Prevention and control of sexually transmitted infections among adolescents: the importance of a socio-ecological perspective--a commentary

Toward a conceptual model linking community violence exposure to HIV-related risk behaviors among adolescents: directions for research

PURPOSE

To present a conceptual framework which accounts for the relationship between community violence exposures (CVEs) and youth HIV risk behaviors.

METHODS

This article provides an overview of existing research on the links between CVE and HIV risk for youth and offers a conceptual framework for clarifying how CVE might contribute to HIV sexual risk behaviors.

RESULTS

Increasing empirical findings substantiate that the links between CVE and HIV risk behaviors among youth are mediated by psychological problem behaviors, low school success rates, and negative peer influences.

CONCLUSIONS

Researchers have identified the behaviors that place teens at risk for becoming infected with HIV. However, most scholars have overlooked the potential importance of CVE in influencing such behaviors. This article presents new directions for adolescent research and HIV interventions on the basis of an integrated conceptual framework.

Migration, neighborhoods, and networks: approaches to understanding how urban environmental conditions affect syndemic adverse health outcomes among gay, bisexual and other men who have sex with men

Adopting socioecological, intersectionality, and lifecourse theoretical frameworks may enhance our understanding of the production of syndemic adverse health outcomes among gay, bisexual and other men who have sex with men (MSM). From this perspective, we present preliminary data from three related studies that suggest ways in which social contexts may influence the health of MSM. The first study, using cross-sectional data, looked at migration of MSM to the gay resort area of South Florida, and found that amount of time lived in the area was associated with risk behaviors and HIV infection. The second study, using qualitative interviews, observed complex interactions between neighborhood-level social environments and individual-level racial and sexual identity among MSM in New York City. The third study, using egocentric network analysis with a sample of African American MSM in Baltimore, found that sexual partners were more likely to be found through face-to-face means than the Internet. They also observed that those who co-resided with a sex partner had larger networks of people to depend on for social and financial support, but had the same size sexual networks as those who did not live with a partner. Overall, these findings suggest the need for further investigation into the role of macro-level social forces on the emotional, behavioral, and physical health of urban MSM.

Neighborhood environment, sexual risk behaviors and acquisition of sexually transmitted infections among adolescents diagnosed with psychological disorders

The association between neighborhood environment and prevalence of STIs, sexual partner variables and condom use among adolescents with psychological disorders was examined. Cross-sectional data in three urban areas of the US (Southeast, Northeast and Midwest) were obtained from 384 sexually active male and female participants who provided urine samples for laboratory-confirmed testing of Neisseria gonorrhoeae, Chlamydia trachomatis and Trichomonas vaginalis. A total of 15.4% of participants tested positive for one of the three STIs. Results indicated that relative to adolescents living in low risk neighborhood environments, those living in high risk environments were significantly more likely to have a STI and to report having casual partners. Findings suggest that in high risk neighborhoods, STI acquisition may be less dependent on condom use and more dependent on other contextual factors. The importance of expanding public health research to include assessment of neighborhood context as a determinant of sexual risk-taking is emphasized.

Applying ecological perspectives to adolescent sexual health in the United States: rhetoric or reality?

This study sought to determine the perspective taken toward understanding adolescent sexual risk behaviors and related biological outcomes (i.e. pregnancy, sexually transmitted diseases) since 1990. We content analyzed 324 abstracts representing observational research published between January 1990 and December 2007 for inclusion of ecological (environmental) factors, level of analysis, sample composition and type of behavioral and biological outcomes. A majority (95%) of studies included individual characteristics; half were void of any environmental factors. Of those including environmental factors, 27% included familial, 23% community, 13% relational and 3% societal factors. Most (80%) were positioned at the individual level of analysis. Samples were diverse (43%) and of mixed gender (71%). Biomarkers of sexually transmitted diseases (7.5%) or pregnancy outcomes (2%) were rare. Ecological inclusion was not related to year of publication. Despite the rhetoric highlighting, the importance of an ecological perspective in understanding adolescent sexual risk behavior, much published research, excludes environmental influences.

