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

Social ecological system framework as a decision-making tool for risk mitigation: A superfund site case study

Several studies have reported vapor intrusion (VI) occurring when volatile organic compound (VOC) vapors are transported through subsurface piping systems into building spaces (e.g. conduit VI). Site-specific risk assessment and risk management practices are complicated and evolving for conduit VI, especially at large hazardous waste sites, like Superfund sites, where many stakeholders are involved and have varied interests. Here, we propose a social ecological system (SES) framework as a decision-making tool to inform risk mitigation decisions. We demonstrate the SES framework using field data associated with a Superfund site near San Francisco, California. We evaluate sewer invert elevation and groundwater elevation data, as well as pre- and post- mitigation VOC concentration data within a sewer system. Unexpectedly, the sewer located above the groundwater table was determined to be a potential source of conduit VI risks. The SES framework describes how typical stakeholders associated with the site can affect and be affected by mitigation activities. It informs decisions about mitigation implementation and long-term operation efficacy by considering stakeholder roles and interests. Ultimately, gas siphons were selected as the mitigation technology for the example site. To date, approximately 6 gas siphons have been installed to mitigate conduit VI risks throughout the community. Collectively, our findings advance risk management decisions and highlight key considerations for risk mitigation approaches at hazardous waste sites, including Superfund sites, especially where VI risks are a concern.

Feasibility of adolescent contraceptive care in the pediatric emergency department: A pilot randomized controlled trial

BACKGROUND

This study assessed feasibility constructs of adolescent contraceptive care in the pediatric emergency department (PED), including contraception initiation.

METHODS

We conducted a randomized trial in two PEDs with pregnancy-capable adolescents aged 15-18 years who were assigned to enhanced usual care (usual) or same-day initiation (same day). All received counseling and clinic referral, but same-day participants could also receive contraception in the PED. We trained PED clinicians in counseling and prescribing. Adolescents and clinicians rated feasibility using five Likert-type items (1 = strongly disagree to 5 = strongly agree) after the session. We assessed PED medication initiation and appropriateness via medical record review and contraception use and side effects at 30 days via adolescent survey. To further explore feasibility, we conducted clinician interviews at study completion; these were audio-recorded, transcribed, and analyzed. We hypothesized contraceptive care would be feasible (defined as average score ≥ 4 across five survey items).

RESULTS

We enrolled 37 adolescents (12 in usual and 25 in same-day), mean age was 16.6 years, 73% were Black, and 19% were Hispanic. We trained 27 clinicians. Average feasibility scores were 4.6 ± 0.4 (adolescents) and 4.1 ± 0.8 (clinicians). Eleven (44%) same-day participants initiated contraception in the PED. One adolescent with migraines initially received estrogen-containing pills; this was corrected after discharge. At 30 days, same-day participants were more likely to report contraception use (78% vs. 13%; p = 0.007). One adolescent reported bloating as a side effect. Clinicians enjoyed delivering contraceptive care, found study resource materials useful, and identified staffing shortages as a barrier to care delivery.

CONCLUSIONS

We are among the first to report on PED-based adolescent contraception initiation to prevent unintended pregnancy. Adolescents and clinicians reported that contraceptive care was feasible. Initiation was common and medications were largely appropriate and tolerated. Future efforts should explore integrating contraceptive care into routine PED care.

"I wouldn't have felt so alone": The sexual health education experiences of transgender and gender diverse youth living in the southeastern United States

BACKGROUND

Transgender and gender diverse youth experience multiple disproportionate adverse sexual health outcomes. Sexual health education teaches knowledge, attitudes, and skills for promoting sexual health, including reducing risk for sexually transmitted infection, HIV acquisition, and unintended pregnancy. Provision of sexual health education may be protective, but research remains scarce.

METHODS

We conducted a multi-stage thematic analysis of 33 in-depth interviews among transgender and gender diverse youth (ages 15-24) living in the southeastern United States on their sexual health education experiences.

RESULTS

Our study participants described school-based sexual health education as unhelpful due to a lack of relevant information, inadequately prepared teachers, and a perceived negative tone toward sexuality. They reported relying on online sources of sexual health information, finding relevant content and community despite some limitations. Participants desired content and pedagogy that expands beyond binary and white-centric presentations of sexuality and gender and sought resources that provide relevant, accurate, and judgment-free information while holding positive framing around sexuality and gender.

CONCLUSION

There is much work needed to improve the breadth, quality, and relevance of school-based sexual health education. Sexual health education can improve by strengthening critical media literacy skills of youth; raising staff cultural competency on gender, race, and sexual identity through training and supports; using culturally relevant and inclusive curricula; and partnering with community-based organizations. Transgender and gender diverse youth would benefit from sexual health education from multiple sources which is queer-friendly, affirms their existence, and provides information on gender, race, and sexuality in positive and expansive ways.

Sexual health knowledge acquisition processes among very young adolescent girls in rural Malawi: Implications for sexual and reproductive health programs

Early adolescence is a period characterized by enormous biological, cognitive, sexual, emotional, and social changes. Sexual curiosity and the desire to acquire sexual health (SH) information are part of these developments. Understanding the SH knowledge acquisition process is critical for designing interventions that can best support very young adolescents (VYAs). This study explored the SH knowledge acquisition processes among VYA girls aged 10 to 14 years who attended the DREAMs Girl Only Clubs (GOCs) and those who did not. The GOCs were a part of a larger comprehensive HIV prevention project called DREAMS (Determined, Resilient, Empowered, AIDS-free, Mentored, and Safe) which provided an evidence-based core package of interventions to VYAs to prevent HIV. In-depth interviews were conducted with 43 VYA girls aged 10-14 years in two rural southern districts of Zomba and Machinga in Malawi. Twenty-three VYA girls were GOC participants and 20 VYAs were not. Guided by the Social Ecological Model, a thematic analysis approach was used to analyze the data with the assistance of Nvivo 12 software. The SH knowledge acquisition processes were the interaction of various factors at the microsystem (self-efficacy, attitudes, trust and the beginning of menstruation), mesosystem (communication of SH issues between VYAs and their immediate family and peers), and exosystem levels (availability of life skills programs and mother-groups in schools and availability of GOCs). Compared to Non-GOC participants, GOC participants demonstrated an in-depth knowledge of SH issues and positive sexual behaviors such as HIV testing. Limitations to SH knowledge acquisition were adult messages' focus on sexual relationship avoidance and on girls who have started menstruation; the perception of adults not being knowledgeable about SH and school teachers hiding some SH information. VYAs' SH interventions that provide VYAs with accurate, consistent, and age-appropriate SH information such as the GOCs have the potential to address the limitations that other sources have in reaching VYAs. Integrating such interventions with programs that empower parents, other adults, and teachers with comprehensive SH information and with skills on how to deliver SH information to VYAs can enhance VYAs' SH knowledge acquisition and influence positive behavior change.

