Jane Dimmitt Champion

A Randomized, Controlled Trial of a Behavioral Intervention to Prevent Sexually Transmitted Disease among Minority Women

BACKGROUND African-American and Hispanic women are disproportionately affected by sexually transmitted diseases, including the acquired immunodeficiency syndrome (AIDS). In the effort to reduce infection rates, it is important to create and evaluate behavioral interventions that are specific to the target populations. METHODS We enrolled women with nonviral sexually transmitted diseases in a randomized trial of a sex- and culture-specific behavioral intervention. The intervention consisted of three small-group sessions of three to four hours each designed to help women recognize personal susceptibility, commit to changing their behavior, and acquire necessary skills. The control group received standard counseling about sexually transmitted diseases. The design of the intervention was based on the AIDS Risk Reduction Model and ethnographic data on the study populations. Participants in both groups underwent screening, counseling, and an interview before randomization and at the 6- and 12-month follow-up visits. The principal outcome variable was subsequent chlamydial or gonorrheal infection, which was evaluated on an intention-to-treat basis by logistic-regression analysis. RESULTS A total of 424 Mexican-Americans and 193 African-American women were enrolled; 313 were assigned to the intervention group and 304 to the control group. The rate of participation in the intervention was 90 percent. The rates of retention in the sample were 82 and 89 percent at the 6- and 12-month visits, respectively. Rates of subsequent infection were significantly lower in the intervention group than in the control group during the first 6 months (11.3 vs. 17.2 percent, P=0.05), during the second 6 months (9.1 vs. 17.7 percent, P=0.008), and over the entire 12-month study period (16.8 vs. 26.9 percent, P=0.004). CONCLUSIONS A risk-reduction intervention consisting of three small-group sessions significantly decreased the rates of chlamydial and gonorrheal infection among Mexican-American and African-American women at high risk for sexually transmitted disease.

Prevention of gonorrhea and chlamydia through behavioral intervention: Results of a two-year controlled randomized trial in minority women

Background: Sexually transmitted disease (STD), including AIDS, disproportionately affects African-American and Hispanic women. Goal: To evaluate efficacy of standard and enhanced (addition of optional support groups) gender- and culture-specific, small-group behavioral interventions, compared to interactive STD counseling, in high risk minority women for two years. Methods: Women with a non-viral STD were treated and enrolled in a randomized trial. Follow-up screens and interviews occurred at 6 months, 1 year, 18 months (short interview, optional exam) and 2 years. The primary outcome was subsequent infection with chlamydia and/or gonorrhea. Secondary outcomes included risky sexual behaviors. We employed logistic regression based on intention-to-treat. Results: Data from 775 women were included; the retention rate was 91%. Adjusted infection rates were higher in the controls in Year 1 (26.8%), Year 2 (23.1%), and cumulatively (39.8%) than in the enhanced (15.4%, P = 0.004; 14.8%, P < 0.03; 23.7%, P < 0.001, respectively) and standard (15.7%, P = 0.006; 14.7%, P = 0.03; 26.2%, P < 0.008, respectively) intervention arms at these time points. Enhanced-intervention women who opted to attend support groups (attendees) had the lowest adjusted infection rates in Year 1 (12.0%) and cumulatively (21.8%). Intervention women in general, but particularly attendees, were significantly less likely than controls to have repeat infections. Multiple partners and unprotected sex with an untreated or incompletely treated partner helped explain group differences in infection. Conclusions: Risk-reduction interventions significantly decreased both single and multiple infective episodes with chlamydia and/or gonorrhea and risky sexual behaviors in the two-year study period. Support-group attendance appeared to contribute additional risk reduction in Year 1.

Behaviors changed by intervention are associated with reduced STD recurrence: the importance of context in measurement.

