摘要：Objectives . We examined the interactive effects of fear of abuse and knowledge of sexually transmitted infections (STIs) on sexual risk behaviors in a sample of young African American women. Methods . We recruited 715 young African American women aged 15 to 21 years from a variety of health clinics and assessed them for fear of abuse because of negotiating condom use, knowledge of STIs, and several sexual risk behaviors. Results . Overall, 75% of young African American women reported inconsistent condom use in the past 60 days. Surprisingly, under relatively higher levels of fear, young women with high STI knowledge were more likely than were those with low STI knowledge to exhibit inconsistent condom use in the past 60 days (89% vs 80%; χ 2 = 4.32; P ≤ .04) and during the last sexual intercourse with a main sexual partner (76% vs 70%; χ2 = 8.06; P ≤ .01). Conclusions . Most HIV prevention interventions focus on increasing knowledge about the transmission of STIs. However, other contextual factors such as fear of abuse because of negotiating condom use may heighten the risk of HIV infection. Our findings highlight the need for combining dating violence prevention activities with STI and HIV prevention programs targeting young African American women. Adolescence is a developmental period typically associated with risky and health-compromising behaviors. With the decrease in age at sexual initiation and the increase in sexual behaviors observed among adolescents, 1 attention to risk factors that may affect the sexual health of adolescents is critical. During adolescence, as girls develop and attempt to maintain dating and sexual relationships, some will experience abuse by a partner, which may adversely affect their ability to negotiate safer-sex practices, including condom use. Dating violence, a pervasive public health problem, affects between 12% and 43% of adolescents in the United States 2 , 3 and has the potential to increase the likelihood that adolescent girls will engage in sexual behaviors that increase their risk for HIV/AIDS. 4 At every phase of the HIV/AIDS epidemic in the United States, from HIV infection to death from AIDS-related complications, African Americans are disproportionately affected when compared with Whites and other racial/ethnic groups. This disparity is most glaring among African American women, whose rate of AIDS diagnosis is approximately 23 times that of White women in the United States. 5 Furthermore, young African Americans in the United States are at increased risk of HIV infection. Among the 18 849 individuals younger than 25 years diagnosed with HIV or AIDS between 2001 and 2004, 64% were African American. 6 As a result of the HIV/AIDS crisis in the African American community, numerous studies have assessed factors associated with HIV risk behaviors among African Americans at the individual (e.g., knowledge, self-efficacy, risk perception), peer (e.g., peer norms for condom use), and societal (e.g., gender norms, gender and economic inequality) level. 7 – 9 These studies have led to programs to address these factors, with the intention of promoting change in HIV risk behaviors. Theories used to guide the development of HIV prevention interventions include the theory of reasoned action 10 and the health belief model. 11 Based on these theories and subsequent prevention programs, behavioral change is more likely to occur with increased knowledge of HIV and other sexually transmitted infections (STIs) among high-risk individuals. There are, however, mixed findings for the effect of HIV/STI knowledge on promoting individuals' behavior change, and the causal link has not been well established. 12 Hence, contextual factors between partners, such as dating violence, may explain sexual risk behaviors beyond increasing knowledge about how HIV and other STIs are transmitted. Social cognitive theory suggests that knowledge, though necessary, may not be sufficient to motivate people to adopt HIV-preventive behaviors; at best, knowledge is a prerequisite for behavior change. 13 Social cognitive theory suggests that self-efficacy is also necessary when reducing risky sexual behavior and increasing safer sexual practices, such as condom use. Previous studies show that adolescents who feel confident in their ability to correctly use condoms, 13 , 14 to negotiate condom use with their partners, 14 , 15 to say “no” to unprotected intercourse, 16 and to discuss their partner's sexual history 15 , 17 are likely to use condoms more often and have lower rates of STIs than are those adolescents who are relatively less confident or self-efficacious. This positive association between self-efficacy and safer sexual practices is important in understanding an adolescent girl's risk of HIV infection, particularly when attempting to negotiate condom use. Fear of an abusive partner might undermine an adolescent girl's self-efficacy to encourage her sexual partner to use condoms. Because of the high rates of HIV infection observed in young women, the field of HIV prevention has seen a growing research interest in the intersection of gender-based violence and HIV infection. Specifically, there is mounting recognition of the effect of gender-based violence on young women's perceived ability to engage in safer sexual practices. 18 However, although most HIV prevention programs subscribe to the belief that knowledge of HIV/STI transmission is necessary to facilitate behavior change, programs often lack a substantial focus on gender-based factors that may compromise or threaten a woman's self-efficacy to enact such change in light of newly acquired HIV/STI prevention knowledge. We focused on abuse—specifically, fear of abuse in adolescent and young-adult dating relationships—and its impact on HIV-related risk behaviors. We assessed the effect of fear of abuse because of attempted condom negotiation on the relation between STI knowledge and high-risk sexual behavior among African American women aged 15 to 21 years. We expected those with low STI knowledge and high fear of abuse because of condom negotiation to be more likely to engage in high-risk sexual behaviors than would those with high STI knowledge and low or no fear of abuse.
