Article
Measuring HIV Knowledge Among Women Incarcerated in Jail
Journal of Correctional Health Care 2014, Vol. 20(3) 213-219 ª The Author(s) 2014 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/1078345814531725 jcx.sagepub.com
Donna W. Roberson, PhD, FNP-BC1
Abstract Incarcerated women often have arresting behaviors that are also high risk for acquiring HIV, such as drug use and sex work. Little research has been done related to HIV knowledge among women in jail. This study assessed HIV knowledge among English-speaking women 18 years and older detained in a large, Southeastern jail (N ¼ 202). HIV knowledge was assessed using the Brief HIV Knowledge Questionnaire. HIV knowledge scores were significantly lower among women over age 50, F(3, 195) ¼ 7.39, p < .001; those with less than a high school education, F(2, 187) ¼ 4.10, p ¼ .018; and those with no history of sexually transmitted infections, F(1, 200) ¼ 7.66, p ¼ .006. Assessment of HIV knowledge among incarcerated women revealed a need for prevention education. Keywords HIV knowledge, HIV prevention, incarcerated women, jail
According to the Centers for Disease Control and Prevention (CDC, 2011), the number of new cases of HIV continues to rise among women in the southern United States, with more new infections being diagnosed in women from ethnic minorities. The primary mode of HIV transmission for women continues to be from heterosexual contact (CDC, 2011; Espinoza et al., 2007). The primary risk factors associated with heterosexual HIV transmission are multiple sex partners and unprotected sex; however, additional factors include poverty, limited access to health care, lack of education, and incarceration (CDC, 2011; Scott, Gilliam, & Braxton, 2005; Swenson et al., 2010). Typically, women are incarcerated in a short-term and more local jail setting prior to sentencing that requires incarceration in the longer term setting of a prison. Women incarcerated in jail frequently have arresting behaviors associated with increased risk for HIV including sex work and substance abuse (Bryan, Robbins, Ruiz, & O’Neill, 2006; Roberson, White, & Fogel, 2009). There is a high rate of
1
East Carolina University, College of Nursing, Greenville, NC, USA
Corresponding Author: Donna W. Roberson, PhD, FNP-BC, East Carolina University College of Nursing, Health Sciences Bldg #2124, Greenville, NC 27858 USA. Email: [email protected]
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homelessness, mental illness, and heavy family care burden among women in detention settings, and many of the women have had very limited health care (Bryan et al., 2006). Swenson and associates (2010) studied African American adolescents in the northeastern and southeastern United States and found that the adolescents had low knowledge of HIV and appropriate condom use and understanding of the need for HIV testing. However, to date, there has been a little assessment of HIV knowledge among women in rural and economically depressed areas (Swenson et al., 2010; Williams, Ekundayo, Udezulu, & Omishakin, 2003). There is continuing evidence that women believe a sexual partner who appears healthy could not have HIV and they have great faith in their partner’s monogamy. Thus, although women recognize that condoms reduce HIV risk, they do not perceive themselves at risk for the disease (Brown & Hill, 2005; Brown & Van Hook, 2006; Espinoza et al., 2007; Swenson et al., 2010). Researchers have found that older women have less knowledge of HIV than younger women and many older women do not perceive themselves at risk for acquiring the virus (Henderson et al., 2004; Lindau, Leitsch, Lundberg, & Jerome, 2006; Orel, Stelle, Watson, & Bunner, 2010). Older women frequently experience a loss of estrogen that may result in atrophied vaginal mucosa. Atrophied vaginal mucosa can tear more easily during sexual intercourse and create an increased risk for HIV acquisition. In addition, as women age, immune system functioning declines, increasing susceptibility to infection. Finally, older women are less likely to consider condoms with intercourse because they no longer have concerns about pregnancy (Lindau et al., 2006). Although many U.S. public schools do teach at least some topics on HIV, sexually transmitted infections (STIs), and pregnancy prevention, the number of states teaching complete prevention programs decreased in 2010 (CDC, 2012). Lack of appropriate HIV/STI education has been cited as a barrier to reducing HIV infection in adolescents (Lloyd et al., 2012). In a study by the Kaiser Family Foundation (2011), the media was a major source of HIV information for Whites, Blacks, and Latinos aged 18 to 29. Despite these sources of HIV information, many people continued to hold at least one misconception about HIV transmission and/or treatment (Kaiser Family Foundation, 2011). Women of all ages need prevention programs that target their deficiencies in knowledge about HIV, condom use strategies, and need for testing (Swenson et al., 2010). Prison offers an opportunity for prevention education and intervention that is often underutilized (Bryan et al., 2006). Most people who are incarcerated initially enter the correctional system through a shorter jail term before reaching the longer stay of prison (Beckwith et al., 2010). Thus, reaching a woman before she progresses to the prison environment may reduce HIV acquisition risk earlier in her life (Roberson et al., 2009). Educational interventions to meet the needs of those incarcerated have been tested in prison settings (Belenko, Shedlin, & Chaple, 2005; Bryan et al., 2006; Hammett & Drachman-Jones, 2006; Oser et al., 2008). However, little work has been done in the jail, where HIV knowledge needs are presumed to be as great as those in prison and prevention education as imperative. Measurement of HIV knowledge would be valuable prior to providing an HIV prevention educational program for women in a jail setting. Therefore, this study, which was part of a larger HIV prevention study for women in jail settings, assessed HIV knowledge among women in jail and evaluated whether knowledge levels were affected by age, race, education, and history of STI.
