Predictors of condom use in sexually active adolescents

Adolescents and sexually transmitted diseases

Pediatricians with busy practices have limited time to spend with each patient. But because much of adolescent morbidity and mortality is related to behavioral issues, time and energy are crucial to providing effective counseling and care to adolescents. Many barriers to provision of services to adolescents exist, including time, space, décor, office hours, office fees, and support personnel. Despite these barriers to care of adolescents and, in particular, sexually active adolescents, the need for pediatricians to provide these services is clear. Services include anticipatory guidance and counseling about developing sexuality and sexual behaviors, as well as management of health consequences of sexual behavior. Primary care providers have an opportunity to assist adolescents to develop mature and healthy sexual relationships. This necessitates a full understanding of each patient's unique situation, listening to adolescents' concerns, and honest and straightforward discussion of sensitive information. Beginning the process of discussion of sexuality and relationships early in the pediatric years may help adolescents and their parents to develop healthy sexual attitudes and behaviors.

Partner condom use among adolescent girls with sexually transmitted diseases

PURPOSE

To explore associations of self-reported condom use with sexual risk knowledge and behaviors, perceptions of peer condom use, and communication with sexual partners about condom use among adolescent girls with sexually transmitted diseases (STDs).

METHODS

Adolescent girls with cervicitis or pelvic inflammatory disease (PID) completed a 62-item self-administered questionnaire on sexual risk knowledge and behaviors, condom use, perceptions of peer condom use, and condom use negotiation with partners. Associations with frequency of condom use and condom use at last sexual intercourse were analyzed.

RESULTS

A total of 24 girls were enrolled: 13 with cervicitis and 11 with PID; 22 had complete data for analysis. Compared with girls who reported low frequency of condom use, girls who reported condom use all or most of the time were younger (16.7 vs. 19.5 years; p = .008), were less likely to have a prior history of STD (67% vs. 0%; p = .03), and were more likely to think that all or most of their friends use condoms (72% vs. 0%; p = .02). Compared with girls who had not used a condom with last sexual intercourse, girls who had used a condom were younger (16.2 vs. 17.9 years; p = .04), had fewer lifetime partners (2.7 vs. 8.4; p = .03) and had higher mean scores in condom use negotiation (29.1 vs. 24.4; p = .02), and were more likely to think that all or most of their friends used condoms (100% vs. 31%; p = .001). Knowledge about condoms and STD prevention was high (mean 14.3 +/- 2.3 of 16) but was not associated with condom use.

CONCLUSIONS

STD interventions for partner condom use among high-risk adolescent girls must recognize the decrease in condom use with increasing age and focus on maintaining safer sex behaviors, building condom use negotiation skills, and promoting the perception of condom use by friends.

Relationship between perceived parental monitoring and young adolescent girls' sexual and substance use behaviors

STUDY OBJECTIVE

The purpose of the study was to examine the independent effects of perceived parental monitoring on sexual experience, contraceptive, and substance use.

DESIGN, SETTING, AND PARTICIPANTS

Adolescent females at an urban-based adolescent clinic (N = 174; 41% sexually experienced) rated the extent to which they were directly and indirectly monitored by their parents.

MAIN OUTCOME MEASURES

These perceptions were compared with reported contraceptive use as well as substance use. Direct parental monitoring was best described using two dimensions: direct monitoring and direct monitoring when with peers.

RESULTS

Direct monitoring was found to be associated with the use of hormonal birth control methods at last intercourse. Direct parental monitoring when with peers was found to be associated with less use of alcohol and cigarettes.

CONCLUSIONS

These data suggest that parental monitoring is a relevant factor for primary care physicians to explore during treatment.

Determinants of condom use to prevent HIV infection among youth in Ghana

PURPOSE

To identify the psychosocial and behavioral factors that influence condom use to reduce the risk of human immunodeficiency virus (HIV) infection among young men in Ghana.