Let's stay together: relationship dissolution and sexually transmitted diseases among parenting and non-parenting adolescents

Relationships influence sexual risk and maternal-child health. Few studies have assessed relationship dissolution and its association with sexually transmitted diseases (STD) among adolescent parents. Our study aimed to describe relationship dissolution among 295 parenting and non-parenting adolescents over an 18-month period and how it related to STD incidence. Results showed that nonparenting adolescents in a relationship with someone other than their baby's father were more likely to have a relationship dissolution over an 18-month period compared to those in a relationship with the baby's father (OR = 1.69, P < .05). Parenting adolescents who ended their relationship with their baby's father were 3 times more likely to get an STD over the course of the study compared to parenting adolescents who remained with their baby's father (39% vs. 13%). Comparatively, nonparenting adolescents who ended their relationship were only 1.4 times more likely to get an STD compared to non-parenting adolescents who remained with their partner (44% vs. 32%). Our results suggest that prevention programs that incorporate male partners and components that strengthen relationship skills may reduce HIV/STD risk and help adolescents adapt during times of transition such as parenthood.

Adolescent pregnancies in the Amazon Basin of Ecuador: a rights and gender approach to adolescents' sexual and reproductive health

In the Andean region of Latin America over one million adolescent girls get pregnant every year. Adolescent pregnancy (AP) has been associated with adverse health and social outcomes, but it has also been favorably viewed as a pathway to adulthood. AP can also be conceptualized as a marker of inequity, since it disproportionately affects girls from the poorest households and those who have not been able to attend school.

Using results from a study carried out in the Amazon Basin of Ecuador, this paper explores APs and adolescents' sexual and reproductive health from a rights and gender approach. The paper points out the main features of a rights and gender approach, and how it can be applied to explore APs. Afterward it describes the methodologies (quantitative and qualitative) and main results of the study, framing the findings within the rights and gender approach. Finally, some implications that could be generalizable to global reserach on APs are highlighted.

The application of the rights and gender framework to explore APs contributes to a more integral view of the issue. The rights and gender framework stresses the importance of the interaction between rights-holders and duty-bearers on the realization of sexual and reproductive rights, and acknowledges the importance of gender–power relations on sexual and reproductive decisions. A rights and gender approach could lead to more integral and constructive interventions, and it could also be useful when exploring other sexual and reproductive health matters.

Economic dependence and unprotected sex: the role of sexual assertiveness among young urban mothers

In the USA, sexual intercourse is the leading route of human immunodeficiency virus transmission among women, primarily through their main partner. Because male condom use is not directly under a woman's control, gender inequalities may help shape this sexual risk behavior. To examine this association, data came from follow-up interviews of young, primarily minority, pregnant women enrolled in a prospective, randomized controlled trial. Specifically, we aimed to determine the relationship between economic dependence on a male partner and condom use, and to establish whether this relationship was mediated by sexual assertiveness. Overall, 28% of women reported being economically dependent on a male partner. Young women dependent on a male partner were 1.6 times more likely to report not using a condom at last sex than women not dependent on their partner (95% confidence interval = 1.11-2.32; p = 0.01). Sexual assertiveness mediated the relationship between economic dependence and condom use (Sobel = 2.05, p = 0.04). Coupled with past research, this study supports the premise that sexual behaviors may be rooted in a complex web of social determinants. Addressing gender inequalities in contextual factors may promote healthier decisions within sexual relationships.

Sexual risk in "mostly heterosexual" young women: influence of social support and caregiver mental health

BACKGROUND

Female youth who describe their sexual orientation as "mostly heterosexual," rather than exclusively heterosexual, display greater sexual risk, yet reasons for this greater risk are not understood. Research is needed to identify factors responsible for health disparities in this population comprising the majority of youth who report a minority sexual orientation.

METHODS

We compared indicators of perceived social support, parental/caregiver mental health, and sexual risk (age at first sexual intercourse, lifetime history of a sexually transmitted infection (STI), lifetime number of sexual partners) among 33 young women describing themselves as mostly heterosexual and 337 indicating they were 100% heterosexual (aged 18-24 years) participating in an urban, multiethnic, community-based cohort study. Linear, logistic, and Cox proportional hazards regression were used to test whether social support and caregiver mental health explained greater sexual risk among mostly heterosexual compared with heterosexual participants.