Background Evaluations of STD/HIV interventions incorporating behavioral and biologic outcomes have not reported strong correspondence. Goal The goal of the study was to demonstrate that behaviors, measured comprehensively, are associated with infection and to delineate the behaviors responsible for reduced infection rates in Project SAFE (Sexual Awareness For Everyone). Study Design Follow-up data from an intervention trial were analyzed to determine: (1) study versus control differences in complex risk behaviors and (2) the overall relationship between these behaviors and infection status (chlamydia and/or gonorrhea), with use of multiple logistic regression. Results Lower infection rates among 249 women who received intervention (compared with 228 controls) were explained by reduced-risk status in 5 modifiable behaviors. The 0 to 12–month logistic regression model (including sex with untreated partner [OR = 5.6], lack of mutual monogamy [OR = 2.4], unsafe sex [OR = 1.9], rapid partner turnover [OR = 2.7], and douching after sex [OR = 1.9]) correctly predicted infection status for 75.3% of participants (71.8% of infected, 76.2% of uninfected). Women in nonmutually monogamous unions who had sex with partners who were untreated or incompletely treated were 13 times more likely to be infected than those who were monogamous and avoided sex with an untreated/incompletely treated partner. Conclusion This intervention reduced infection rates by maintaining low-risk behaviors and changing high-risk behaviors. We elucidated the complex relationship between behavior and infection by incorporating context into variable conceptualization and considering several behaviors simultaneously.

Cervicitis and genitourinary symptoms in women culture positive for Mycoplasma genitalium.

Problem  Mycoplasma genitalium has been associated with male urethritis. We sought to relate M. genitalium to genitourinary signs and symptoms in women.

Sexual abuse and sexual risk behaviors of minority women with sexually transmitted diseases

The relationship between sexual abuse and sexually transmitted disease (STD) represents an important and underinvestigated context of domestic violence. This study examined the association between sexual abuse, sexual risk behaviors, and risk for reinfection and HIV among minority women with STD. Mexican American and African American women (n = 617) with active STD entered a randomized study of behavioral intervention to reduce STD recurrence. Each underwent questioning at entry regarding sexual abuse and sexual risk behaviors. Comparisons of these behaviors using chi-square, t tests, and logistic regression were made by history of sexual abuse. Sexually abused women were more likely to have lower incomes, earlier coitus, STD history, currently abusive partners, new sex partners, anal sex, and bleeding with sex, placing them at increased risk for STD reinfection and HIV. Due to this association with sexual risk behavior, assessment for sexual abuse is essential in programs focusing on STD/HIV prevention.

Woman Abuse, Assimilation, and Self-Concept in a Rural Mexican American Community

This study proposed to describe the effect of assimilation on self-concept and abuse in a rural, minority population of Mexican American women. Ethnic language translations were developed to enable investigation with a rural, Spanish-speaking, Mexican American population. Reassessment of reliability and validity of both English and Spanish translations of instrumentation for a rural population was performed. Data were collected through convenience sampling from both rural battered womens shelters and rural community service centers. Significant differences were found between groups of abused (n = 85) versus non-abused (n = 84) women on dimensions of self-concept. Assimilation variables found to be significantly correlated with self-concept for abused and non-abused Mexican American women included language, attitudes toward traditionalfamily structure, and values. Significant differences werefound between abused and non-abused Mexican American women in attitudes toward traditional family structure and sex-role identification.

THE CONTEXT OF SEXUALLY TRANSMITTED DISEASE: LIFE HISTORIES OF WOMAN ABUSE

Approximately 25%-50% of women with sexually transmitted diseases (STDs), including AIDS, are involved in abusive relationships. Numerous characteristics associated with a past history of abuse are also risk factors for STD infection, including multiple partner relationships, substance abuse, early age at first coitus, and partner control of the relationship. Research has identified psychological effects of previous abuse, including depression, minimal control in relationships, and decreased self-efficacy. These effects may prevent abused women with STDs from making behavioral changes to prevent recurrence and transmission of disease. Life history methodology was used to understand the context of the interrelationships between STD and woman abuse in 30 Mexican American and African American womens lives. A focus on the context of abused womens partner relationships and aspects of personal control within these relationships may facilitate effective behavioral change, risk reduction, and subsequent decrease in incidence of STDs and woman abuse.

Use of a video-ethnographic intervention (PRECESS Immersion Method) to improve skin-to-skin care and breastfeeding rates.