Methods Following university institutional review board approval, a large Southeastern detention center was used for the study. In this jail, women are housed in cellblocks based on level of criminal charge (violent vs. nonviolent offense). The cellblock used for this study had a capacity of 48 women who
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were considered nonviolent offenders. The research team did not ask the women why they were incarcerated, but many disclosed their charges in the group sessions. Common charges disclosed were sex work/prostitution, possession of controlled substances, uttering (writing checks for which adequate funds were not available), failure to appear (did not come to court on the scheduled court date), probation violations, and possession with intent to sell (most often marijuana or crack cocaine). Participants in the convenience sample were at least 18 years of age, English speaking, not infected with HIV (by self-report), and eligible for release into the surrounding county (not a federal or state inmate). The women were approached as a group when they were released from their cells into the common area for recreation time. Most (90%) were interested in participating in the study. Those who were not interested often wanted to use the telephones and did not want to miss their turn or just said ‘‘not interested.’’ About 7% of women were ineligible for reasons that included not returning to the surrounding county, being a federal or state detainee, and not speaking English (n ¼ 3). Interested women were taken by the investigator to a table away from the gathering area to be screened for eligibility and to provide full informed consent. HIV knowledge was assessed using the Brief HIV Knowledge Questionnaire (HIV-KQ18). Carey and Shroder (2002) found an acceptable internal consistency (a ¼ .75 to .89) and test–retest stability (rs ¼ .76 to .94) of the tool in three randomized control samples (N ¼ 1,033). The HIV-KQ18 was strongly correlated to a longer, previously validated tool (rs ¼ .93 to .97). The HIV-KQ18 has been used in a variety of settings, including prisons, and has proven to be reliable and valid even with low-literacy participants. The HIV-KQ18 has 18 statements about HIV. Respondents are asked whether they believe the statement is true or false; if they are not sure, they can answer ‘‘don’t know.’’ (Table 2 lists the questions from the HIV-KQ18). The tool’s heavy emphasis on the sexual transmission of HIV was considered advantageous for this study because of the larger study focus on the prevention of heterosexual transmission of HIV. The author read the HIV-KQ18 to each woman privately. When a participant questioned the meaning of a statement, the same explanation was provided each time. One statement routinely caused questions: ‘‘People are likely to get HIV by deep kissing, putting their tongue in their partner’s mouth, if their partner has HIV.’’ In this region, people use the term ‘‘French kissing’’ so this item was explained by saying, ‘‘It says people can get HIV by French kissing someone with HIV.’’ The Statistical Package for the Social Sciences (SPSS) version 18 was used to compute descriptive characteristics of the sample and responses to each item of the questionnaire. The relationship of HIV knowledge to age, race, education level, and history of STIs was analyzed with Pearson correlations, chi-square, and analysis of variance (ANOVA). For statistically significant ( p < .05) ANOVA results, the post hoc Tukey analysis was used to determine differences among groups.
Results A total of 202 women participated in this study. Of those women ineligible for inclusion in the study, 10 lived outside the county or were moving out of the area upon release, 7 were awaiting transfer to a state prison, and 5 were awaiting transfer to a federal prison. Of the approximately 22 women who declined to participate, 3 did not speak English and 19 expressed a lack of time or interest in the study. The majority of participants were women of color (n ¼ 141) and most self-identified as African American (n ¼ 115). Demographic characteristics of the sample are summarized in Table 1. Internal consistency of the tool in this sample was calculated as a ¼ .79. Scores on the HIVKQ18 ranged widely. Average percent correct was 79%, with scores ranging from 17% to
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Table 1. Demographic Characteristics of Sample (n, %). Variable Marital status Single Married Divorced Partnered Separated Total Missing Sexual orientation Men only Both genders Women only Prefer not to answer Total Missing Occupation Other None Student Health care Daycare Technical/trade Total Missing Education High school/GED < High school Post high school Associate’s degree Bachelor’s degree Graduate degree Total Missing
112 35 21 18 3 189 13
(59) (18) (11) (10) (2)
171 13 4 2 190 12
(90) (7) (2) (1)
58 32 22 15 15 9 190 12
(31) (17) (12) (8) (8) (5)
77 75 38 6 1 2 199 3
(39) (38) (19) (3) (.5) (1)
100% correct. Results of item scorings are summarized in Table 1. Age was found to have a relationship with HIV-KQ18 scores, F(3, 195) ¼ 7.37, p < .001. Women over 50 years of age scored significantly lower (M ¼ 61.4, SD ¼ 22.42) on the HIV-KQ18 as compared to women younger than 30 (M ¼ 81.7, SD ¼ 15.97), women aged 30 to 39 (M ¼ 80.3, SD ¼ 15.14), and women aged 40 to 49 (M ¼ 78.5, SD ¼ 19.83). Having a history of STI was also found to be related to HIVKQ18 scores, F(1, 200) ¼ 7.66, p ¼ .006. Those women with no prior history of an STI had significantly lower HIV knowledge scores (M ¼ 75.3, SD ¼ 19.59) as compared to those with a history of at least one STI (M ¼ 82.2, SD ¼ 15.57). Although there was no statistically significant difference in knowledge scores between high school graduates (M ¼ 81.9, SD ¼ 17.81) and women with post-high school education (M ¼ 80.3, SD ¼ 14.19), those with less than a high school education scored significantly lower (M ¼ 73.9, SD ¼ 19.11); F(2, 187) ¼ 4.10, p ¼ .018. There was no relationship between ethnicity and HIV knowledge in this sample. Age and STI history independently predicted HIV knowledge.
