order to develop effective interventions targeting men and women. The definitions and tools for measurement of concepts such as physical violence, forced sex, HIV risk, and serostatus disclosure need to be harmonized in the future. Finally, combining qualitative and quantitative research methods will help to describe the context and scope of the problem. The service implications of these studies are significant. HIV counseling and testing programs offer a unique opportunity to identify and assist women at risk for violence and to identify women who may be at high risk for HIV as a result of their history of assault. In addition, violence prevention programs, in settings where such programs exist, also offer opportunities to counsel women about their risks for sexually transmitted diseases and HIV.

Quality of life among women living with HIV: the importance violence, social support, and self care behaviors

This paper describes the relationship between psychosocial factors and health related quality of life among 287 HIV-positive women using items from the Medical Outcomes Study HIV Health Survey to measure physical functioning, mental health and overall quality of life. Multivariate models tested the relative importance of sociodemographic characteristics, HIV-related factors and psychosocial variables in explaining these quality of life outcomes. A history of child sexual abuse and adult abuse, social support and health promoting self-care behaviors were the psychosocial factors studied. Women in the sample were on average 33 years old and had known they were HIV-positive for 41 months; 39% had been hospitalized at least once due to their HIV; 83% had children; 19% had a main sex partner who was also HIV-positive. More than one-half of the women (55%) had a history of injection drug use and 63% reported having been physically or sexually assaulted at least once as an adult. A history of childhood sexual abuse. reported by 41% of the sample, was significantly related to mental health after controlling for sociodemographic and HIV-related characteristics. Women with larger social support networks reported better mental health and overall quality of life. Women who practiced more self-care behaviors (healthy diet and vitamins, adequate sleep and exercise, and stress management) reported better physical and mental health and overall quality of life. The high prevalence of physical abuse and child sexual abuse reported by this sample underscores the importance of screening for domestic violence when providing services to HIV-positive women. That such potentially modifiable factors as social support and self care behaviors are strongly associated with health-related quality of life suggests a new opportunity to improve the lives of women living with HIV.

An Introduction to Concept Mapping as a Participatory Public Health Research Method

In this article, the authors introduce concept mapping as a useful participatory research method for public health researchers interested in generating hypotheses and developing theory. The authors first provide an overview of concept mapping, which combines qualitative approaches with quantitative analytical tools to produce visual displays of the relationship between ideas. Then, they present an illustrative research application of the method to the exploration of women’s perceptions of the relationship between residential neighborhood factors and intimate partner violence experiences. They give attention to the data collection and analysis procedures and to demonstrating the intricacies of using concept mapping for public health research purposes. Finally, the article concludes with a discussion of the unique contributions and challenges associated with concept mapping.

Interpersonal conflict and physical violence during the childbearing year

Reducing physical abuse directed at women by male partners is one of the nations Year 2000 health objectives. An important target group for achieving this health objective is pregnant women. The present study examines the frequency, severity, perpetrators and psychosocial correlates of violence during the childbearing year. A panel of 275 women were interviewed 3 times during pregnancy and at 6 months postpartum. Moderate or severe violence was somewhat more common during the postpartum period than during the prenatal period--19% of women reported experiencing moderate or severe violence prenatally, compared to 25% in the postpartum period. For partner-perpetrated violence, being better educated was associated with increased risk of violence as was having had a sex partner who ever shot drugs; being older, having a confidant and having social support from friends were significant protective factors. For violence perpetrated by someone other than a male partner, having a confidant was a significant protective factor. Obstetric care providers who routinely come in contact with pregnant women, as well as emergency department staff, need to be systematically screening for violence against women. Efforts to enhance womens social support networks should be included in primary and secondary prevention programs.

Women's Opinions About Domestic Violence Screening and Mandatory Reporting

BACKGROUND The purpose of this paper is to describe womens opinions and policy preferences concerning domestic violence screening and mandatory reporting. METHODS This case-control study included 202 abused women and 240 randomly selected non-abused women recruited from a large metropolitan health maintenance organization who were interviewed by telephone. Of these women, 46.6% had a college degree, 53.4% were white, and 60% had a household income of

Women's lives after an HIV-positive diagnosis: disclosure and violence

50,000 or more. RESULTS Forty-eight percent of the sample agreed that health care providers should routinely screen all women, with abused women 1.5 times more likely than non-abused women to support this policy. For mandatory reporting, 48% preferred that it be the womans decision to report abuse to the police. Women thought it would be easier for abused women to get help with routine screening (86%) and mandatory reporting (73%), although concerns were raised about increased risk of abuse with both screening (43%) and reporting (52%) policies. Two thirds of the sample thought women would be less likely to tell their health care providers about abuse under a mandatory reporting policy. Interventions offered in managed care settings that would be well received, according to the women in this study, include counseling services, shelters, and confidential hotlines. CONCLUSIONS Women expressed fears and concerns about negative consequences of routine screening and, even more so, for mandatory reporting. Domestic violence policies and protocols need to address the safety, autonomy, and confidentiality issues that concern women.