METHODS

This study used a cross-sectional design in which data on a community-based sample of 601 young men, 15-24 years of age, were collected by a household survey instrument. For a conceptual framework, the study used constructs from the Health Belief Model (HBM) and Social Learning Theory (SLT) in the Ghanaian context.

RESULTS

While 65% of the sexually active male respondents had used condoms at least once, only 25% had used condoms at last intercourse. Findings from multiple logistic regression analysis indicate that perceived susceptibility to HIV infection, perceived self-efficacy to use condoms, perceived barriers to condom use, and perceived social support were significant predictors of condom use. The most important finding, however, is that perceived barriers significantly interacted with perceived susceptibility and self-efficacy. Subjects who perceived a high level of susceptibility to HIV infection and a low level of barriers to condom use were almost six times as likely to have used condoms at last intercourse, compared to others. Similarly, young men who perceived a high level of self-efficacy to use condoms and a low level of barriers to condom use were nearly three times more likely to have used condoms at last intercourse when compared to others.

CONCLUSION

These results suggest that HIV prevention programs for youth should emphasize personal vulnerability to acquired immunodeficiency syndrome, instill in youth the self-belief that they can use condoms any time, and address how to overcome barriers to condom use.

Adolescents with psychiatric disorders and the risk of HIV

OBJECTIVE

To review literature relevant to human immunodeficiency virus (HIV)-associated risk behaviors among adolescents with psychiatric disorders and psychological influences on risk behaviors.

METHOD

This report is based on review of 66 articles, which comprise all of the relevant literature in the English language.

RESULTS

Although the seroprevalence of HIV in adolescents with psychiatric disorders is unknown, studies indicate that adolescents with psychiatric disorders are at greater risk than their peers because of increased rates of unsafe sexual practices, impulsivity, self-destructive attitudes, cognitive immaturity, high rates of substance use, self-cutting behavior, and the sequelae of sexual abuse.

CONCLUSION

Directions are proposed for the design of developmentally appropriate, clinically oriented HIV prevention interventions based on the relationships between psychological dysfunction, social stressors, and HIV risk behaviors.

The validity of self-reported condom use among adolescents

BACKGROUND

Research and public health interventions designed to reduce the risk of sexually transmitted diseases (STDs) often are based on self-reported condom use. Yet, validation of self-reported condom use, in particular with adolescents, has rarely been described in the literature.

METHODS

Baseline data were obtained from 540 adolescents, 13-21 years of age, enrolled in a 1-year longitudinal study of health beliefs, sexual behaviors, and STD acquisition. Of the 445 participants reporting to be sexually active, 404 (90.8%) agreed to a complete physical examination, including a genital examination, with STD screening after completing the self-administered written questionnaire. Participants' written self-report of condom use was compared to histories obtained by clinicians and laboratory diagnosis of acute STDs to assess validity of written self-report.

RESULTS

Complete data were available for 321 females and 77 males of whom 52 females and 5 males had laboratory evidence of 63 infections. Although three individuals who had STDs reported to be consistent users of condoms, a significant association (P < 0.05) was found between those who reported more frequent condom use with the last two partners and the absence of STDs.

CONCLUSION

In this group of adolescents, self-report of condom use with the last two partners was associated with the absence of an acute STD. This finding suggests that self-reported condom use is a valid indicator of risk for STDs, with implication for those working with adolescents clinically and in research contexts.

The role of condom motivation education in the reduction of new and reinfection rates of sexually transmitted diseases among inner-city female adolescents

The purpose of this study was to document the effectiveness of small group condom motivation education in reducing new and reinfection rates of sexually transmitted diseases (STD) among female teenagers. Two hundred and five (205) female adolescents (age 13-20) with a current STD were studied at two sites of a Teen Health Clinic. There were 86 teens in the Study Group and 119 in the Comparison Group. Patients were sampled from December 1992 to July 1993. The patients in the Study Group received a condom motivation class given by the clinic STD educator in small groups of four or more adolescents. The Comparison Group, comparable in age and ethnicity, received treatment for their STD but did not participate in condom motivation classes. All teens were given treatment and condoms. The sample was followed for 6 months. The total number of patients returning with new infections was 21 (14.7%). The total number of patients with reinfections was 14 (9.8%). There were no significant differences between the Study and Comparison Group on return rates, new and reinfection rates or on any socio-demographic variables. The comparison of these groups suggests that a specific condom motivation class has minimal effectiveness in urban teens. However, almost 70% of the teens returned to the clinic for their scheduled visits. It is suggested that adolescent clinics which combine family planning and STD treatment services maintain high client enrollment and therefore may be ideal locations to initiate new and continuous interventions for condom use especially for high risk teens.