Efficacy of a Digital Health Preventive Intervention for Adolescents With HIV or Sexually Transmitted Infections and Substance Use Disorder: Protocol for a Randomized Controlled Trial

BACKGROUND

HIV or sexually transmitted infections remain a significant public health concern in the United States, with adolescents affected disproportionately. Adolescents engage in HIV/STI risk behaviors, including drug use and condomless sex, which increase the risk for HIV/STIs. At-risk adolescents, many of whom are racial minorities, experience HIV/STI disparities. Although at-risk adolescents are disproportionately affected by HIV/STI risk behaviors and infections and although the Centers for Disease Control and Prevention recommends routine HIV/STI testing for adolescents, relatively few adolescents report having ever been tested for HIV/STI. With expected increases in health clinic visits as a result of the Affordable Care Act combined with technological advances, health clinics and mobile health (mHealth), including apps, provide innovative contexts and tools to engage at-risk adolescents in HIV/STI prevention programs. Yet, there is a dearth of efficacious mHealth interventions in health clinics to prevent and reduce both condomless sex and drug use and increase HIV/STI testing for at-risk adolescents.

OBJECTIVE

To address this gap in knowledge, we developed a theory-driven, culturally congruent mHealth intervention (hereon referred to as S4E [Storytelling 4 Empowerment]) that has demonstrated feasibility and acceptability in a clinical setting. The next step is to examine the preliminary efficacy of S4E on adolescent HIV/STI testing and risk behaviors. This goal will be accomplished by 2 aims: the first aim is to develop a cross-platform and universal version of S4E. The cross-platform and universal version of S4E will be compatible with both iOS and Android operating systems and multiple mobile devices, aimed at providing adolescents with ongoing access to the intervention once they leave the clinic, and the second aim is to evaluate the preliminary efficacy of S4E, relative to usual care control condition, in preventing or reducing drug use and condomless sex and increasing HIV/STI testing in a clinical sample of at-risk adolescents aged 14-21 years living in Southeast Michigan.

METHODS

In this study, 100 adolescents recruited from a youth-centered community health clinic will be randomized via blocked randomization with random sequences of block sizes to one of the 2 conditions: S4E mHealth intervention or usual care. Theory-driven and culturally congruent, S4E is an mHealth adaptation of face-to-face storytelling for empowerment, which is registered with the Substance Abuse and Mental Health Services Administration's National Registry of Evidence-Based Programs and Practices.

RESULTS

This paper describes the protocol of our study. The recruitment began on May 1, 2018. This study was registered on December 11, 2017, in ClinicalTrials.gov. All participants have been recruited. Data analysis will be complete by the end of March 2024, with study findings available by December 2024.

CONCLUSIONS

This study has the potential to improve public health by preventing HIV/STI and substance use disorders.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03368456; https://clinicaltrials.gov/study/NCT03368456.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/47216.

Integrated Theory-Based Health and Development Interventions for Young People: A Global Scoping Review

BACKGROUND

Most health and developmental issues affecting young people are interrelated. However, few interventions address multiple behavioral domains simultaneously or are based on theories that encompass a holistic perspective of youth development.

AIM

The purpose of this scoping review was to identify and describe the range of theory-based, multibehavioral health interventions aimed at improving two or more of the following behavioral youth outcomes: (1) sexual and reproductive health; (2) education and employment; (3) violence; and (4) substance use.

METHODS

Interventions conducted worldwide and published in English or Spanish between January 2000 and July 2020 were identified using four databases: PubMed, PsycINFO, LILACS, and SciELO.

RESULTS

A total of 11,084 articles were identified, of which 477 were retrieved and assessed for eligibility. Twenty-three articles (evaluating 21 interventions) ultimately met the inclusion criteria. Most interventions were conducted in the United States and addressed two behavioral domains of interest, although seven interventions incorporated three domains, and one incorporated all four. Substance use was the most common domain (16 interventions) but only in the United States/Canada, followed by sexual and reproductive health (14 interventions). All produced significant improvement in at least one outcome or for at least one subgroup of youth. The most common theoretical foundations were positive youth development and social learning theory.

CONCLUSION

Integrated interventions that are theory based and evidence informed can support positive development and empower youth to make healthy decisions. Further efforts are needed to address structural and policy issues that affect young people's developmental opportunities and health outcomes.

Socio-cultural factors perceived to influence sexual behaviours of adolescents in Ethiopia

BACKGROUND

Adolescence is a period of transition from childhood to adulthood. It is the age of experimentation. They are vulnerable to the undesirable effect of sexual and reproductive health (SRH) problems such as human immunodeficiency virus, sexually transmitted infections and unsafe abortion and childbirth-related risks.

AIM

To explore and describe perceived organisational, community and societal level factors that influence sexual behaviours among adolescents in Ethiopia.

SETTING

The study was conducted by public health care organisations, youth centres and non-governmental organisations in Addis Ababa, Ethiopia.

METHODS

A qualitative descriptive study design was conducted with purposively selected health professionals and adolescents in Addis Ababa from June 2019 to February 2020. The data were collected using in-depth interviews, key informant interviews and focus group discussions. Transcribed interviews were imported to ATLAS. ti 7 for coding, categorising and creating themes using thematic analysis. Lincoln and Guba's model was used to ensure trustworthiness and ethical standards were applied.

RESULTS

Poor school involvement, social norms on sexual behaviour and lack of condom acceptability by the general population, financial problems and the gap in law enforcement were found perceived factors influencing sexual behaviour of adolescents.

CONCLUSION

Adolescents are engaging in various risky sexual behaviours because of various organisational, community level and societal level factors, which emphasises the need to introduce social and culturally acceptable age-appropriate comprehensive sexuality education for adolescents and other multilevel interventions.Contribution: Provide an in-depth understanding of the influence of sociocultural issues related to adolescent sexual behaviour for health system stakeholders.

Social support and very young adolescent girl's knowledge on sexual relationships: A comparative qualitative study of Girl Only Clubs' participants and non-participants in rural Malawi

Early sexual relationships are associated with an increased risk of acquiring sexually transmitted diseases including HIV/AIDs, teenage pregnancies, and unsafe abortions among other negative health outcomes. Understanding sexual relationships among very young adolescents (VYAs) is important to equip them to protect themselves from negative sexual health (SH) outcomes. DREAMS (Determined, Resilient, Empowered, AIDS-free, Mentored, and Safe) is an HIV prevention initiative that provided an evidence-based core package of interventions to VYAs to prevent HIV acquisition in 15 countries in sub-Saharan Africa. The Girl Only Club (GOC) was the primary context for the interventions. Our objective in this study was to explore if there was any difference in social support (SS) received concerning sexual relationships between the VYA girls who attended GOCs and those who did not. In-depth interviews were conducted with 43 VYA girls, aged 10-14 years, in two rural southern districts, Zomba and Machinga, in Malawi. Twenty-three VYA girls were participants in GOCs and 20 VYA girls did not participate. A thematic, descriptive approach that involved a constant comparative analysis guided the data analysis, and Nvivo 12 software was used. In both study sites available SS concerning sexual relationships is informational support including information from parents, older relatives, and friends. However, club participants differed from non-club participants in sexual and reproductive health (SRH) knowledge and use. Club participants reported consulting others on decision-making and information on sexual relationships; receiving detailed SH information from clubs; condom use due to education received from the clubs; quitting sexual relationships; and correcting misinformation with club information. GOC participants received more SS which made them more knowledgeable and better at handling sexual relationship issues than those not in clubs. Interventions that integrate SS including social asset building and safe spaces are critical for VYA SRH programming.

Uptake of and adherence to oral pre-exposure prophylaxis among adolescent girls and young women at high risk of HIV-infection in Kampala, Uganda: A qualitative study of experiences, facilitators and barriers

Background

There is limited information on factors that influence oral pre-exposure prophylaxis (PrEP) uptake and adherence among adolescent girls and young women (AGYW). We conducted a qualitative methods study to explore experiences, facilitators and barriers of PrEP uptake and adherence to PrEP among AGYW at risk of Human Immunodeficiency Virus (HIV) infection in Kampala, Uganda.