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Table 2. HIV Knowledge Items With Mean Percentage Answering Correctly. Item
Mean (SD)
1. Coughing and sneezing DO NOT spread HIV. (T) 2. A person can get HIV by sharing a glass of water with someone who has HIV. (F) 3. Pulling out the penis before a man climaxes/cums keeps a woman from getting HIV during sex. (F) 4. A woman can get HIV if she has anal sex with a man. (T) 5. Showering, or washing ones’ genitals/private parts, after sex keeps a person from getting HIV. (F) 6. All pregnant women infected with HIV have babies born with AIDS. (F) 7. People who have been infected with HIV quickly show serious signs of being infected. (F) 8. There is a vaccine that can stop adults from getting HIV. (F) 9. People are likely to get HIV by deep kissing, putting their tongue in their partner’s mouth, if their partner has HIV. (F) 10. A woman cannot get HIV if she has sex during her period. (F) 11. There is a female condom that can help decrease a woman’s chance of getting HIV. (T) 12. A natural skin condom works better against HIV than does a latex condom. (F) 13. A person will NOT get HIV if she or he is taking antibiotics. (F) 14. Having sex with more than one partner can increase a person’s chance of being infected with HIV. (T) 15. Taking a test for HIV one week after having sex will tell a person if she or he has HIV. (F) 16. A person can get HIV by sitting in a hot tub or a swimming pool with a person who has HIV. (F) 17. A person can get HIV from oral sex. (T) 18. Using Vaseline or baby oil with condoms lowers the chance of getting HIV. (F)
.59 .78 .90 .91 .92 .61 .78 .75 .74
(.492) (.414) (.299) (.286) (.278) (.489) (.417) (.433) (.441)
.95 .40 .64 .91 .98
(.227) (.491) (.482) (.293) (.156)
.80 .84 .86 .87
(.399) (.366) (.352) (.341)
N ¼ 202 for all items; correct answers in parentheses (T ¼ true; F ¼ false).
Discussion As described by other researchers, the participants in this study had deficiencies in HIV knowledge and it was evident that common misconceptions regarding HIV infection remain (Kaiser Family Foundation, 2011; Swenson et al., 2010). As seen previously, older women in this study had lower knowledge than their younger peers (Henderson et al., 2004; Lindau et al., 2006; Orel et al., 2010). HIV prevention education was not taught in the schools in this region when the older women would have been in attendance. In fact, abstinence was still the prevalent education program taught in most United States schools at the time (Landry, Kaeser, & Richards, 1999). In this study, the majority of the women under age 30 were likely to have had at least some HIV and STI prevention education in school. The association of increased HIV knowledge with a history of STIs was interesting. One would hope this finding is associated with more comprehensive HIV and STI prevention education when they were diagnosed with the STI. It would have been helpful to know how long it had been since the woman had been diagnosed with an STI and what type of education she received with that diagnosis. Given the differences in HIV knowledge by age, education, and STI history, the findings from this study indicated that a tailored HIV prevention program would be beneficial for women in jail. For example, for a younger incarcerated woman, discussion of common myths may be adequate; for an older woman, however, transmission and condom use may be needed, as well. Limitations of this study include inability to generalize the findings to all incarcerated women, but rather only to those incarcerated in similar settings with similar backgrounds. The sample does seem to reflect the ethnic backgrounds of women incarcerated across the United States (Roberson et al., 2009). The sample size was adequate and the HIV-KQ18 appropriate for measurement of HIV knowledge in this group.
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Conclusion The findings in this study indicated a need for HIV knowledge and prevention information for women in this jail setting. Although most women recognized some sexual risks associated with the transmission of HIV, education is needed that focuses on modes of transmission and means of protection (barriers). It may be useful to include discussions that dispel myths about HIV acquisition. One 24-year-old woman said that she was well informed about HIV. However, when she was talking about her friend infected with HIV coming to visit, she said, ‘‘I clean my toilet with bleach and bleach all the towels she touches in the bathroom.’’ In the unique setting of a jail, inmates move in and out quickly—staying as little as a few hours or as long as several months. There are also high rates of recidivism; 12 participants were returned to jail or sentenced to prison during this study. Short jail stays require rapid assessment of HIV knowledge among the women. Use of the HIV-KQ-18 provides a reliable rapid assessment that can lead to individualized prevention education. Creating prevention education programs tailored to population deficiencies has been called for in the literature (Bryan et al., 2006; Swenson et al., 2010). Even with higher HIV knowledge among women with an STI history, myths about HIV transmission risks (casual contact) remain. The women in this study were excited to be the focus of the study and they recognized a large need for HIV education. More work is needed to measure HIV knowledge across different regions and populations of women to inform our prevention education efforts. Future work should include development of tailored education programs based on HIV knowledge assessment that can be delivered quickly and easily by jail health care staff or officers (in the instance of no health care staff). Declaration of Conflicting Interests The authors disclosed no conflicts of interest with respect to the authorship and/or publication of this article. For information about JCHC’s disclosure policy, please see the Self-Study Exam.