The association of sexual risk behaviors and problem drug behaviors in high school students

PURPOSE

To examine the associations among early age of onset of sexual intercourse and drug use, lifetime and current problem drug behaviors, and sexual risk behaviors.

METHODS

The 1993 Massachusetts Youth Risk Behavior Survey was administered to a sample of 3,054 students from randomly selected high schools and classrooms; 36% (1,078) consistently reported having had sexual intercourse. Three indicators of sexual risk behaviors were assessed: (1) number of lifetime sexual partners, (2) number of recent partners, and (3) condom nonuse at last intercourse. Three sets of independent variables were analyzed: (1) age of onset of sexual intercourse and drug use, (2) lifetime drug use, and (3) recent drug use.

RESULTS

Years of sexual intercourse, early age of onset of marijuana and cocaine use, lifetime frequency of marijuana, crack/freebase cocaine and alcohol use, and black race accounted for moderate amounts of the variation in the number of lifetime sexual partners. Years of sexual intercourse, early age of onset of marijuana use and cocaine use, lifetime frequency of crack/freebase and marijuana use, and recent use of cocaine, alcohol, and cigarettes accounted for smaller but significant amounts of the variation in the number of recent partners. Students more likely to report recent condom nonuse were older, females, had more years of sexual intercourse, had tried cocaine at a younger age, had used marijuana and cocaine more times (lifetime), and had more frequent recent use of marijuana.

CONCLUSION

Increased frequency and severity of drug use behaviors and more years of sexual intercourse are associated with an increased number of sexual partners and recent condom nonuse. These findings may guide history-taking and referral practices of health care providers. Programs designed to prevent sexually transmitted diseases and pregnancy should address drug use as well as sexual behavior.

Human immunodeficiency virus risk behavior among white and Asian/Pacific Islander high school students in the United States: does culture make a difference?

PURPOSE

This article analyzes sexual behavior among white and Asian/Pacific Islander (API) adolescents, to determine the risk for human immunodeficiency virus (HIV) transmission from a multicultural point of view.

METHODS

A total of 5,385 white and 408 API high school students were included. The national school-based Youth Risk Behavior Survey (YRBS 1991) was used.

RESULTS

After controlling for academic performance, white students were 2.3 times more likely to communicate about acquired immunodeficiency syndrome (AIDS)/HIV, 2.7 times more likely to be sexually experienced, and 2.5 times more likely to use alcohol or other drugs before sex than APIs. There were no significant differences between these two groups in the age of initiating sex, the number of lifetime partners, the proportion of being currently sexually active (having had sex during the past 3 months), and condom use behavior. Although APIs had a low rate of AIDS/HIV, they have behaviors at as high a risk as white students once they became sexually experienced, and they have an even greater number of recent partners if they are currently sexually active. Use of alcohol or other drugs before sex and condom use is significantly related.

CONCLUSIONS

Given the importance of attention to risks among API adolescents, this study underscores the need for more research to explore how culture values play a role among all API students, those who are sexually experienced, and those who are currently sexually active API students, to develop culturally sensitive AIDS/HIV prevention programs.