Methods

This study was nested in a prospective cohort study that offered daily oral PrEP to AGYW. Between April 2019 and October 2020 we conducted in-depth interviews with 26 AGYW aged 14–24 years who had been offered or had been using PrEP for at least 6 months, including PrEP adherers (8), non-adherers (8) and those who had declined PrEP (10). After 12 months, follow-up interviews were conducted with 12 AGYW who had adhered to PrEP and those who had dropped it. Thematic analysis was conducted and data were further examined and categorized into the 5 constructs of the Socio-Ecological Model (SEM).

Results

PrEP uptake and adherence were facilitated by factors including: perceptions that one’s own or partner’s sexual behaviour was high risk, a negative attitude towards condoms, social support and wanting to maintain a negative HIV status after receiving a negative HIV test result. Good adherence to PrEP was enabled by effective counselling, support tools such as alarms and phone reminders and incentives like free treatment for STIs and other illnesses during study visits. Barriers to uptake included: anxiety about the pill burden, perceptions of being too young for PrEP and fear of being labelled `prostitute’ or `HIV positive’. Poor adherence was attributed to doubt over the efficacy of PrEP as a result of beliefs that because HIV was incurable, no medicine could prevent it. Alcohol use, side effects experienced, and mobility all had a negative impact on adherence. The majority of PrEP users reported feeling safe as a result of using PrEP which had both good and negative implications on their sexual behaviour, specifically the number of sexual partners and condom use.

Conclusion

Addressing community misconceptions to maximize uptake of PrEP among AGYW is important. Targeted education messages, and counselling to address misconceptions in ways that capture the attention of AGYW in communities are required.

Associations of a Multilevel School Health Program and Health Outcomes Among Lesbian, Gay, and Bisexual Youth

Lesbian, gay, and bisexual (LGB) adolescents are often at higher risk than their heterosexual peers for adverse sexual health, violence, mental health, and substance use outcomes. Schools are a vital resource for enhancing protective behaviors and reducing risk behaviors. Sixteen school districts selected schools to implement a sexual health program (exposed) or usual programming (unexposed). We analyzed LGB student health outcomes using 2015 and 2017 Youth Risk Behavior Surveys. Analyses compared LGB student health outcomes by exposure status across time points using a multilevel approach. Program exposure was associated with decreased odds of ever having sex, ever testing for HIV, and using effective hormonal birth control, and an increased odds of condom use. There were no significant findings among secondary violence, mental health, and substance use outcomes. This evaluation highlights the potential for schools to reduce sexual risk behaviors among LGB youth, and opportunities to improve access to health services.

COVID-19 preventive behavior among university students in Southeast Asia: Effects of knowledge, concern, awareness, and perceived risk

The persistent rise of pandemics across the globe in recent times has led to the prescription of several collaborative preventive strategies to reduce the effect that the pandemic has on public health. Consistent monitoring and surveillance appear to be the only available approach to detecting and classifying the issues of public health threats. Global pandemic threats demand public co-operation to take preventive actions at a personal level so that the risk of infectious diseases can be contained. Said that, this study explored the influence of awareness of precaution measures (APM), concerns about coronavirus disease 2019 (COVID-19) (CAC), knowledge of COVID-19 (KOC), and perceived risk (PRK) on preventive behavior (PRB), as well as the effect of age and gender on the relationships among the studied variables. Quantitative data were collected from 551 university students across Malaysia and Vietnam through field survey and online survey, respectively. The data collection was performed from 13 March to 23 March 2020. Partial least square structural equation modeling (PLS-SEM) was employed for data analysis. The multiple group analysis (MGA) technique was applied to compare the data retrieved from the respondents based on age and gender. The results revealed that APM, CAC, KOC, and PRK on PRB significantly influenced PRB toward COVID-19. In light of the two personal factors, age and gender, significant variances were noted for age and KOC, while PRK on PRB on the PRB toward COVID-19. Based on the study outcomes, APM emerged as the most significant predictor of PRB, followed by PRK on PRB, and CAC. Since a large fraction of the world reside in rural areas and have high-level interaction with animals, the provision of education at all level can harness the attitude to adopt PRB toward COVID-19. As such, policymakers need to work with the young generation so that the latter may serve as change agents to spread the message of taking precautions and adopting effective PRB toward COVID-19.

Addressing HIV/Sexually Transmitted Diseases and Pregnancy Prevention Through Schools: An Approach for Strengthening Education, Health Services, and School Environments That Promote Adolescent Sexual Health and Well-Being

Adolescents' health behaviors and experiences contribute to many outcomes, including risks for HIV, other sexually transmitted diseases, and unintended pregnancy. Public health interventions and approaches addressing risk behaviors or experiences in adolescence have the potential for wide-reaching impacts on sexual health and other related outcomes across the lifespan, and schools are a critical venue for such interventions. This paper describes a school-based program model developed by the Centers for Disease Control and Prevention's Division of Adolescent and School Health for preventing HIV/sexually transmitted diseases, unintended pregnancy, and related health risk behaviors and experiences among middle and high school students. This includes a summary of the theoretical and evidence base that inform the model, and a description of the model's activities, organized into three key strategies (sexual health education, sexual health services, and safe and supportive environments) and across three cross-cutting domains (strengthening staff capacity, increasing student access to programs and services, and engaging parent and community partners). The paper also outlines implications for adolescent health professionals and organizations working across schools, clinics, and communities, to address and promote adolescent sexual health and well-being.

More than the sum of their parts: A dyad-centered approach to understanding adolescent sexual behavior

BACKGROUND

Research has documented multiple levels of influences on adolescent sexual behavior, but has generally focused less on the relational nature of this behavior. Studies with dyadic data have provided important findings on relationship process, including the role of gender in different-sex dyads. However, both of these bodies of literature typically utilize a variable-centered approach, which examines average influences of particular variables on sexual behavior. This study expands upon this research by presenting a dyad-centered approach to adolescent sexual behavior that can identify types of couples based on patterns of multidimensional risk and protective factors.

METHODS

I demonstrate the dyad-centered approach using data from different-sex dyads in the National Longitudinal Study of Adolescent to Adult Health to uncover profiles marked by individual, parent, peer, and religion predictors for both male and female partners.

RESULTS

Analyses uncovered five classes of dyadic influences, four of which were marked by relative similarity between partners and one marked by lesser approval of sex for women compared to men. Dyads marked by both partners intending to have sex and being in a context that is more approving of sex were more likely to engage in sexual intercourse.

CONCLUSIONS

Findings demonstrate the heterogeneity of influences and intentions to have sex among adolescent couples, and identify profiles of dyads who are more likely to engage in sexual intercourse. This approach can explicate dyadic processes involved in sexual behavior and the types of couples that exist in a population, leading to more tailored and efficacious interventions.

Incidence of syphilis infection and syphilis-related care utilization among adolescents and young adults living with HIV

BACKGROUND

Incidence of syphilis has been rising in recent years and disproportionately affects young adults, racial/ethnic minority men, and people living with HIV. This study describes patterns of syphilis infection and syphilis-related care utilization among adolescents and young adults living with HIV (AYALH) in Philadelphia.