Funding The authors disclosed receipt of the following financial support for the research, authorship and/or publication of this article: Funding for this study was provided by the Robert Wood Johnson Foundation Nurse Faculty Scholars Program #66531.
References Beckwith, C., Liu, T., Bazerman, L., DeLong, M., Desjardins, S., Poshkus, M., & Flanigan, T. (2010). HIV risk behavior before and after HIV counseling and testing in jail: A pilot study. Journal of Acquired Immune Deficiency Syndrome, 53, 485–490. doi:10.1097/QAI.0b013e3181c997b1 Belenko, S., Shedlin, M., & Chaple, M. (2005). HIV risk behaviors, knowledge and prevention service experiences among African American and other offenders. Journal of Health Care for the Poor and Underserved, 16, 108–129. Brown, E., & Hill, M. (2005). Perceptions of HIV risks and prevention strategies by rural and small city African Americans who use cocaine: Views from the inside. Issues in Mental Health Nursing, 26, 359–377. doi:10. 1080/01612840590922416 Brown, E., & Van Hook, M. (2006). Risk behavior, perceptions of HIV risk, and risk-reduction behavior among a small group of rural African American women who use drugs. Journal of the Association of Nurses in AIDS Care, 17, 42–50. doi:10.1016/j.jana.2006.07.004 Bryan, A., Robbins, R., Ruiz, M., & O’Neill, D. (2006). Effectiveness of an HIV prevention intervention in prison among African Americans, Hispanics, and Caucasians. Health Education and Behavior, 33, 154–177. doi:10.1177/1090198105277336
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Carey, M., & Shroder, K. (2002). Development and psychometric evaluation of the brief HIV knowledge questionnaire. AIDS Education and Prevention, 14, 172–182. Centers for Disease Control and Prevention, Division of HIV/AIDS Prevention. (2011). HIV among women. Retrieved from http://www.cdc.gov/hiv/topics/women/ Centers for Disease Control and Prevention. (2012). HIV, other STD and pregnancy prevention education in public secondary schools—45 states, 2008–2010. Morbidity and Mortality Weekly Report, 61, 222–228. Retrieved from http://www.cdc.gov/mmwr/preveiw/mmwrhtml/mm6113a2.htm Espinoza, L., Hall, I., Hardnett, F., Selik, R., Qiang, L., & Lee, L. (2007). Characteristics of persons with heterosexually acquired HIV infection, United States 1999–2004. American Journal of Public Health, 97, 144–149. Hammett, T. M., & Drachman-Jones, A. (2006). HIV/AIDS, sexually transmitted diseases, and incarceration among women: National and southern perspectives. Sexually Transmitted Diseases, 33, S17–S22. Henderson, S., Bernstein, L., St. George, D., Doyle, J., Paranjape, A., & Corbie-Smith, G. (2004). Older women and HIV: How much do they know and where are they getting their information? Journal of the American Geriatric Society, 52, 1549–1553. Kaiser Family Foundation. (2011). HIV/AIDS at 30: A public opinion perspective. Menlo Park, CA: Author. Landry, D., Kaeser, L., & Richards, C. (1999). Abstinence promotion and the provision of information about contraception in public school district sexuality education policies. Family Planning Perspective, 31, 280–286. Retrieved from http://www.guttmacher.org/pubs/journals/3128099.html Lindau, S., Leitsch, S., Lundberg, K., & Jerome, J. (2006). Older women’s attitudes, behavior, and communication about sex and HIV: A community-based study. Journal of Women’s Health, 15, 747–752. Lloyd, S. W., Ferguson, Y. O., Corbie-Smith, G., Ellison, A., Blumenthal, C., Council, B. J., . . . Akers, A. (2012). The role of public schools in HIV prevention: Perspectives from African Americans in the rural south. AIDS Education and Prevention, 24, 41–53. doi:10.1521/aeap.2012.24.1.41 Orel, N., Stelle, C., Watson, W., & Bunner, B. (2010). No one is immune: A community education partnership addressing HIV/AIDS and older adults. Journal of Applied Gerontology, 29, 352–370. doi:10.1177/ 0733464809337412 Oser, C., Havetis, J., Mooney, J., Statoti-Tindall, M., Knudsen, H., Duvall, J., & Leukefeld, C. (2008). Racial differences in HIV/AIDS discussion strategies and sexual risk behaviors among drug-abusing female criminal offenders. Journal of Pyschoactive Drugs, 40, 483–492. Roberson, D., White, B., & Fogel, C. (2009). Factors influencing adherence with anti-retroviral therapy for HIV infected female inmates. Journal of the Association of Nurses in AIDS Care, 20, 50–61. Scott, K., Gilliamb, A., & Braxton, K. (2005). Culturally competent HIV prevention strategies for women of color in the United States. Health Care for Women International, 26, 17–45. doi:10.1080/ 07399330590885795 Swenson, R., Rizzo, C., Brown, L., Vanable, P., Carey, M., Valois, R., . . . Romer, D. (2010). HIV knowledge and its contribution to sexual health behaviors of low-income African American adolescents. Journal of the National Medical Association, 102, 1173–1182. Williams, P., Ekundayo, O., Udezulu, I., & Omishakin, A. (2003). An ethnically sensitive gender-specific HIV/ AIDS assessment of African American women: A comparative study of urban and rural American communities. Family Community Health, 26, 108–123.