Consequences of sexual decisions: the perceptions of rural adolescents

The purpose of this study was to examine the content of adolescent thinking about the consequences of choosing abstinence, sexual intercourse with a condom, and unprotected intercourse. Consequences for the relationship and for each partner's thoughts and feelings were explored. Participants were 116 high school students living in a rural area of a midwestern state; their average age was 16 years. They completed a series of open-ended questions about possible outcomes to a scenario involving sexual decision making. Content analysis of responses revealed that about half of the participants associated abstinence with positive consequences; however, it was also associated with insecurity and the possibility of losing the relationship. Sexual intercourse with a condom was viewed as an indication of caring and responsibility and was associated with positive outcomes for the relationship. Identified consequences of unprotected intercourse were almost entirely negative. Some differences in perceived consequences were influenced by the gender of the partner. Integration of these findings into programs designed to prevent sexual risk-taking is discussed.

Compliance with follow-up care among adolescent males with sexually transmitted diseases

The aim of the study was to investigate behavioral and sociodemographic characteristics of a sample of 45 male adolescents with sexually transmitted diseases who attended family planning clinics. Low rates of compliance with follow-up care were noted. Only 13 (28.9%) males returned to the clinic for their scheduled appointments. Neither behavioral nor sociodemographic variables were related to compliance.

Substance use, coping, and safer sex practices among adolescents with hemophilia and human immunodeficiency virus. The Hemophilia Behavioral Intervention Evaluative Project Committee

PURPOSE

To examine the use of alcohol and other drugs (AOD) to cope with the human immunodeficiency virus (HIV), the use of AOD before or during sex by 306 adolescent males with HIV and hemophilia, and its association with safer sex practices.

METHODS

A survey instrument was administered to adolescents at 11 sites of the Hemophilia Behavioral Intervention Evaluative Project. Survey questions focused on knowledge of sexual activity, safer sex practices, AOD use, attitudinal and behavioral influences of parents, peers and sex partners, communication patterns, and perceived facilitators and barriers to practicing safer sex.

RESULTS

A total of 68% of all respondents reported using condoms every time they had heterosexual sex. Respondents who did not use AOD to cope were more likely than AOD copers to report that they disclose their HIV status to all sex partners, talk to all of their sex partners about safer sex, find the use of condoms more enjoyable, and have sex partners who approved of their use of condoms. Condom use was not related to the use of AOD to cope or the use of AOD with the most recent female sex partner.

CONCLUSIONS

The use of AOD to cope with HIV and its use before or during sex was negatively associated with certain safer sex attitudes and practices. AOD use may help facilitate HIV transmission among adolescents with HIV and/or hemophilia.

Psychosocial conventionality, health orientation, and contraceptive use in adolescence

PURPOSE

The purpose of this paper is to determine psychosocial and behavioral factors that are associated with variation in contraceptive use among adolescents. Because regular use of contraception may be seen both as a conventional behavior and as a health-protective behavior, analyses assess the association between psychosocial conventionality and health orientation, on the one hand, and variation in contraceptive use, on the other.

METHODS

Analyses are based on an urban sample of 971 white, African-American, and Hispanic male and female sexually active high school students. Study participants filled out a 38-page questionnaire that included a wide range of measures derived from Problem-Behavior Theory.

RESULTS

Correlational analysis and hierarchical regression analysis indicate that more regular contraceptive use is associated with greater psychosocial conventionality and also with greater orientation toward health for both male and female adolescents. These relationships hold when the sociodemographic characteristics of race/ethnicity, socioeconomic status, grade in school, family composition, and pregnancy experience are controlled. The linkages of psychosocial conventionality and health orientation to contraceptive behavior are stronger for African-American than for white and Hispanic adolescents.

CONCLUSIONS

The present findings establish a more comprehensive and more distal set of influences on regularity of contraceptive use. In its negative relationship to problem behavior and its positive linkage with health behavior, contraceptive behavior may be seen as part of a larger, organized system of behavior in this stage of development (i.e., a more conventional adolescent lifestyle).

The relationship between knowledge about sexually transmitted diseases and actual sexual behaviour in a group of teenage girls

PURPOSE

To assess longitudinally the relationship between knowledge about sexually transmitted diseases (STDs) and sexual behaviour, contraceptive use, STD protection and social class in a group of Swedish teenage girls.