RESULTS

Compared with exclusively heterosexuals, mostly heterosexuals reported less social support from family (p=0.01) and friends (p=0.02) and were more likely to report primary male caregiver (though not primary female caregiver) histories of depression (p<0.0001), treatment for depression (p<0.0001), and problems with drug use (p=0.005). Differences in perceived family social support and caregiver mental health and substance use partially mediated relationships between sexual orientation and sexual risk.

CONCLUSIONS

Compared with exclusively heterosexual female youth, mostly heterosexual female youth may have poorer relationships with their family and others in their social networks, and this may contribute to their elevated health risks. Additional research is needed to understand causal mechanisms responsible for sexual orientation disparities in sexual risk.

Low School Engagement and Sexual Behaviors among African American Youth: Examining the Influences of Gender, Peer Norms, and Gang Involvement

This research examined whether negative peer influences (i.e., norms favoring risky sex and drug use and gang involvement) mediated the relationship between school engagement (i.e., grade point averages [GPAs] obtained from school records and student-teacher connectedness) and sexual behaviors (i.e., sexual début, sex without condoms, group sex, and sex while using drugs) among African American high school adolescents, and whether these relationships varied by gender. Five hundred sixty-three high school adolescents (ages 13 to 19) completed self-administered questionnaires that assessed school engagement markers (GPAs obtained from student records, and student-teacher connectedness), peer influences, sexual début, and risky sex (sex without condoms, group sex, and sex while using drugs). Major findings for boys indicate that GPA was negatively associated with both sexual début and risky sex. Additionally, the relationship between student-teacher connectedness and risky sex was mediated by gang involvement. For girls, higher GPAs were associated with fewer norms favoring risky sex and drug use and such norms were associated with sexual début. Moreover, the relationship between GPA, sexual début and risky sex was mediated by risky peer norms. Intervention programs to delay sexual début and reduce risky sex among youths should attend to the gendered ways through which such behaviors occur.

Disparities in the patterns and determinants of HIV risk behaviors among adolescents entering substance abuse treatment programs

BACKGROUND

Black youth are disproportionately affected by the HIV/AIDS epidemic. This study examined disparities in patterns and determinants of sexual risk behaviors among black and white adolescents in substance abuse treatment programs.

METHODS

We used pooled clinical data collected from 4,565 sexually active 12-17-year-old black (29.7%) and white (70.3%) adolescents entering outpatient and residential substance abuse treatment programs nationally. Multivariate logistic regression analyses were used to examine racial differences in patterns of sexual risk behaviors and the associations of these behaviors with demographic, socioenvironmental and psychosocial risk factors, including substance use and abuse, symptoms of mental disorders and criminal behaviors.

RESULTS

Blacks were significantly more likely than whites to have had sex with multiple partners, purchased or traded sex and used substances to enhance their sexual experiences, even after adjusting for demographic, socioenvironmental and psychosocial risk factors. Substance use and abuse, internalizing symptoms and drug-related crimes were significantly associated with engaging in > or =2 sexual risk behaviors in both groups. Disparities in determinants of HIV risk were also found. For instance, male gender, single-parent custody and history of criminal justice involvement were associated with having had sex with multiple partners among blacks but not among whites. Demographic, socioenvironmental and psychosocial risk factors accounted for up to 30% of the variance in sexual risk in both groups.

CONCLUSIONS

Black adolescents with substance use problems are at greater risk for HIV infection than their white peers because of their higher rates of sexual risk behaviors. Differences in co-occurring psychosocial problems did not fully explain racial disparities in sexual risk behaviors. HIV prevention programs for black adolescents in treatment should consider both individual and broader contextual factors that co-occur with sexual risk behaviors.

Multiple sexual partnership mediates the association between early sexual debut and sexually transmitted infection among adolescent and young adult males in Nigeria

OBJECTIVES

To assess the relationship between early sexual debut, risky sexual behaviours and sexually transmitted infections (STIs) among young males.