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Measuring HIV Knowledge Among Women Incarcerated in Jail
Journal of Correctional Health Care 2014, Vol. 20(3) 213-219 ª The Author(s) 2014 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/1078345814531725 jcx.sagepub.com
Donna W. Roberson, PhD, FNP-BC1
Abstract Incarcerated women often have arresting behaviors that are also high risk for acquiring HIV, such as drug use and sex work. Little research has been done related to HIV knowledge among women in jail. This study assessed HIV knowledge among English-speaking women 18 years and older detained in a large, Southeastern jail (N ¼ 202). HIV knowledge was assessed using the Brief HIV Knowledge Questionnaire. HIV knowledge scores were significantly lower among women over age 50, F(3, 195) ¼ 7.39, p < .001; those with less than a high school education, F(2, 187) ¼ 4.10, p ¼ .018; and those with no history of sexually transmitted infections, F(1, 200) ¼ 7.66, p ¼ .006. Assessment of HIV knowledge among incarcerated women revealed a need for prevention education. Keywords HIV knowledge, HIV prevention, incarcerated women, jail
According to the Centers for Disease Control and Prevention (CDC, 2011), the number of new cases of HIV continues to rise among women in the southern United States, with more new infections being diagnosed in women from ethnic minorities. The primary mode of HIV transmission for women continues to be from heterosexual contact (CDC, 2011; Espinoza et al., 2007). The primary risk factors associated with heterosexual HIV transmission are multiple sex partners and unprotected sex; however, additional factors include poverty, limited access to health care, lack of education, and incarceration (CDC, 2011; Scott, Gilliam, & Braxton, 2005; Swenson et al., 2010). Typically, women are incarcerated in a short-term and more local jail setting prior to sentencing that requires incarceration in the longer term setting of a prison. Women incarcerated in jail frequently have arresting behaviors associated with increased risk for HIV including sex work and substance abuse (Bryan, Robbins, Ruiz, & O’Neill, 2006; Roberson, White, & Fogel, 2009). There is a high rate of
1
East Carolina University, College of Nursing, Greenville, NC, USA
Corresponding Author: Donna W. Roberson, PhD, FNP-BC, East Carolina University College of Nursing, Health Sciences Bldg #2124, Greenville, NC 27858 USA. Email: [email protected]
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homelessness, mental illness, and heavy family care burden among women in detention settings, and many of the women have had very limited health care (Bryan et al., 2006). Swenson and associates (2010) studied African American adolescents in the northeastern and southeastern United States and found that the adolescents had low knowledge of HIV and appropriate condom use and understanding of the need for HIV testing. However, to date, there has been a little assessment of HIV knowledge among women in rural and economically depressed areas (Swenson et al., 2010; Williams, Ekundayo, Udezulu, & Omishakin, 2003). There is continuing evidence that women believe a sexual partner who appears healthy could not have HIV and they have great faith in their partner’s monogamy. Thus, although women recognize that condoms reduce HIV risk, they do not perceive themselves at risk for the disease (Brown & Hill, 2005; Brown & Van Hook, 2006; Espinoza et al., 2007; Swenson et al., 2010). Researchers have found that older women have less knowledge of HIV than younger women and many older women do not perceive themselves at risk for acquiring the virus (Henderson et al., 2004; Lindau, Leitsch, Lundberg, & Jerome, 2006; Orel, Stelle, Watson, & Bunner, 2010). Older women frequently experience a loss of estrogen that may result in atrophied vaginal mucosa. Atrophied vaginal mucosa can tear more easily during sexual intercourse and create an increased risk for HIV acquisition. In addition, as women age, immune system functioning declines, increasing susceptibility to infection. Finally, older women are less likely to consider condoms with intercourse because they no longer have concerns about pregnancy (Lindau et al., 2006). Although many U.S. public schools do teach at least some topics on HIV, sexually transmitted infections (STIs), and pregnancy prevention, the number of states teaching complete prevention programs decreased in 2010 (CDC, 2012). Lack of appropriate HIV/STI education has been cited as a barrier to reducing HIV infection in adolescents (Lloyd et al., 2012). In a study by the Kaiser Family Foundation (2011), the media was a major source of HIV information for Whites, Blacks, and Latinos aged 18 to 29. Despite these sources of HIV information, many people continued to hold at least one misconception about HIV transmission and/or treatment (Kaiser Family Foundation, 2011). Women of all ages need prevention programs that target their deficiencies in knowledge about HIV, condom use strategies, and need for testing (Swenson et al., 2010). Prison offers an opportunity for prevention education and intervention that is often underutilized (Bryan et al., 2006). Most people who are incarcerated initially enter the correctional system through a shorter jail term before reaching the longer stay of prison (Beckwith et al., 2010). Thus, reaching a woman before she progresses to the prison environment may reduce HIV acquisition risk earlier in her life (Roberson et al., 2009). Educational interventions to meet the needs of those incarcerated have been tested in prison settings (Belenko, Shedlin, & Chaple, 2005; Bryan et al., 2006; Hammett & Drachman-Jones, 2006; Oser et al., 2008). However, little work has been done in the jail, where HIV knowledge needs are presumed to be as great as those in prison and prevention education as imperative. Measurement of HIV knowledge would be valuable prior to providing an HIV prevention educational program for women in a jail setting. Therefore, this study, which was part of a larger HIV prevention study for women in jail settings, assessed HIV knowledge among women in jail and evaluated whether knowledge levels were affected by age, race, education, and history of STI.