METHODS

Girls starting their upper secondary school education were invited to attend a teenage clinic during a period of 2 years (5 visits). Questions were asked about family situation, sexual activity, contraceptives, STD protection and knowledge about STD. Gynaecological examinations were performed on entry and completion, and when necessary during the observation period.

RESULTS

Eighty-eight girls completed all visits during the observation period. At 16 years of age there were no significant differences in knowledge about various STD and STD protection between girls from different social classes or with respect to coital experience, age of coitarche and the subsequent number of sexual partners at 18 years of age. At 18 years of age there was a better knowledge about STDs and the need for STD protection (p < 0.01) among girls with coital experience compared with those who had no coital experience. Girls reporting many lifetime partners were best informed, but in spite of solid knowledge they did not protect themselves from infection. Even though 34% of the girls with coital experience were found to harbour a STD during the course of this study, almost all girls denied the possibility of having acquired or transmitted an infection.

CONCLUSIONS

Although girls were well-informed about sexually transmitted diseases and knew how to avoid infections this knowledge had little influence on behaviour.

Women's beliefs concerning condom acquisition and use

Condoms are a time-honored and reliable method of protection against pregnancy and sexually transmitted infections. However, their use, and thus their effectiveness, is determined by individual behavior. The purpose of this paper is to report attitudes and salient beliefs related to condom use in a sample of adult women. The study used Ajzen and Fishbein's Theory of Planned Behavior to identify modal, salient beliefs regarding condom acquisition and use as intentional behaviors. The study sample consisted of 58 community women who reported using condoms for contraceptive purposes within the last five years. In face-to-face, audiotaped interviews, open-ended questions were used to solicit beliefs regarding condom acquisition and use. All subject narratives were content-analyzed for recurrent themes. Women cited accessibility and effectiveness in preventing pregnancy and sexually transmitted diseases as both advantages and as factors contributing to the ease of acquisition and use. Disadvantages and factors that might deter condom acquisition and use included embarrassment, objections by male partner, and effect on spontaneity. Overall, subjects exhibited accurate knowledge regarding the benefits of condom acquisition and use. However, it is possible that expressed negative beliefs could take precedence in decision-making and reduce the probability of consistent condom use.

The benefits of school-based condom availability: cross-sectional analysis of a comprehensive high school-based program

OBJECTIVES

To analyze the benefits of a school-based condom availability program relative to the risks that such a program may incur.

METHODS

A confidentially-administered survey instrument was completed by 152 randomly selected high-school students (approximately 14% of the entire student population).

RESULTS

The respondents had a mean age of 15.9 years (range: 14-19 years) and a proportionate gender distribution. Ninety-three percent of all respondents had "heard of" the school's program and knew from whom they could receive condoms. Twenty-six percent of the respondents had received condoms from the program with 67% using them. Of those receiving condoms but not using them, more than half did not need them, owing to absence of anticipated sexual activity. Of the nonreceivers, 53% had never had sexual intercourse and 27% received condoms from other sources. The benefit of the program by aiding a sexually-active student was found to be more than three times as great as the risk of encouraging a nonsexually active student to have sexual intercourse (RR = 3.2; 95% C.I. = 2.1, 4.9). The prevalence of sexual activity among all respondents was not significantly higher than the state's average based on gender and age (59.8% vs. 54.5%; z = 1.24, p > .05, n.s.).

CONCLUSION

Given the lack of increased sexual activity and the favorable benefit-risk ratio, we conclude that school-based condom availability is successfully utilized by sexually-active adolescents and may be an effective means to reduce potentially harmful outcomes, such as unintended pregnancy and sexually-transmitted diseases.