METHODS

The study was cross-sectional analytical in design and involved 1278 Nigerian males aged 15-24 years. Logistic regression was used in assessing the statistical relationship between early sexual debut (<16 years) and self-reported STIs (history of at least one of three symptoms - painful urination, genital discharge, and genital ulcer/sore - within the past 12 months), with demographic factors, sexual behaviours and psychosocial measures controlled for.

RESULTS

The prevalence of self-reported symptoms was 4.2% for genital discharge, 4.1% for painful urination, and 2.0% for genital sore/ulcer. Overall, 6.8% had STI symptom(s). At bivariate analysis, early sexual debut (p = 0.021), multiple partners (p < 0.001), concurrent partners (p = 0.002), and sex with casual/commercial partners (p = 0.013) were associated with STIs. At multivariate analysis, early sexual debut (odds ratio [OR] = 2.12, 95% confidence interval [CI] = 1.17-3.84) remained significantly associated with STIs. Multiple sexual partnership (OR = 2.00, 95% CI = 1.13-3.52) was also significantly associated with STIs, and is a mediator of the association between early debut and STI.

CONCLUSIONS

Multiple sexual partners and early sexual debut are associated with STIs among adolescent and young adult males.

Multilevel predictors of inconsistent condom use among adolescent mothers

OBJECTIVES

We used Bronfenbrenner's ecological systems theory to identify factors that predicted never or sometimes using condoms in a multiethnic cohort of adolescent mothers.

METHODS

We interviewed adolescent mothers within 48 hours of delivery and surveyed them 6 and 12 months after delivery (n = 636). We used multinomial logistic regression to identify individual-, dyad-, family-, and peer and community-level factors associated with never or sometimes using versus always using condoms during intercourse at 12 months postpartum.

RESULTS

Pregnancy status, partner refusal to use condoms, intimate partner violence, and race/ethnicity predicted both never and sometimes using condoms. Condom use 6 months earlier and church attendance also predicted never using condoms, whereas maternal monitoring was an additional predictor for sometimes using condoms.

CONCLUSIONS

Overlapping yet distinct risk profiles predicted never or sometimes using versus always using condoms. Factors from multiple levels of influence affected the condom use behaviors of adolescent mothers indicating that multilevel interventions are needed to promote safer sexual practices among these young women.

Changes in sexual risk behavior as young men transition to adulthood

CONTEXT

Understanding how young men's sexual risk behaviors change during the transition from adolescence to early adulthood is important for the design and evaluation of effective strategies to reduce the transmission of HIV and other STDs.

METHODS

Data from three waves of the National Survey of Adolescent Males (1988, 1991 and 1995) were used to categorize 1,880 respondents into clusters according to sexual risk behaviors. Univariate and bivariate analyses were conducted to assess associations between clusters and rates of self-reported STD diagnoses and positive chlamydia tests.

RESULTS

Two dimensions of sexual risk-taking defined the clusters: partner characteristics and condom use. More than 50% of men remained in low-risk groups over time. In the first two waves, 24-32% of men reported engaging in high-risk behaviors (risky partners, condom nonuse); these behaviors were associated with elevated levels of STD outcomes. Nearly 40% of men who entered a high-risk group in the first two waves transitioned to a lower risk group by the third wave. Nine percent of men either engaged in increasingly risky behaviors or maintained membership in high-risk groups; elevated STD rates characterized both trajectories. Low condom use combined with having multiple partners during adolescence was associated with elevated STD rates in the year preceding the third wave; high condom use coupled with having risky partners was not.

CONCLUSIONS

The prominence of low-risk behaviors over time suggests that most young men avoid sexual risk-taking. Effective strategies to reduce HIV and STD risk in young men must simultaneously address multiple dimensions of sexual behavior.

Condom use among high-risk adolescents: anticipation of partner disapproval and less pleasure associated with not using condoms

OBJECTIVE

We determined the association of demographic, psychosocial, and contextual factors with condom use among a large community sample of at-risk adolescents recruited from four locations in the U.S.