Methods Following university institutional review board approval, a large Southeastern detention center was used for the study. In this jail, women are housed in cellblocks based on level of criminal charge (violent vs. nonviolent offense). The cellblock used for this study had a capacity of 48 women who
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were considered nonviolent offenders. The research team did not ask the women why they were incarcerated, but many disclosed their charges in the group sessions. Common charges disclosed were sex work/prostitution, possession of controlled substances, uttering (writing checks for which adequate funds were not available), failure to appear (did not come to court on the scheduled court date), probation violations, and possession with intent to sell (most often marijuana or crack cocaine). Participants in the convenience sample were at least 18 years of age, English speaking, not infected with HIV (by self-report), and eligible for release into the surrounding county (not a federal or state inmate). The women were approached as a group when they were released from their cells into the common area for recreation time. Most (90%) were interested in participating in the study. Those who were not interested often wanted to use the telephones and did not want to miss their turn or just said ‘‘not interested.’’ About 7% of women were ineligible for reasons that included not returning to the surrounding county, being a federal or state detainee, and not speaking English (n ¼ 3). Interested women were taken by the investigator to a table away from the gathering area to be screened for eligibility and to provide full informed consent. HIV knowledge was assessed using the Brief HIV Knowledge Questionnaire (HIV-KQ18). Carey and Shroder (2002) found an acceptable internal consistency (a ¼ .75 to .89) and test–retest stability (rs ¼ .76 to .94) of the tool in three randomized control samples (N ¼ 1,033). The HIV-KQ18 was strongly correlated to a longer, previously validated tool (rs ¼ .93 to .97). The HIV-KQ18 has been used in a variety of settings, including prisons, and has proven to be reliable and valid even with low-literacy participants. The HIV-KQ18 has 18 statements about HIV. Respondents are asked whether they believe the statement is true or false; if they are not sure, they can answer ‘‘don’t know.’’ (Table 2 lists the questions from the HIV-KQ18). The tool’s heavy emphasis on the sexual transmission of HIV was considered advantageous for this study because of the larger study focus on the prevention of heterosexual transmission of HIV. The author read the HIV-KQ18 to each woman privately. When a participant questioned the meaning of a statement, the same explanation was provided each time. One statement routinely caused questions: ‘‘People are likely to get HIV by deep kissing, putting their tongue in their partner’s mouth, if their partner has HIV.’’ In this region, people use the term ‘‘French kissing’’ so this item was explained by saying, ‘‘It says people can get HIV by French kissing someone with HIV.’’ The Statistical Package for the Social Sciences (SPSS) version 18 was used to compute descriptive characteristics of the sample and responses to each item of the questionnaire. The relationship of HIV knowledge to age, race, education level, and history of STIs was analyzed with Pearson correlations, chi-square, and analysis of variance (ANOVA). For statistically significant ( p < .05) ANOVA results, the post hoc Tukey analysis was used to determine differences among groups.
Results A total of 202 women participated in this study. Of those women ineligible for inclusion in the study, 10 lived outside the county or were moving out of the area upon release, 7 were awaiting transfer to a state prison, and 5 were awaiting transfer to a federal prison. Of the approximately 22 women who declined to participate, 3 did not speak English and 19 expressed a lack of time or interest in the study. The majority of participants were women of color (n ¼ 141) and most self-identified as African American (n ¼ 115). Demographic characteristics of the sample are summarized in Table 1. Internal consistency of the tool in this sample was calculated as a ¼ .79. Scores on the HIVKQ18 ranged widely. Average percent correct was 79%, with scores ranging from 17% to
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Table 1. Demographic Characteristics of Sample (n, %). Variable Marital status Single Married Divorced Partnered Separated Total Missing Sexual orientation Men only Both genders Women only Prefer not to answer Total Missing Occupation Other None Student Health care Daycare Technical/trade Total Missing Education High school/GED < High school Post high school Associate’s degree Bachelor’s degree Graduate degree Total Missing
112 35 21 18 3 189 13
(59) (18) (11) (10) (2)
171 13 4 2 190 12
(90) (7) (2) (1)
58 32 22 15 15 9 190 12
(31) (17) (12) (8) (8) (5)
77 75 38 6 1 2 199 3
(39) (38) (19) (3) (.5) (1)
100% correct. Results of item scorings are summarized in Table 1. Age was found to have a relationship with HIV-KQ18 scores, F(3, 195) ¼ 7.37, p < .001. Women over 50 years of age scored significantly lower (M ¼ 61.4, SD ¼ 22.42) on the HIV-KQ18 as compared to women younger than 30 (M ¼ 81.7, SD ¼ 15.97), women aged 30 to 39 (M ¼ 80.3, SD ¼ 15.14), and women aged 40 to 49 (M ¼ 78.5, SD ¼ 19.83). Having a history of STI was also found to be related to HIVKQ18 scores, F(1, 200) ¼ 7.66, p ¼ .006. Those women with no prior history of an STI had significantly lower HIV knowledge scores (M ¼ 75.3, SD ¼ 19.59) as compared to those with a history of at least one STI (M ¼ 82.2, SD ¼ 15.57). Although there was no statistically significant difference in knowledge scores between high school graduates (M ¼ 81.9, SD ¼ 17.81) and women with post-high school education (M ¼ 80.3, SD ¼ 14.19), those with less than a high school education scored significantly lower (M ¼ 73.9, SD ¼ 19.11); F(2, 187) ¼ 4.10, p ¼ .018. There was no relationship between ethnicity and HIV knowledge in this sample. Age and STI history independently predicted HIV knowledge.