Reasons for condom utilization among high-risk adolescent girls

Two hundred forty-eight adolescent girls responded to a list of 30 statements describing reasons for using and not using condoms. For 24 of the statements, most adolescents (> 70%) gave the same response regarding why they did or did not use condoms. Therefore, only the six remaining statements were used in further analyses. The relationship between the six statements and psychosexual history, condom use, and sexually transmitted disease (STD) history was examined. Those adolescent girls who had been sexually active longer were more likely to report lack of enjoyment as a reason that they did not use condoms (P < .03), and those adolescents who had been sexually active less time were more likely to report personal (P < .005) and partner (P < .0006) enjoyment of sex with condoms as a reason for using condoms. Longer relationships before intercourse were associated with having condoms available (P < .01) and partner insistence on their use (P < .02). Partner insistence on condom use was related to fewer episodes of sexually transmitted diseases (P = .03). These findings indicate the importance of relationship and partner variables in adolescent girls' perceptions of condom use.

Measurement of condom use in 72 studies of HIV-preventive behaviour: a critical review

Ninety-four distinct measures of condom use were identified in a review of 72 psychosocial studies of HIV-prevention. A coding scheme was developed which characterised each measure in terms of: (1) type of measure (e.g. frequency of use, use at last intercourse), (2) response alternatives (e.g. Likert scale), (3) recall period (e.g. lifetime, last month), (4) partner specification (e.g. 'new' partner), and (5) activity specification (e.g. vaginal or anal intercourse). Results show a great deal of inconsistency in measurements of condom use across studies. Single-item frequency or consistency measures were most common. Several difficulties with measures employed to date were identified. These included indeterminate reliability and validity of measures, lack of attention to the epidemiological significance of different types of use and terminological and self-presentational problems with items assessing use. Implications of extant measurement approaches for the accumulated knowledge base on predictors of 'safer' sex and suggestions for future research in this area are outlined.

The impact of AIDS on an urban population of high-risk female minority adolescents: implications for intervention

PURPOSE

This study's purpose was to describe acquired immunodeficiency syndrome (AIDS)-related concerns, risk behaviors, and psychosocial/situational determinants of condom use among an urban minority population of sexually active, adolescent girls. In addition we sought to define the accuracy of personal AIDS risk-assessment, the relative importance of AIDS in relation to other concerns, and the broader context of sexual experience and attitudes in this population.

METHODS

A cross-sectional interview study was conducted involving sexually active female adolescents attending a pediatric clinic in an inner-city university-affiliated community hospital. Sixty-nine subjects (ages 13-19 yr, 90% African-American) were enrolled. While the goals of this study were primarily descriptive, subject characteristics felt to impact on condom use were identified prior to data collection and were examined against several measures of usage including: use at the time of last sexual intercourse, overall frequency of condom use, and reported behavior change to include initiation of or increased condom usage.

RESULTS

Forty-one percent of participants reported knowing someone with AIDS. Global concern regarding this disease was high, although worry about poverty-related issues was often greater. Despite concern and high measures of AIDS risk (median number of sex partners, 3; past sexually transmitted disease, 55%; past pregnancy 77%), most participants perceived themselves to be at low personal risk owing to current monogamy, lack of intravenous drug use, and implicit trust in their partner's safety. Discussion with their partner about actual risk and awareness of the importance of past behaviors was generally lacking. Although 98% were aware that condoms may prevent AIDS, 64% used condoms half of the time or less when they had sex and use appeared to be primarily for contraception. Several intrinsic cognitive/psychological and extrinsic social/situational factors were found to correlate with measures of condom use.

CONCLUSIONS

Participants' sexual histories and behavior emphasize the need for concern regarding AIDS risk in this population. Patterns of sexual behavior and beliefs regarding committed relationships raise challenging questions regarding how to motivate sexually active members of this population to use condoms more frequently. Programs aimed at AIDS prevention among urban minority adolescents need to be cognizant of the larger personal and sociocultural context in which these teenagers are making health-behavior choices.

Adolescent sexual activity

Adolescents are becoming sexually active at younger ages. One half of the adolescents in the United States are sexually active. This article reviews adolescent sexual activity, including rates of sexual activity, sexual practices, gay and lesbian youth, and factors affecting the initiation of sexual activity. In addition, adolescent pregnancy, with possible outcomes and effects on teen parents and their offspring, is discussed.