METHODS

We enrolled 1,410 adolescents/young adults between the ages of 15 and 21 with a history of unprotected sex in the past 90 days at four study sites. Subjects completed an audio-assisted, computerized assessment that gathered information about sexual behavior and its contexts, substance use, and relevant risk and protective attitudes.

RESULTS

Nearly two-thirds of adolescents did not use condoms at the time of last intercourse and adolescents reported a mean of 15.5 (median = 5) unprotected intercourse occasions in the past 90 days. Controlling for relevant demographic variables, not using condoms was associated with the perception that condoms reduce sexual pleasure, the perception that partners will not approve of condom use, and less discussion with partners about condoms.

CONCLUSIONS

Even across racial/ethnic groups, gender, and geographic locations, several important correlates of adolescents' sexual risk reduction were identified. Many adolescents may feel that condoms reduce their sexual pleasure and fear partner reactions if they initiate condom use. These attitudes may be malleable through clinical and community-based interventions.

Psychosocial predictors of HIV-associated sexual behaviors and the efficacy of prevention interventions in adolescents at-risk for HIV infection: what works and what doesn't work?

The HIV epidemic among adolescents in the United States is inherently tied to individual, psychosocial, and cultural phenomena. Expanding intervention development and implementation to incorporate a broader spectrum of determinants of adolescents' sexual risk for sexually transmitted infections (STIs)/HIV acquisition may provide an opportunity to prevent disease transmission more effectively. To address the STI/HIV prevention needs of adolescents, we highlight research assessing adolescents' sexual risk behavior and place the findings in the context of the diverse array of psychosocial factors influencing adolescents. This synthesis provides an opportunity to examine why adolescents engage in risky sexual behavior and to review the effectiveness of theory-based prevention programs. Subsequently, we offer recommendations for improving future programs aimed at reducing the incidence of STI/HIV infection among adolescents.

Sex, drugs and sexually transmitted infections in British university students

Summary:

Understanding predisposing factors for sexually transmitted infections (STIs) in young adults may identify targets for public health interventions. We conducted a cross-sectional web-based survey of university students’ sexual attitudes, behaviours and lifestyles and self-reported rates of STI. A total of 827 students responded, 22.4% had two or more sexual partners in the previous year with inconsistent condom use and the lifetime prevalence of STIs was 9.6%. Factors associated with a diagnosis of STI were increasing age and number of sexual partners ever, female gender (adjusted odds ratio [AOR] 2.70, 95% confidence interval [CI] 1.31, 5.56) and use of crack (AOR 10.45, 95% CI 1.46, 75.16). For female students, these were increasing age and number of partners ever, whereas for male students having sex with other men (bisexual AOR 4.8, 95% CI 1.02, 22.595, homosexual AOR 17.66, 95% CI 3.03, 103.04) and use of crack (AOR 32.24, 95% CI 3.33, 312.08). Multiple partners and recreational drug use may predict incidence of STI. Prevention strategies need to aim at reducing risk behaviour across various activities.

HIV preventive interventions for adolescents: a look back and ahead

HIV and sexual risk continue to be central threats to the health and well-being of adolescents in the United States and abroad. Great strides have been made in creating interventions that reduce contracting and transmitting the deadly virus among adolescents. Numerous interventions have been designed and evaluated, with many having positive results in reducing adolescents' HIV risk behavior. However, the complexity of adolescents as well as limited effects on many sexual risk outcomes indicate that much more work needs to be done. This article provides a review of the literature on interventions among adolescents, summarizing why adolescents provide a unique challenge for HIV prevention, the intervention approaches that have been taken, and the challenges and recommendations for the future as the field confronts the neurobiologic dimension of risk.

Personal, relational, and peer-level risk factors for laboratory confirmed STD prevalence among low-income African American adolescent females

OBJECTIVES

To identify risk factors for laboratory confirmed sexually transmitted disease (STD) prevalence among low-income African American adolescent females living in a high-risk urban area of the Southern United States.