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Table 2. HIV Knowledge Items With Mean Percentage Answering Correctly. Item
Mean (SD)
1. Coughing and sneezing DO NOT spread HIV. (T) 2. A person can get HIV by sharing a glass of water with someone who has HIV. (F) 3. Pulling out the penis before a man climaxes/cums keeps a woman from getting HIV during sex. (F) 4. A woman can get HIV if she has anal sex with a man. (T) 5. Showering, or washing ones’ genitals/private parts, after sex keeps a person from getting HIV. (F) 6. All pregnant women infected with HIV have babies born with AIDS. (F) 7. People who have been infected with HIV quickly show serious signs of being infected. (F) 8. There is a vaccine that can stop adults from getting HIV. (F) 9. People are likely to get HIV by deep kissing, putting their tongue in their partner’s mouth, if their partner has HIV. (F) 10. A woman cannot get HIV if she has sex during her period. (F) 11. There is a female condom that can help decrease a woman’s chance of getting HIV. (T) 12. A natural skin condom works better against HIV than does a latex condom. (F) 13. A person will NOT get HIV if she or he is taking antibiotics. (F) 14. Having sex with more than one partner can increase a person’s chance of being infected with HIV. (T) 15. Taking a test for HIV one week after having sex will tell a person if she or he has HIV. (F) 16. A person can get HIV by sitting in a hot tub or a swimming pool with a person who has HIV. (F) 17. A person can get HIV from oral sex. (T) 18. Using Vaseline or baby oil with condoms lowers the chance of getting HIV. (F)
.59 .78 .90 .91 .92 .61 .78 .75 .74
(.492) (.414) (.299) (.286) (.278) (.489) (.417) (.433) (.441)
.95 .40 .64 .91 .98
(.227) (.491) (.482) (.293) (.156)
.80 .84 .86 .87
(.399) (.366) (.352) (.341)
N ¼ 202 for all items; correct answers in parentheses (T ¼ true; F ¼ false).
Discussion As described by other researchers, the participants in this study had deficiencies in HIV knowledge and it was evident that common misconceptions regarding HIV infection remain (Kaiser Family Foundation, 2011; Swenson et al., 2010). As seen previously, older women in this study had lower knowledge than their younger peers (Henderson et al., 2004; Lindau et al., 2006; Orel et al., 2010). HIV prevention education was not taught in the schools in this region when the older women would have been in attendance. In fact, abstinence was still the prevalent education program taught in most United States schools at the time (Landry, Kaeser, & Richards, 1999). In this study, the majority of the women under age 30 were likely to have had at least some HIV and STI prevention education in school. The association of increased HIV knowledge with a history of STIs was interesting. One would hope this finding is associated with more comprehensive HIV and STI prevention education when they were diagnosed with the STI. It would have been helpful to know how long it had been since the woman had been diagnosed with an STI and what type of education she received with that diagnosis. Given the differences in HIV knowledge by age, education, and STI history, the findings from this study indicated that a tailored HIV prevention program would be beneficial for women in jail. For example, for a younger incarcerated woman, discussion of common myths may be adequate; for an older woman, however, transmission and condom use may be needed, as well. Limitations of this study include inability to generalize the findings to all incarcerated women, but rather only to those incarcerated in similar settings with similar backgrounds. The sample does seem to reflect the ethnic backgrounds of women incarcerated across the United States (Roberson et al., 2009). The sample size was adequate and the HIV-KQ18 appropriate for measurement of HIV knowledge in this group.
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Journal of Correctional Health Care 20(3)
Conclusion The findings in this study indicated a need for HIV knowledge and prevention information for women in this jail setting. Although most women recognized some sexual risks associated with the transmission of HIV, education is needed that focuses on modes of transmission and means of protection (barriers). It may be useful to include discussions that dispel myths about HIV acquisition. One 24-year-old woman said that she was well informed about HIV. However, when she was talking about her friend infected with HIV coming to visit, she said, ‘‘I clean my toilet with bleach and bleach all the towels she touches in the bathroom.’’ In the unique setting of a jail, inmates move in and out quickly—staying as little as a few hours or as long as several months. There are also high rates of recidivism; 12 participants were returned to jail or sentenced to prison during this study. Short jail stays require rapid assessment of HIV knowledge among the women. Use of the HIV-KQ-18 provides a reliable rapid assessment that can lead to individualized prevention education. Creating prevention education programs tailored to population deficiencies has been called for in the literature (Bryan et al., 2006; Swenson et al., 2010). Even with higher HIV knowledge among women with an STI history, myths about HIV transmission risks (casual contact) remain. The women in this study were excited to be the focus of the study and they recognized a large need for HIV education. More work is needed to measure HIV knowledge across different regions and populations of women to inform our prevention education efforts. Future work should include development of tailored education programs based on HIV knowledge assessment that can be delivered quickly and easily by jail health care staff or officers (in the instance of no health care staff). Declaration of Conflicting Interests The authors disclosed no conflicts of interest with respect to the authorship and/or publication of this article. For information about JCHC’s disclosure policy, please see the Self-Study Exam.
Funding The authors disclosed receipt of the following financial support for the research, authorship and/or publication of this article: Funding for this study was provided by the Robert Wood Johnson Foundation Nurse Faculty Scholars Program #66531.