Effects of high school driver education on motor vehicle crashes, violations, and licensure

Objectives: This research addresses four questions: (1) What role do health care providers play in womens disclosure to others of their HIV-positive status? (2) What are womens concerns and experiences with disclosure? (3) What violence do women living with HIV experience? (4) How is the violence related to their diagnosis and disclosures? Methods: Participants were 310 HIV-positive women enrolled in an HIV primary care clinic in an urban teaching hospital. Women were interviewed once using both quantitative and qualitative methods. Results: Women had known they were HIV-positive for an average of 5.8 years; 22% had an HIV-positive partner; 58% had disclosed their status to more than 10 people; and 68% had experienced physical abuse and 32% sexual abuse as an adult. Fifty-seven percent of the sample reported that a health care provider had told them to disclose to their sex partners. Women who were afraid of disclosure-related violence (29%) were significantly more likely than those who were not to report that a health care provider helped them with disclosure (21% vs. 10%). Although 4% reported physical abuse following a disclosure event, 45% reported experiencing emotional, physical, or sexual abuse at some time after their diagnosis. Risk factors for experiencing abuse after diagnosis were a prior history of abuse, drug use, less income, younger age, length of time since diagnosis, and having a partner whose HIV status was negative or unknown. Conclusions: Identifying women at risk for abuse after an HIV-positive diagnosis is important for those who provide HIV testing and care. Routine screening for interpersonal violence should be incorporated into HIV posttest counseling and continuing primary care services.

HIV/AIDS and Intimate Partner Violence: Intersecting Women's Health Issues in the United States

OBJECTIVE We sought evidence in the research literature to determine if (1) high school-aged persons who enroll in a driver education course have fewer motor vehicle-related crashes or violations, or are more likely to obtain a drivers license, than those who do not enroll in driver education courses, and (2) the availability of high school driver education courses is associated with lower community rates of motor vehicle crashes among young drivers. METHODS To be included, a study must: (1) assess the effects of driver education courses or legislation for high school-aged persons; (2) present non-self-reported data for at least one of the following outcome measures: driver licensure rates, motor vehicle-related violations, or crashes; (3) include some form of no intervention comparison group; (4) adequately control for potentially confounding variables; (5) randomly assign participants to control or treatment groups, if a controlled trial. RESULTS Nine studies met our inclusion criteria. Based on these studies, there is no convincing evidence that high school driver education reduces motor vehicle crash involvement rates for young drivers, either at the individual or community level. In fact, by providing an opportunity for early licensure, there is evidence that these courses are associated with higher crash involvement rates for young drivers. CONCLUSIONS Although few driver education curricula have been carefully evaluated, in the absence of evidence that driver education reduces crash involvement rates for young persons, schools and communities should consider other ways to reduce motor vehicle-related deaths in this population, such as graduated licensing.

Women living with HIV: Disclosure, violence, and social support

This article reviews 35 U.S. studies on the intersection of HIV and adult intimate partner violence (IPV). Most studies describe rates of IPV among women at risk or living with HIV/AIDS and identify correlates, using multiple types of convenience samples (e.g., women in methadone treatment, women in shelters or clinics), cross-sectional designs, and self-reported risk behaviors. HIV-positive women appear to experience any IPV at rates comparable to HIV-negative women from the same underlying populations; however, their abuse seems to be more frequent and more severe. The authors found only four relevant interventions and none addressed sexually transmitted HIV and partner violence risk reduction simultaneously. There is a critical need for research on (a) causal pathways and cumulative effects of the syndemic issues of violence, HIV, and substance abuse and (b) interventions that target IPV victims at risk for HIV, as well as HIV-positive women who may be experiencing IPV.

BICYCLE HELMET LAWS AND EDUCATIONAL CAMPAIGNS: AN EVALUATION OF STRATEGIES TO INCREASE CHILDREN'S HELMET USE

This paper describes the frequency of womens disclosure of their HIV status, examines the extent to which they experience adverse social and physical consequences when others learn they are infected, and analyzes correlates of these negative outcomes. There were 257 HIV-positive women between the ages of 18 and 44, recruited from HIV/AIDS primary care clinics and from community sites, who completed a face-to-face interview. Women in the sample were 33 years old on average; 92% were African-American; 54% had less than 12 yeas of education; 56% had used intravenous drugs; and 30% knew they were HIV positive for 5 or more years. There were 97% who disclosed their HIV status; 64% told more than 5 people. Negative consequences associated with others knowing they were HIV-positive were reported by 44%, most commonly the loss of friends (24%), being insulted or sworn at (23%), and being rejected by family (21%). There were 10 women (4%) who reported being physically or sexually assaulted as a result of their being HIV positive, and 16% reported having no one they could count on for money or a place to stay. Violence was widespread in this sample, with 62% having experienced physical or sexual violence, including sexual abuse or rape (27%), being beaten up (34%), and weapon-related violence (26%). Logistic regression analysis indicated that women with a history of physical and sexual violence were significantly more likely to experience negative social and physical consequences when their infection became known to others, adjusting for age and the number of people women had disclosed to, both of which were only marginally significant. Partner notification policies and support programs must be responsive to the potential negative consequences associated with others learning that a woman is HIV positive. The high rates of historical violence in the lives of women living with HIV underscore the need for routine screening and intervention for domestic violence in all settings that provide health care to HIV-positive women.