METHODS

Participants were 715 African American adolescent females recruited from urban clinics. Data collection occurred from 2002 to 2004 and included an audio-computer assisted self-interview lasting about 60 minutes and a self-collected vaginal swab for NAAT to detect Trichomonas vaginalis, Chlamydia trachomatis, and Neisseria gonorrhoeae. Ten personal-level risk factors were assessed as well as 8 risk factors involving either peer or relational factors.

RESULTS

Adolescents (28.8%) tested positive for at least 1 STD. Six personal-level and 4 social-level measures achieved a bivariate screening level of significance. In the multivariate model, only 3 measures achieved significance: gang involvement, social support from peers, and fear of condom use negotiation. Compared to those who had never belonged to a gang, those who had were about 4.2 times more likely (95% CI = 2.16-9.44) to test positive. Adolescents' who had higher levels of fear pertaining to condom use negotiation were more likely to test positive as were adolescents who perceived higher levels of social support from their peers.

CONCLUSIONS

This finding suggests and supports the utility of designing interventions for high-risk African American adolescent females that incorporate objectives to modify the significant social influences related to STD acquisition.

Co-occurrence of intoxication during sex and sexually transmissible infections among young African American women: does partner intoxication matter?

Background: The co-occurrence of a behaviour (being intoxicated on alcohol/drugs during sex) with a disease outcome [laboratory-confirmed sexually transmissible infection (STI) prevalence] among young African American women and their male sex partners was studied. Methods: A cross-sectional study was conducted. Recruitment and data collection occurred in three clinics located in a metropolitan city of the Southern USA. A total of 715 African American adolescent females (15–21 years old) were enrolled (82% participation rate). The primary outcome measure was the analysis of self-collected vaginal swabs using nucleic acid amplification assays for Trichomonas vaginalis, Chlamydia trachomatis, and Neisseria gonorrhoeae. Results: After controlling for age and self-efficacy to negotiate condom use, young women’s alcohol/drug use while having sex was not significantly associated with STI prevalence [adjusted odds ratios (AOR) = 1.29, 95% confidence interval (CI) = 0.90–1.83]. However, using the same covariates, the association between male partners’ alcohol/drug use and sexually transmitted disease prevalence was significant (AOR = 1.44, 95% CI = 1.03–2.02). Young women reporting that their sex partners had been drunk or high while having sex (at least once in the past 60 days) were ~1.4 times more likely to test positive for at least one of the three assessed STIs. Conclusion: Young African American women reporting a male sex partner had been intoxicated during sex were significantly more likely to have an STI. The nature of this phenomenon could be a consequence of women’s selection of risky partners and lack of condom use possibly stemming from their intoxication or their partners’ intoxication.

Sexual agency versus relational factors: a study of condom use antecedents among high-risk young African American women

Background: The influence that female partners exert regarding condom use is not well known. In the present study, the relative roles of personal sexual agency and relational factors in determining whether young African American women engaged in unprotected vaginal sex (UVS) were studied. Methods: A cross sectional study of 713 young, African American women (aged 15–21 years) was conducted. Data were collected using an audio-computer assisted self-interview. Three measures of sexual agency were assessed and three relational factors were assessed. To help assure validity in the outcome measure, condom use was assessed in five different ways. Multivariate analyses were used to determine whether variables independently predicted UVS. Results: Two of the six predictor variables achieved multivariate significance with all five measures of condom use: (1) fear of negotiating condom use with male partners, and (2) indicating that stopping to use condoms takes the fun out of sex. A relational factor (male-dominated power imbalances) achieved multivariate significance for four of the five measures of UVS. A sexual agency factor (whether young women greatly enjoyed sex) achieved multivariate significance for three of the five measures. Conclusion: The results suggest that young African American women at high-risk of sexually transmissible infections (STI)/HIV acquisition may experience male-dominated power imbalances and also fear the process of negotiating condom use with their male partners. Although these factors were independently associated with UVS, two factors pertaining to sexual agency of these young women were also important predictors of UVS. Intervention efforts designed to avert STI/HIV acquisition among young African American women should therefore include programs to address both sexual agency and relational factors.