METHODS

We conducted a retrospective cohort study of AYALH receiving care at an adolescent-specialty clinic who received a syphilis test and/or benzathine penicillin for syphilis treatment from 2011 to 2018 (N = 335). Syphilis incidence rates were calculated by baseline demographic characteristics and by calendar year. Recurrent survival analysis was used to explore how demographic and neighborhood-level factors were associated with incident syphilis and syphilis-related care utilization.

RESULTS

Syphilis-related care was provided 145 times and there were 109 episodes of confirmed syphilis among 83 unique participants between 2011 and 2018. The overall syphilis incidence rate was 13.50 (95% CI: 10.9-16.5) cases per hundred person-years. Participants assigned male sex at birth had higher hazards of infection (HR: 6.12, 95% CI: 1.53-24.48), while older participants (HR: 0.64, 95% CI: 0.58-0.72) and those living further from the clinic had lower hazards of infection (HR: 0.97, 95% CI: 0.94-1.00). Race, insurance status, neighborhood diversity index, and neighborhood social disadvantage index were not associated with hazard of infection or syphilis-related care utilization.

CONCLUSIONS

Our study found high incidence of syphilis infection among a cohort of AYALH. Integrating comprehensive sexually transmitted infection prevention services into HIV care and improving syphilis prevention services in communities with high syphilis rates should be a priority in future intervention work.

The role of food security in increasing adolescent girls' agency towards sexual risk taking: qualitative findings from an income generating agricultural intervention in southwestern Kenya

BACKGROUND

Food insecurity is an important underlying driver of HIV risk and vulnerability among adolescents in sub-Saharan Africa. In this region, adolescents account for 80% of all new HIV infections. The primary purpose of this analysis is to understand perceived mechanisms for how a multisectoral agricultural intervention influenced sexual risk taking among HIV-affected adolescents in southwestern Kenya.

METHODS

We conducted semi-structured, individual interviews with 34 adolescent-caregiver dyads who were participants in Adolescent Shamba Maisha (NCT03741634), a sub-study of adolescent girls and caregivers with a household member participating in the Shamba Maisha trial (NCT01548599), a multi-sectoral agricultural and microfinance intervention. Interviews were audiotaped, transcribed, translated, and analyzed using framework and interpretive description analysis methods.

RESULTS

Adolescents receiving the Shamba Maisha intervention described no longer needing to engage in transactional sex or have multiple concurrent sexual partners as a way to meet their basic needs, including food. Key mechanisms for these effects include greater sexual agency among adolescent girls, and increased confidence and self-efficacy in overcoming existing reciprocity norms and sexual relationship power inequity; as well as staying in school. The intervention also increased caregiver confidence in talking about adolescent sexual reproductive health issues. In contrast, driven primarily by the need for food and basic needs, girls in the control arms described engaging in transactional sex, having multiple sexual partners, being unable to focus in school, getting pregnant or becoming HIV infected.

CONCLUSION

These findings emphasize the need to address food insecurity as a part of structural interventions targeting adolescent HIV risk in low-resource countries. We recommend that future interventions build upon the Shamba Maisha model by combining sustainable agricultural production, with household level interventions that deliberately target gender norms that contribute to unequal power dynamics.

A Longitudinal Analysis of the Impact of Health Behavior Campaigns on HIV-Risk Behaviors and HIV Incidence in Eswatini

Between 2010 and 2015, Eswatini conducted mass media health behavior campaigns (HBCs) designed to avert new HIV infections. Using longitudinal data from the nationally representative Swaziland HIV Incidence Measurement Survey of 2011, we describe the impact of exposure to HBCs on selected HIV risk behaviors and HIV incidence among sexually active, HIV-negative adults (n = 11,232). Exposure to partner reduction HBCs was significantly associated with reporting fewer (i.e., 1 versus 2, or 2 versus ≥ 3) sexual partners in the prior 6 months at baseline among women (aOR = 3.02; 95% CI 1.38, 6.62); and at both baseline and at 6-months follow-up for men (aOR = 2.26; 95% CI 1.49, 3.44; aOR = 1.95, 95% CI [1.26-3.00], respectively). Despite these reported partner reductions, there was no association between HBC exposure and prospectively observed HIV seroconversions (n = 121). This analysis strengthens the evidence that HIV prevention at the population level requires integrated strategies.

Girl-only clubs' influence on SRH knowledge, HIV risk reduction, and negative SRH outcomes among very young adolescent girls in rural Malawi

BACKGROUND

Early adolescence is an important period to lay the foundation for positive sexual health development that can overcome sexual and reproductive health (SRH) challenges faced by very young adolescents (VYAs) as they reach puberty and sexual debut. In this study, we explored the following questions: first, what are the experiences of VYA girls on DREAMS' Go Girl club participation? Second, how does club participation influence the VYAs SRH knowledge to reduce their risk for HIV and negative sexual health outcomes?

METHODS

This was a qualitative study in which twenty-three in-depth interviews were conducted with VYA girls aged 12-14 years. These girls were enrolled in girl-only clubs in two rural southern districts in Malawi. The clubs were a part of larger comprehensive HIV prevention project called DREAMS (Determined, Resilient, Empowered, AIDS-free, Mentored, and Safe) which provided an evidence-based core package of interventions to VYAs to prevent HIV. Interventions included improved access to key health services, education support, social skills, asset building, and economic strengthening. Narrative inquiry was used to generate first-hand accounts of the girls' experiences with club participation. Thematic analysis was used to generate themes from the transcribed stories.

RESULTS

Six main themes were generated: 1) reasons for joining the clubs with desire to learn about SRH as a motivation for joining the clubs.; 2) influence on gender norms and roles whereby participants described a change of gender roles and norms at home; 3) influence on child abuse practices whereby participants reported a decline in child abusive practices at home;4) influence on life skills and social networks whereby participants described learning about networking; 5) support to go back to school whereby out-of-school girls described how economic empowerment of their guardians facilitated their return to school; and 6) influence of clubs on SRH knowledge acquisition and behaviours whereby participants described acquiring knowledge on sexual health issues.

CONCLUSION

Girls-only HIV and SRH programs coupled with economic empowerment for their families can be effective in keeping VYA girls in school and improving SRH knowledge and health seeking behavior.

Exploring Condom Use Behaviors Among African American Adolescent Boys in the Deep South

Risky sexual behaviors among adolescents can increase adverse outcomes including unplanned pregnancy or contraction or transmission of disease. Adolescents who engage in risky sexual activities are at increased risk for adverse health and social outcomes compared to those who do not engage. Despite declines in adolescent pregnancy and birth rates, the diagnosis of sexually transmitted infections (STIs) is steadily increasing among adolescents. Moreover, African American adolescent boys in the United States, specifically in the southeastern region are disproportionally at greater risk for STIs, and STI diagnosis within this population has increased over time, compared to their white counterparts. This study sought to identify factors associated with condom use among adolescent boys in the Deep South. Using data from the Mobile Youth Survey, a longitudinal adolescent community-based survey, this study assessed the relationship between personal, behavioral, and environmental factors and condom use among African American adolescent boys (14–19 years). Younger participants (14–15 and 16–17) were more likely to use a condom during the last sexual intercourse compared to older participants (18–19 years). High positive attachment to boy/girlfriend was associated with increased condom use. The number of sexual partners, age at their first sexual encounter, recent sexual behavior, and having an STI were also associated with increased condom use among participants. The study provides further insights into factors associated with condom use among African American adolescent boys and results can inform the development of sexual health interventions.