PURPOSES Skin-to-skin care after birth often is absent, interrupted, or delayed for routine procedures. The purposes of this project were to improve skin-to-skin care and exclusive breastfeeding at hospital discharge. METHODS For Part 1, we used a descriptive observational design, with video-ethnography and interaction analysis (PRECESS-Practice, Reflection, Education and training, Combined with Ethnography for Sustainable Success), during a 5-day quality improvement pilot study in a U.S. hospital (August 13-17, 2010). For Part 2, we used electronic health record review to test for differences in monthly rates of skin-to-skin care and exclusive breastmilk feeding (baseline, July 2010; post-intervention, August-December 2010). RESULTS In Part 1, 11 mothers and babies participated: 10 (91%) received immediate skin-to-skin care, eight (73%) received uninterrupted skin-to-skin care, nine (82%) planned to breastfeed, six (67%) of these babies were exclusively breastfeeding at hospital discharge, and five (83%) of the six babies who completed all nine instinctive stages during skin-to-skin care were exclusively breastfeeding at hospital discharge. In our subsequent review (Part 2), we found a significant improvement (25% above baseline) in the overall rate of skin-to-skin care across post-intervention months (Pearson χ(2)=23.798, df=5, p<0.000), predominantly from improvements in the cesarean section population. The rates of exclusive breastfeeding showed no significant change. CONCLUSIONS The PRECESS immersion method may help to rapidly improve skin-to-skin care. Babies who undergo all nine stages during skin-to-skin care may be more likely to exclusively breastfeed. Mothers need support during skin-to-skin care to recognize their babys readiness to breastfeed. Skin-to-skin care during cesarean surgery may reduce maternal stress and improve satisfaction with the surgical experience.

Comparison of a theory-based (AIDS Risk Reduction Model) cognitive behavioral intervention versus enhanced counseling for abused ethnic minority adolescent women on infection with sexually transmitted infection: Results of a randomized controlled trial ☆

BACKGROUND Ethnic minority adolescent women with a history of sexual or physical abuse and sexually transmitted infections represent a vulnerable population at risk for HIV. Community-based interventions for behavior modification and subsequent risk reduction have not been effective among these women. OBJECTIVES To evaluate the effects of a theory-based (AIDS Risk Reduction Model) cognitive behavioral intervention model versus enhanced counseling for abused ethnic minority adolescent women on infection with sexually transmitted infection at 6 and 12 months follow-up. DESIGN Controlled randomized trial with longitudinal follow-up. SETTINGS Southwestern United States, Metropolitan community-based clinic. PARTICIPANTS Mexican-and-African American adolescent women aged 14-18 years with a history of abuse or sexually transmitted infection seeking sexual health care. METHODS Extensive preliminary study for intervention development was conducted including individual interviews, focus groups, secondary data analysis, pre-testing and feasibility testing for modification of an evidence-based intervention prior to testing in the randomized controlled trial. Following informed consents for participation in the trial, detailed interviews concerning demographics, abuse history, sexual risk behavior, sexual health and physical exams were obtained. Randomization into either control or intervention groups was conducted. Intervention participants received workshop, support group and individual counseling sessions. Control participants received abuse and enhanced clinical counseling. Follow-up including detailed interview and physical exam was conducted at 6 and 12 months following study entry to assess for infection. Intention to treat analysis was conducted to assess intervention effects using chi-square and multiple regression models. RESULTS 409 Mexican-(n=342) and African-(n=67) American adolescent women with abuse and sexually transmitted infection histories were enrolled; 90% intervention group attendance; longitudinal follow-up at 6 (93%) and 12 (94%) months. Intervention (n=199) versus control (n=210) group participants experienced fewer infections at 0-6 (0% versus 6.6%, p=.001), 6-12 (3.6% versus 7.8%, p=.005, CI 95% lower-upper .001-.386) and 0-12 (4.8% versus 13.2%, p=.002, CI 95% lower-upper, .002-.531) month intervals. CONCLUSIONS A cognitive behavioral intervention specifically designed for ethnic minority adolescent women with a history of abuse and sexually transmitted infection was effective for prevention of infection. These results provide evidence for development of evidence-based interventions for sexually transmitted infection/HIV. Implications include translation to community-clinic-based settings for prevention of adverse outcomes regarding sexual health of adolescent women.

Minority adolescent women with sexually transmitted diseases and a history of sexual or physical abuse

Life history methods were used to obtain a more in-depth understanding of the configuration of psychosocial and situational factors that are associated with high-risk sexual behavior among minority adolescent women with a history of sexual or physical abuse and sexually transmitted disease (STD), to facilitate development of behavioral risk-reduction interventions. Study participants ranged in age from 14 to 18 years; 19 were Mexican American and 11 were African American. Women were recruited from clinics in a metropolitan health district. Various constitutive patterns unfolded during interview analysis including “fearing,” “trusting,” and “being a woman.” The study revealed the perceptions of an extremely high-risk population of adolescent women regarding their STD risk, the context of their sexual relationships, sexual risk behaviors, contraception, and STD prevention, screening, and treatment practices. Intervention strategies based upon these findings are described.