References Beckwith, C., Liu, T., Bazerman, L., DeLong, M., Desjardins, S., Poshkus, M., & Flanigan, T. (2010). HIV risk behavior before and after HIV counseling and testing in jail: A pilot study. Journal of Acquired Immune Deficiency Syndrome, 53, 485–490. doi:10.1097/QAI.0b013e3181c997b1 Belenko, S., Shedlin, M., & Chaple, M. (2005). HIV risk behaviors, knowledge and prevention service experiences among African American and other offenders. Journal of Health Care for the Poor and Underserved, 16, 108–129. Brown, E., & Hill, M. (2005). Perceptions of HIV risks and prevention strategies by rural and small city African Americans who use cocaine: Views from the inside. Issues in Mental Health Nursing, 26, 359–377. doi:10. 1080/01612840590922416 Brown, E., & Van Hook, M. (2006). Risk behavior, perceptions of HIV risk, and risk-reduction behavior among a small group of rural African American women who use drugs. Journal of the Association of Nurses in AIDS Care, 17, 42–50. doi:10.1016/j.jana.2006.07.004 Bryan, A., Robbins, R., Ruiz, M., & O’Neill, D. (2006). Effectiveness of an HIV prevention intervention in prison among African Americans, Hispanics, and Caucasians. Health Education and Behavior, 33, 154–177. doi:10.1177/1090198105277336
Downloaded from jcx.sagepub.com at GEORGIAN COURT UNIV on March 9, 2015
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Carey, M., & Shroder, K. (2002). Development and psychometric evaluation of the brief HIV knowledge questionnaire. AIDS Education and Prevention, 14, 172–182. Centers for Disease Control and Prevention, Division of HIV/AIDS Prevention. (2011). HIV among women. Retrieved from http://www.cdc.gov/hiv/topics/women/ Centers for Disease Control and Prevention. (2012). HIV, other STD and pregnancy prevention education in public secondary schools—45 states, 2008–2010. Morbidity and Mortality Weekly Report, 61, 222–228. Retrieved from http://www.cdc.gov/mmwr/preveiw/mmwrhtml/mm6113a2.htm Espinoza, L., Hall, I., Hardnett, F., Selik, R., Qiang, L., & Lee, L. (2007). Characteristics of persons with heterosexually acquired HIV infection, United States 1999–2004. American Journal of Public Health, 97, 144–149. Hammett, T. M., & Drachman-Jones, A. (2006). HIV/AIDS, sexually transmitted diseases, and incarceration among women: National and southern perspectives. Sexually Transmitted Diseases, 33, S17–S22. Henderson, S., Bernstein, L., St. George, D., Doyle, J., Paranjape, A., & Corbie-Smith, G. (2004). Older women and HIV: How much do they know and where are they getting their information? Journal of the American Geriatric Society, 52, 1549–1553. Kaiser Family Foundation. (2011). HIV/AIDS at 30: A public opinion perspective. Menlo Park, CA: Author. Landry, D., Kaeser, L., & Richards, C. (1999). Abstinence promotion and the provision of information about contraception in public school district sexuality education policies. Family Planning Perspective, 31, 280–286. Retrieved from http://www.guttmacher.org/pubs/journals/3128099.html Lindau, S., Leitsch, S., Lundberg, K., & Jerome, J. (2006). Older women’s attitudes, behavior, and communication about sex and HIV: A community-based study. Journal of Women’s Health, 15, 747–752. Lloyd, S. W., Ferguson, Y. O., Corbie-Smith, G., Ellison, A., Blumenthal, C., Council, B. J., . . . Akers, A. (2012). The role of public schools in HIV prevention: Perspectives from African Americans in the rural south. AIDS Education and Prevention, 24, 41–53. doi:10.1521/aeap.2012.24.1.41 Orel, N., Stelle, C., Watson, W., & Bunner, B. (2010). No one is immune: A community education partnership addressing HIV/AIDS and older adults. Journal of Applied Gerontology, 29, 352–370. doi:10.1177/ 0733464809337412 Oser, C., Havetis, J., Mooney, J., Statoti-Tindall, M., Knudsen, H., Duvall, J., & Leukefeld, C. (2008). Racial differences in HIV/AIDS discussion strategies and sexual risk behaviors among drug-abusing female criminal offenders. Journal of Pyschoactive Drugs, 40, 483–492. Roberson, D., White, B., & Fogel, C. (2009). Factors influencing adherence with anti-retroviral therapy for HIV infected female inmates. Journal of the Association of Nurses in AIDS Care, 20, 50–61. Scott, K., Gilliamb, A., & Braxton, K. (2005). Culturally competent HIV prevention strategies for women of color in the United States. Health Care for Women International, 26, 17–45. doi:10.1080/ 07399330590885795 Swenson, R., Rizzo, C., Brown, L., Vanable, P., Carey, M., Valois, R., . . . Romer, D. (2010). HIV knowledge and its contribution to sexual health behaviors of low-income African American adolescents. Journal of the National Medical Association, 102, 1173–1182. Williams, P., Ekundayo, O., Udezulu, I., & Omishakin, A. (2003). An ethnically sensitive gender-specific HIV/ AIDS assessment of African American women: A comparative study of urban and rural American communities. Family Community Health, 26, 108–123.
Downloaded from jcx.sagepub.com at GEORGIAN COURT UNIV on March 9, 2015