Congenital syphilis in East Baton Rouge parish, Louisiana: providers' and women's perspectives

Background

Congenital syphilis is completely preventable through screening and treatment, but rates have been rising in the United States. Certain areas are at particularly high risk. We aimed to assess attitudes, knowledge, and barriers around effective prevention of congenital syphilis among health care providers and community women potentially at risk.

Methods

Two parallel studies were conducted: in-depth interviews with health care providers and focus groups with community women in the area of Baton Rouge, Louisiana. Each group was questioned about their experience in providing or seeking prenatal care, knowledge and attitudes about congenital syphilis, sources of information on testing and treatment, perceptions of risk, standards of and barriers to treatment. Results were transcribed into QSR NVivo V10, codes developed, and common themes identified and organized.

Results

Providers identified delays in testing and care, lack of follow-through with partner testing, and need for community connection for prevention, as major contributors to higher rates of congenital syphilis. Women identified difficulties in accessing Medicaid contributing to delayed start of prenatal care, lack of transportation for prenatal care, and lack of knowledge about testing and prevention for congenital syphilis.

Conclusions

Providers and community members were in broad agreement about factors contributing to higher rates of congenital syphilis, although some aspects were emphasized more by one group or another. Evidence-based interventions, likely at multiple levels, need to be tested and implemented to eliminate congenital syphilis.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-020-05753-6.

Sexually Transmitted Diseases Among College Students in Sierra Leone: A Life Course Ecological Analysis

Applying life course theory, this study examined the direct and indirect effects of adverse childhood experiences (ACEs) on the risk of contracting sexually transmitted diseases (STDs), mediated by early sexual activity (first sexual experience before age 15), number of lifetime sex partners, and mental health problems. The link between ACEs and mental health on college students' sexual risk is still understudied. Using cross-sectional data from a sample of 327 college students in Sierra Leone, this study tested the hypothesized mediation model using structural equation modeling analysis. The results showed that ACEs significantly increased sexual risks. Specifically, ACEs increased the risk of early initiation of sexual activity and the number of lifetime sex partners, which in turn increased the risk of STDs. Furthermore, ACEs significantly predicted negative mental health and were significantly associated with an increased risk of STDs. Effective future intervention strategies should include health education programs to address the lifelong effects of ACEs and mental health treatment.

Testing a Tailored Social-Ecological Model for Autism Spectrum Disorders

OBJECTIVE

To propose a tailored social ecological model for Autism Spectrum Disorders and explore relationships between variables in a large nationally-representative dataset.

METHODS

A tailored social-ecological model was developed and examined across variables in the 2016/2017 National Survey of Children's Health. A series of iterative multivariable logistic regressions were performed including individual, family, and community/neighborhood variables. A multivariable logistic regression using state-level fixed effects was performed to understand dynamics related to macro-level policies.

RESULTS

In the full model, gender, disability severity, certain types of insurance coverage and household income were significantly related to ASD diagnosis. Females had lower odds of a diagnosis compared to males (aOR: 0.27; CI:0.18-0.41). Children with at least one other moderate/severe disability had odds 7.61 higher (CI:5.36-10.82) of a diagnosis than children without moderate/severe disabilities. Children with public insurance only (aOR:1.66; CI:1.14-2.41) or both private and public insurance coverage (aOR: 2.62; CI:1.6-4.16) had higher odds of a diagnosis compared to children with private insurance only. For those who reported it was "somewhat" or "very often" hard to cover basics with their income, odds of a diagnosis were higher compared to those who reported it was "never" or "hardly ever" hard to cover basics (aOR: 1.676; CI:0.21-2.56).

CONCLUSIONS FOR PRACTICE

Patterns of ASD diagnosis are related to individual and family characteristics. There is some evidence that a child's environment has some relationship to reported ASD diagnosis. Professionals should be aware of an individual's environmental factors or context when assessing for ASD.

Racial and ethnic comparison of ecological risk factors and youth outcomes: A test of the desensitization hypothesis

Minority youth, because of structural, ecological, and societal inequalities, are at heightened risk of reporting depression and experiencing negative sanctions associated with delinquency. Sociological theories suggest that greater exposure to ecological risk factors at the peer, family, school and community levels are associated with elevated rates of youth depression and delinquency. Desensitization theory posits that repeated exposures to ongoing stressors result in a numbing of psychological and behavioral responses. Thus, it remains unclear whether racial/ethnic differences exist with regards to how contextual stressors correlate with depression and delinquency. Using a sample of 616 Black, 687 Latinx, and 1,318 White youth, this study explores racial/ethnic differences across four ecological risk factors of risky peers, low family warmth, poor school engagement, and community violence as they relate to youth delinquency and depression. Data were collected through in-school survey of youth from 16 public schools surrounding a major city in the Midwest. Significant racial/ethnic differences provided partial support for the desensitization theory. Among Black youth, the magnitude of relationships between ecological risk factors and delinquency was significantly weaker for three of the four predictors and for all four predictors of depression in comparison to White youth. Among Latinx youth, the magnitude of relationships between ecological risk factors was significantly weaker for depression, but not delinquency, in comparison to White youth. Results indicate that ecological risk factors may have differential associations to youth depression and delinquency, which may call for culturally tailored intervention approaches.

Illicit drug use and sexually transmitted infections among young adults in the US: evidence from a nationally representative survey

Young people aged 15-24 years account for half of all new sexually transmitted infections (STIs) in the United States. The aim of this study was to examine the cross-sectional associations of factors linked to STIs among US young adults (18-25 years). This study used the 2015-2018 pooled National Survey on Drug Use and Health data on 55,690 young adults. Almost 3.4% of the respondents reported having an STI in the past year. Among the participants, 38.4% used illicit drugs and 3.7% reported a history of delinquency in the past year. In the survey-weighted logistic regression model, odds for contracting STIs in the preceding year was higher among adults aged 22-25 versus 18-21 years (OR:1.26, 95%CI:1.12-1.42); male versus female (OR:2.44, 95%CI:2.11-2.82); non-Hispanic African American versus non-Hispanic White (OR:1.77, 95%CI:1.55-2.02); widowed/separated/divorced (OR:1.93, 95%CI:1.36-2.75) and never married (OR:1.29, 95%CI:1.07-1.55) versus married; full-time/part-time employed (aOR:1.17, 95% CI:1.04-1.31) compared to unemployed/other; history of delinquency (OR:2.31, 95%CI:1.89-2.83); and use of illicit drugs in the last year (OR:3.10, 95%CI:2.77-3.47). High incidence of illicit drug use by the young adults and its strong association with STI incidence in recent years warrant special attention. Tailored preventive measures should be focused on key predictors.

Navigating new sexual partnerships in midlife: a socioecological perspective on factors shaping STI risk perceptions and practices

OBJECTIVE

Despite increases in STIs among those over 40, little is known about the social context of STI transmission among people experiencing relationship transition in midlife, and few sexual health promotion initiatives are targeted at this group. This study sought to identify factors shaping STI risk perceptions and practices among midlife individuals either contemplating or having sex with new partners following the end of a long-term relationship.