Poverty, gender inequities, and women's risk of human immunodeficiency virus/AIDS

Entrenched economic and gender inequities together are driving a globally expanding, increasingly female, human immunodeficiency virus (HIV)/AIDS epidemic. To date, significant population-level declines in HIV transmission have not been observed, at least in part because most approaches to prevention have presumed a degree of individual control in decision making that does not speak to the reality of women's and girls' circumstances in many parts of the world. Such efforts have paid insufficient attention to critical characteristics of the risk environment, most notably poverty and gender power inequities. Even fewer interventions have addressed specific mechanisms through which these inequities engender risky sexual practices that result in women's disproportionately increased vulnerabilities to HIV infection. This article focuses on identifying those mechanisms, or structural pathways, that stem from the interactions between poverty and entrenched gender inequities and recommending strategies to address and potentially modify those pathways. We highlight four such structural pathways to HIV risk, all of which could be transformed: (1) lack of access to critical information and health services for HIV/sexually transmitted infection (STI) prevention, (2) limited access to formal education and skill development, (3) intimate partner violence, and (4) the negative consequences of migration prompted by insufficient economic resources. We argue for interventions that enhance women's access to education, training, employment, and HIV/STI prevention information and tools; minimize migration; and by working with men and communities, at the same time reduce women's poverty and promote gender-equitable norms. In conclusion, we identify challenges in developing and evaluating strategies to address these structural pathways.

The protective value of school enrolment against sexually transmitted disease: a study of high-risk African American adolescent females

OBJECTIVE

To identify whether school enrolment is protective against laboratory-confirmed diagnosis of sexually transmitted diseases (STDs) and against a spectrum of sexual risk factors.

METHODS

A cross-sectional study of 715 African-American adolescent females (15-21 years old) was conducted. Data collection included an audio-computer-assisted self-interview lasting about 60 min and a self-collected vaginal swab for nucleic acid amplification testing of Trichomonas vaginalis, Chlamydia trachomatis and Neisseria gonorrhoeae.

RESULTS

In total, 65% were enrolled in school. After adjusting for age and whether adolescents resided with a family member, those not enrolled were twice as likely to test positive for one of the three STDs compared with those enrolled (adjusted OR2; 95% CI 1.38 to 2.91). Similarly, school enrolment was protective against risk factors contributing to STD acquisition. The measures of sexual risk behaviour of 8 of 10, retained significance after adjusting for the covariates, and 2 of the 3 psychosocial mediators retained significance.

CONCLUSION

This study provides initial evidence suggesting that keeping high-risk African-American adolescent females in school (including forms of school that occur after high-school graduation) may be important from a public health standpoint.

Using clinical classification trees to identify individuals at risk of STDs during pregnancy

CONTEXT

Few studies have used classification tree analysis to produce empirically driven decision tools that identify subgroups of women at risk of STDs during pregnancy. Such tools can guide care, treatment and prevention efforts in clinical settings.

METHODS

A sample of 647 women aged 14-25 attending two urban obstetrics and gynecology clinics in 2001-2004 were surveyed in their second and third trimesters. Baseline predictors at the individual, dyad, and family and community levels were used to develop a classification tree that differentiated subgroups of women by STD incidence at 35 weeks' gestation. Logistic regression analyses were conducted to assess whether the classification tree groups or commonly used risk factors better predicted STD incidence.

RESULTS

Nineteen percent of women had an incident STD during pregnancy. Classification tree analysis identified three subgroups with a high STD incidence (33-61%), one with a moderate incidence (16%) and three with a low incidence (6-11%). Women in subgroups with high STD incidence included those not living with the partner with whom they conceived and those who had a moderate or a high level of depression, a history of STDs and a low level of social support. A logistic regression model using groups defined by the classification tree analysis had better predictive ability than one using common demographic and sexual risk predictors.

CONCLUSION

This classification tree identified risk factors not captured by traditional risk screenings, and could be used to guide STD treatment, care and prevention within the prenatal care setting.

AIDS prevention in late adolescent college students from Spain and Portugal

OBJECTIVES

The aim of this study was to determine the factors related to the adoption of effective methods for preventing AIDS, particularly condom use, in university students from Spain and Portugal.