METHODS

Participants were purposively selected from respondents to Britain's third National Survey of Sexual Attitudes and Lifestyles, using three eligibility criteria: aged 40-59, reported experience of the end of a marital or cohabiting relationship with an opposite-sex partner in the past 5 years, and willingness to participate in a qualitative interview. Qualitative data were generated via face-to-face interviews with 10 women and 9 men and analysed inductively using thematic analysis, with themes then organised using a socioecological framework.

RESULTS

Participants' accounts of new sexual partnerships in midlife indicate that STI risk perceptions and practices are shaped by factors operating at multiple levels across the socioecological arena (individual, partnership, peers and communities, societal). Constraints on, and resources for, the navigation of sexual safety include self-perceived STI risk rooted in past rather than present circumstances; legacies of mistrust within former relationships; intersecting gender-age dynamics in negotiation of risk prevention strategies with new partners; peers and younger relatives' influences on understandings of sexual risk and safety; postrelationship change in social networks that increase or mitigate vulnerability to sexual risk; age-related barriers to accessing condoms; and disconnection from safer sex messaging and services culturally coded as for the young.

CONCLUSIONS

Improving sexual health among midlife adults requires age-sensitive interventions designed to address multilevel constraints, and harness positive influences, on the navigation of sexual safety at this stage of life.

Using Social Ecological Theory to Identify Factors Associated With Risky Sexual Behavior in Cambodian Adolescent Girls and Young Women Aged 10 to 24 Years: A Systematic Review

There is an increase in risky sexual behavior (RSB) in Cambodian female youth aged 10 to 24 years, which can contribute to detrimental sexual and reproductive health due to the increased risk of acquiring sexually transmitted infections, unintended pregnancies, or abortions. Bronfenbrenner’s social ecological model was used to identify factors at personal, microenvironment, and macroenvironment levels potentially associated with RSB. A systematic literature review employing PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines was conducted to search 8 databases for articles published between 1994 and 2019. A risk of bias tool was applied for methodological quality of the 4 included studies. RSB is associated with multiple factors including sexual debut at young age, alcohol and substance abuse, multiple partners, living away from parents or orphan status, peer delinquency, non-use of condoms by partners, transactional sex, low education and socioeconomic status, and no access to sexual and reproductive health services. Multipronged preventive strategies operating at different levels are recommended in terms of including sex education and increasing reproductive health literacy programs at the schools and community programs for safe sex, condom use and sexual negotiation skills, and access to modern contraceptive methods.

Individual and Neighborhood Factors Associated With Sexual Behavior Classes in an Urban Longitudinal Sample

BACKGROUND

This study aimed to increase understanding of the clustering of sexual behaviors in an urban sample of emerging adults, and the individual and neighborhood factors associated with sexual behavior patterns to provide insight into reducing the disproportionate burden of poor sexual outcomes among urban African Americans.

METHODS

We draw on 2 cohorts of urban, predominantly African American youth first assessed at age 6 years and follow-up to emerging adulthood (mean age, 20 years; n = 1618). Latent class analyses by gender identified co-occurrence of sexual behavior.

RESULTS

We found 3 classes for both males and females: high-risk (13% of males, 15% of females), low-risk (54% of males, 56% of females) and no-risk (33% of males, 29% of females). Membership in the high-risk class was associated with school dropout, a substance use disorder diagnosis, having a criminal arrest, pregnancy, and sexually transmitted diseases for both males and females. High-risk females also had higher rates of depression. Low-risk males and females also had elevated risk of pregnancy and parenthood. Neighborhood factors distinguished the high- and no-risk classes for males and females, including the neighborhood environment scale, which assessed poverty, safety, drug activity, and crime/violence in the neighborhood. Neighborhood religiosity was inversely associated with membership in the high-risk class compared with the no-risk class for females only. Neighborhood racism distinguished those in the high-risk class compared with the no-risk class for males.

CONCLUSIONS

Future work should take into account the clustering of sexual risk behaviors. Specific neighborhood factors could be addressed to reduce sexual health disparities.

Promoting access to health information

Purpose

Describe the design of a health information and technology educational intervention that promotes health information sharing and technology use for older adult African Americans to support access to health information. The paper aims to discuss this issue.

Design/methodology/approach

The study team developed a novel method to design the intervention. It drew upon three approaches: intergenerational technology transfer, participatory design and community-based participatory research.

Findings

Older adult African Americans (55+) with diabetes and young adults (18–54) connected to them via familial or naturally occurring social networks designed the intervention, which was conducted in the two study sites in Michigan, USA. In total, 29 participants helped design the intervention. Four themes emerged concerning factors that promote intergenerational information exchange in the context of technology and health. First, focus on one technology skill. Second, working together in small groups is preferred. Third, patience is essential. Last, physical capabilities (i.e., eyesight, operating on relatively small screens) and literacy levels should be considered.

Originality/value

This novel method of having participants from the sample population select the health information materials and technology exercises serves as a guide for implementing health information and education interventions aimed at technology use to support self-management for vulnerable patient populations.

Perceptions and intervention preferences of Moroccan adolescents, parents, and teachers regarding risks and protective factors for risky sexual behaviors leading to sexually transmitted infections in adolescents: qualitative findings

BACKGROUND

Sexual choices and practices of adolescents living in conservative societies, including Morocco, can be influenced either positively or negatively by the prevailing contextual and social norms. These norms not only limit the access to reproductive health information and services but also lead to abstinence among devout adolescents. Thus, identifying contextual risks and protective factors of risky sexual behaviors leading to sexually transmitted infections (STIs) in adolescents, as well as exploring perceptions of adolescents, parents and teachers regarding effective intervention preferences could improve the sexual health of adolescents.

METHODS

We conducted a qualitative study using focus group discussions (FGDs) based on the socio-ecological model as a theoretical framework. Sample groups of adolescents, parents, and teachers were selected from two public middle schools (disadvantaged and advantaged according to socio-economic level) in Taza city, Morocco, from May to July 2016. Participants were polled on protective factors and perceived facilitators of risky sexual behaviors leading to sexually transmitted infections (STIs) in adolescents as well on their perception of intervention preferences to reduce the risks. Three sets of data were initially formed, coded, and analyzed using thematic analysis.

RESULTS

Seventeen FGDs were conducted, including 8 groups of adolescents (28 boys and 28 girls, 14-16 years old), 5 groups of parents (21 males and 5 females), and 4 groups of teachers (13 males and 5 females). Five overall themes seemed to influence risky sexual behaviors in adolescents: (1) risky sexual practices and STIs; (2) the adolescent's social domain; (3) the role of school; (4) media, including internet and social media; and (5) socio-cultural norms. Participants also suggested a number of possible interventions to improve the sexual health of adolescents and to reduce the risk of STIs, which could be applied at multiple levels.

CONCLUSIONS

Successful intervention programs should target the multifaceted factors affecting the adolescent's sexual behaviors, from the individual to the societal level. Allowing parents, teachers, and adolescents to work together could help reduce the socio-cultural and personal barriers that prevent effective communication about sexuality. Furthermore, schools can play a vital role in reducing risky sexual behaviors and STI acquisition rates in adolescents by promoting sex education in school curriculum and encouraging adolescents to engage in extracurricular activities and awareness campaigns.

Facilitators and Barriers to Adherence to Antiretroviral Therapy and Retention in Care Among Adolescents Living with HIV/AIDS in Zambia: A Mixed Methods Study

Little is known about the factors that contribute to the losses during stages of the HIV continuum of care (CoC) and specifically during the latter stages of antiretroviral (ART) adherence and retention in HIV care among adolescents living with HIV/AIDS (ALHA) in sub-Saharan Africa. We conducted a mixed-methods study: six focus group discussions with 43 ALHA (age 17-19); in-depth interviews with four (age 18-19): and survey-based interviews with 330 ALHA (age 18-19) to identify, understand, and describe factors contributing to the losses in the latter stages of the CoC among ALHA in Zambia. Through focus group discussions and in-depth interviews, ALHA identified barriers at the intrapersonal level (e.g., poverty; lack of adequate nutrition; fear of stigma), interpersonal level (e.g., stigma; disrespectful treatment by providers), institutional/facility level (e.g., lack of adolescent specific services), and community level (e.g., lack of collaboration among organizations; social norms). In quantitative interviews, we found that 46% (101/220) of ALHA reported missing any clinic appointments in the past three months, and about 19% (41/221) reporting missing one or more doses of ART in the last week. Logistic regressions indicate that walking to the site of appointment and being currently employed were predictive of missed visits. Findings highlight the complexity of the multiple factors that are unique to ALHA in Zambia, which should be addressed to improve adherence to ART and retention in HIV.

A Rapid Review of Sexual Wellbeing Definitions and Measures: Should We Now Include Sexual Wellbeing Freedom?

An increasing number of studies refer to sexual wellbeing and/or seek to measure it, and the term appears across various policy documents, including sexual health frameworks in the UK. We conducted a rapid review to determine how sexual wellbeing has been defined, qualitatively explored and quantitatively measured. Eligible studies selected for inclusion from OVID Medline, PsychInfo, PubMed, Embase, CINAHL were: in English language, published after 2007, were peer-reviewed full articles, focused on sexual wellbeing (or proxies for, e.g. satisfaction, function), and quantitatively or qualitatively assessed sexual wellbeing. We included studies with participants aged 16-65. Given study heterogeneity, our synthesis and findings are reported using a narrative approach. We identified 162 papers, of which 10 offered a definition of sexual wellbeing. Drawing upon a socio-ecological model, we categorised the 59 dimensions we identified from studies under three main domains: cognitive-affect (31 dimensions); inter-personal (22 dimensions); and socio-cultural (6 dimensions). Only 11 papers were categorised under the socio-cultural domain, commonly focusing on gender inequalities or stigma. We discuss the importance of conceptualising sexual wellbeing as individually experienced but socially and structurally influenced, including assessing sexual wellbeing freedom: a person's freedom to achieve sexual wellbeing, or their real opportunities and liberties.

Multilevel elements associated with HIV serosorting for sexual encounters: a scoping literature review

A scoping literature review to identify the multilevel HIV serosorting related elements was developed. Articles from EBSCO, PubMed, PsyNET and Science Direct with serosort* or serosorting at the tittle or abstract, written in English or Spanish were included. No restriction in type of population or design were applied. 239 records were retrieved after duplicates removed, but 181 references were extracted for full-text review. Individual level: HIV knowledge, serostatus, risk perceptions, abilities to disclose and for condom use negotiation, motivations, use of drugs, stigma, attitudes toward condom use, and perceptions/beliefs about the HIV and related treatments, HIV infection rates/testing and behavioral factors. Interpersonal level: social networks, abilities (sexual behavior negotiation, and communication). Community level: stigma, social norms, access to HIV related services. Structural level: political context, HIV related funding and public policies. HIV Serosorting is not solely an interpersonal behavior it involves multilevel elements that must be acknowledged by professionals and stakeholders.

Getting youth PrEPared: adolescent consent laws and implications for the availability of PrEP among youth in countries outside of the United States

INTRODUCTION

Youth under the age of 25 are at high risk for HIV infection. While pre-exposure prophylaxis (PrEP) has the potential to curb new infections within this population, it is unclear how country-specific laws and policies that govern youth access to sexual and reproductive health (SRH) services impact access to PrEP. The purpose of this review was to analyse laws and policies concerning PrEP implementation and SRH services available to youth in countries with a high HIV incidence. To the best of our knowledge this is the first systematic assessment of country-level policies that impact the availability of PrEP to adolescent populations.

METHODS

We conducted a review of national policies published on or before 12 June 2018 that could impact adolescents' access to PrEP, SRH services and ability to consent to medical intervention. Countries were included if: (1) there was a high incidence of HIV; (2) they had active PrEP trials or PrEP was available for distribution; (3) information regarding PrEP guidelines were publicly available. We also included a selected number of countries with lower adolescent HIV incidence. Internet and legal database searches were used to identify policies relevant to adolescent PrEP (e.g. age of consent to HIV testing).

RESULTS AND DISCUSSION

Fifteen countries were selected for inclusion in this review. Countries varied considerably in their respective laws and policies governing adolescents' access to PrEP, HIV testing and SRH services. Six countries had specific polices around the provision of PrEP to youth under the age of 18. Five countries required people to be 18 years or older to access HIV testing, and six countries had specific laws addressing adolescent consent for- and access to- contraceptives.

CONCLUSIONS

Adolescents' access to PrEP without parental consent remains limited or uncertain in many countries where this biomedical intervention is needed. Observational and qualitative studies are needed to determine if and how adolescent consent laws are followed in relation to adolescent PrEP provisions. Intensified efforts to amend laws that limit adolescent access to PrEP and restrict the establishment of national guidelines supporting adolescent PrEP are also needed to address the epidemic in this group.

Effectiveness of an education health programme about Middle East respiratory syndrome coronavirus tested during travel consultations

OBJECTIVE

We aimed to evaluate the level of knowledge of Middle East respiratory syndrome coronavirus (MERS-CoV) among Hajj pilgrims before and after an education health programme during international vaccine consultations in France.

STUDY DESIGN

A cross-sectional study was performed in the consultation for travel medicine and international vaccination in Reims University Hospital between July 2014 and October 2015.

METHODS

Consecutive adults (>18 years old) who attended for pre-Hajj meningococcal vaccination were eligible to complete an anonymous questionnaire with closed answers to evaluate their level of knowledge about MERS-CoV. To evaluate the effectiveness of the information given during the consultation, the same questionnaire was completed by the Hajj pilgrim before and after the consultation, where the information about MERS-CoV was provided.

RESULTS

Among 82 Hajj pilgrim adults enrolled in the study, less than 25% were aware of the routes of transmission, symptoms and preventive behaviours to adopt abroad or in case of fever. Pilgrims had a higher rate of correct responses on each question at the time they completed the second questionnaire, as compared with the first, with 11 of 13 questions answered significantly better after delivery of educational information about MERS-CoV. However, although the rate of correct answers to the questions about routes of transmission, symptoms, preventive behaviours to adopt in case of fever and time delay between return and potential MERS-CoV occurrence increased significantly after receiving the information, the rates remained below 50%.

CONCLUSION

Information given during travel consultations significantly increases the general level of knowledge, but not enough to achieve epidemic control.