STUDY DESIGN

A cross-sectional and cross-cultural study. Data were obtained by questionnaire.

METHOD

The variables analysed in the sample of Spanish and Portuguese students were: the perceptions of benefits and barriers to condom use; perceived self-efficacy in the negotiation of condom use; and in using a condom in difficult situations; and the perceptions of vulnerability, severity and risk.

RESULTS

The data showed similarities between the Spanish and Portuguese students in the high frequency of condom use and the weight of self-efficacy for negotiating and ensuring condom use. However, data also reflected differences between the countries especially with regard to the weight of benefits and costs in the adoption of prevention methods.

CONCLUSIONS

These findings suggest that the different realities for each country or context must be considered in the design of AIDS prevention programmes aimed at late adolescents. Whereas in both countries prevention programmes should encourage the ability to negotiate condom use, Portuguese programmes must underline the benefits of condom use, and Spanish programmes should aim to analyse the importance of barriers to condom use for the students to reduce these and to replace costs with benefits.

A decade in review: building on the experiences of past adolescent STI/HIV interventions to optimise future prevention efforts

The major purpose of this article is to systematically review and synthesise empirical findings from selected adolescent STI/HIV interventions conducted in the United States between 1994 and 2004. Specifically, the most current adolescent STI risk reduction interventions conducted in diverse venues, such as in the community, schools, clinics, and specialised adolescent centres (that is, detention homes and drug programmes) were examined for reported efficacy, and were assessed for programmatic and methodological strengths and weaknesses. Next, a subset of programmatic characteristics was identified that were associated with the efficacy of STI risk reduction programmes both within a particular venue, as well as across all venues. Finally, we discuss the research and practice implications of these findings for optimising future evidence based STI risk reduction programmes for adolescents in the United States.

Preventing sexually transmitted infections among adolescents: ‘the glass is half full’

PURPOSE OF REVIEW

Given the disproportionate burden of sexually transmitted infections for adolescents, there is an urgent need to identify effective prevention programs.

RECENT FINDINGS

This review documents the efficacy of recent sexually transmitted infection-prevention programs. Overall, the review identified few sexually transmitted infection-prevention trials published since 2000. Moreover, considerable variability in program efficacy was observed across studies. Some studies observed changes in sexually transmitted infection-associated risk behaviors, while only a few identified reductions in biologically confirmed sexually transmitted infections. In general, few programs demonstrated consistency of effects and a significant magnitude of effects across a broad range of outcomes.

SUMMARY

New and innovative approaches are needed to amplify sexually transmitted infection intervention effects. Program development and evaluation needs to continue in a coordinated, scientifically rigorous fashion to optimize impact and, as important, to sustain effects over protracted periods. Furthermore, for interventions with demonstrated efficacy, a critical challenge is to translate them into sustainable programs that are widely disseminated. Ultimately, preventing sexually transmitted infections in adolescents does not only depend on the development of effective interventions alone, but on how effectively these interventions can be translated and integrated into self-sustaining components of clinic, school or community programs, particularly in those areas and among adolescent populations most adversely impacted by the epidemic of sexually transmitted infection.

A programmatic and methodologic review and synthesis of clinic-based risk-reduction interventions for sexually transmitted infections: research and practice implications

The over-arching goal of this article is to systematically review and synthesize empirical findings for sexually transmitted disease risk-reduction programs that were developed and implemented specifically for adolescents seeking health care services at clinical venues. The objective is to examine the reported efficacy of these programs in reducing adolescents' sexually transmitted infection (STI)-associated behavior, in enhancing theoretically and empirically important psychosocial mediators associated with the adoption of STI-preventive behaviors, and, most important, in reducing adolescents' risk of acquiring an STI. In addition, our review assesses program and methodologic characteristics of the studies, determines compliance with standardized reporting guidelines, identifies a subset of program characteristics that are related to efficacy in terms of modifying adolescents' sexual risk behaviors, and examines the research and practice implications of these findings for implementing evidence-based STI risk-reduction programs in clinics.