Teen mothers' educational attainment and their children's risk for teenage childbearing

The children of teen mothers are at elevated risk for becoming teen parents themselves. The current study aimed to identify how levels of mothers' education were associated with risk of teenage childbearing for children of teen versus nonteen mothers. Through structural equation modeling, we tested whether children's environmental and personal characteristics in adolescence and subsequent sexual risk behaviors mediated the relationship between their mothers' educational attainment and their risk for teenage childbearing. With multiple-group models, we assessed whether the associations of maternal educational attainment with children's outcomes were similar for the children of teen and nonteen mothers. The sample (N = 1,817) contained linked data from female National Longitudinal Survey of Youth, 1979 (NLSY79) participants and their first-born child (son or daughter) from the NLSY79 Children and Young Adults. The mediating pathways linking higher levels of maternal education to lower risk for teenage childbearing, and magnitudes of the associations, were mostly similar for children of teen and nonteen mothers. However, nonteen mothers experienced greater associations of their high school diploma attainment (vs. no degree) with some of their children's outcomes. Also, the association of earning a high school diploma (vs. a GED) with household incomes was greater for nonteen mothers; there was no significant difference between degree types for teen mothers. Findings provide support for teen mother secondary school support programming, but point to a need for further research regarding the long-term behavioral and social outcomes associated with the high school equivalency certificate for teen mothers and their children. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Emergency Department Directors Are Willing to Expand Reproductive Health Services for Adolescents

STUDY OBJECTIVE

Nearly 20 million adolescents receive emergency department (ED) care each year, many of whom have untreated reproductive health issues. ED visits represent an opportunity to provide appropriate care, however, ED physician reproductive health care practices and capabilities in the United States have not been described. We sought to characterize pediatric ED director's individual practice and ED system resources for providing adolescent reproductive health care.

DESIGN, SETTING, PARTICIPANTS, AND INTERVENTIONS

We invited pediatric ED division and/or medical directors nationally to participate in an anonymous, online survey.

MAIN OUTCOME MEASURES

Outcomes included ED directors' personal practice regarding providing adolescent patients reproductive health care, and their ED's resources and standard practice regarding screening adolescents for sexually transmitted infections (STIs) and other reproductive health concerns.

RESULTS

One hundred thirty-five of 442 (30.5%) ED directors responded. Respondents were 73% (90/124) male, with a median of 18 (interquartile range, 13-23) years of experience and 63% (84/134) working in urban EDs. Seventy-one percent (90/130) preferred face-to-face interviews for obtaining a sexual history, but only 59% (77/130) of participants "always ask parents to leave the room for sensitive questions." Eighty-four percent (106/127) were receptive to pregnancy prevention interventions being initiated in the ED, with 75% (80/106) of those willing to provide an intervention. Only 16% (21/128) indicated their ED has a universal STI screening program, and only 18% (23/126) "always" successfully notify patients of a positive STI test.

CONCLUSION

ED directors are comfortable providing adolescent reproductive health care, and many individual- and ED-level opportunities exist to provide improved reproductive health care for adolescents in the ED.

HIV Prevention Among Young Women in South Africa: Understanding Multiple Layers of Risk

Despite concerted prevention efforts, young South African women remain at the epicenter of the HIV epidemic. Although these women have grown up in a community powerfully affected by HIV, systematic investigation into how this "second generation" of HIV-affected youth navigates HIV risk is lacking. This study qualitatively explored a complex interplay of factors influencing HIV risk among young pregnant women in KwaZulu-Natal, South Africa. We conducted in-depth interviews with 35 pregnant women (22 HIV-uninfected and 13 HIV-infected) aged 18-21, 18 healthcare providers, and focus groups with 19 community stakeholders. Among the young women, HIV knowledge was high, and many reported taking some action to prevent pregnancy or HIV; however, these efforts were not routinely implemented. Themes related to HIV acquisition risk from all participants were organized using a socioecological framework and revolved around individual and developmental experiences (personal experience with HIV, perceived invincibility), family barriers (lack of adult supervision, pressure to leave school), relational barriers (lack of disclosure and partner communication, "burn out" around attempts to discuss condom use with partners, overdependence on partners), community-level barriers (township environment, lack of structured activities), and social barriers (poverty, HIV-related stigma). Some novel concepts emerged from the data, including an understanding of how overdependence on the romantic relationship may develop. Current HIV prevention efforts, including traditional HIV counseling and testing, condom distribution, and biomedical agents for HIV prevention, are unlikely to be effective without a broader, ecological up-to-date understanding of the evolving, intertwined, and complex constellation of factors that drive HIV risk behavior in this high-risk population.

Sexual Teen Dating Violence Victimization: Associations With Sexual Risk Behaviors Among U.S. High School Students

Adolescent dating violence may lead to adverse health behaviors. We examined associations between sexual teen dating violence victimization (TDVV) and sexual risk behaviors among U.S. high school students using 2013 and 2015 National Youth Risk Behavior Survey data (combined n = 29,346). Sex-stratified logistic regression models were used to estimate these associations among students who had dated or gone out with someone during the past 12 months (n = 20,093). Among these students, 10.5% experienced sexual TDVV. Sexual TDVV was positively associated with sexual intercourse before age 13, four or more lifetime sexual partners, current sexual activity, alcohol or drug use before last sexual intercourse, and no pregnancy prevention during last sexual intercourse. Given significant findings among both sexes, it is valuable for dating violence prevention efforts to target both female and male students.

Knowledge, beliefs, and perceptions of tuberculosis among community members in Ntcheu district, Malawi

Introduction

The global burden of tuberculosis (TB) remains significantly high, with overreliance on biomedical interventions and inadequate exploration of the socioeconomic and cultural context of the infected population. A desired reduction in disease burden can be enhanced through a broader theoretical understanding of people’s health beliefs and concerns about TB. In this qualitative study, we explore the knowledge, beliefs, and perceptions of community members and people diagnosed with TB toward TB in Ntcheu district, Malawi.

Methods

Using a qualitative phenomenological study design, data were obtained from eight focus-group discussions and 16 individual in-depth interviews. The community’s experiences and perceptions of TB were captured without using any preconceived framework. Adult participants who had had or never had a diagnosis of TB were purposively selected by sex and age and enrolled for the study. Discussions and individual interviews lasting about 60 minutes each were audiotaped, transcribed, and translated into English and analyzed using MaxQDA 10 software for qualitative analysis.

Results

Most participants believed that TB was curable and would go for diagnosis if they had symptoms suggestive of the disease. However, based on their beliefs, individuals expressed some apprehension about the spread of TB and the social implications of being diagnosed with the disease. This perception affected participants’ responses about seeking diagnosis and treatment.

Conclusion

A supportive and collective approach consisting of a combination of mass media, interactive communication campaigns, emphasizing TB symptoms, transmission, and stigma could be useful in addressing barriers to early diagnosis and care-seeking behavior.

Community Stakeholders' Perceptions of the Role of Family in HIV Prevention in Iringa, Tanzania

Although HIV is identified as a family disease, the overall response to the global HIV epidemic continues to predominantly focus on individuals. The aim of this qualitative study was to explore how the role of the family in HIV prevention is perceived by community-based stakeholders. Understanding the role of the family within the context of the HIV/AIDS is essential for community/public health nurses. In total, 34 stakeholders participated in the study. Three major categories were identified namely: fostering positive intra-familial relations, utilizing external resources, and barriers to family roles. The study findings have implications for community-based HIV family interventions.

Examination of Behavioral, Social, and Environmental Contextual Influences on Sexually Transmitted Infections in At Risk, Urban, Adolescents, and Young Adults

BACKGROUND

Despite the large body of extant literature on sexually transmitted infections (STIs) in adolescents and young adults (AYAs), more research on social and environmental contextual factors is needed. Also, further examination of STI indicators by gender remains a critical area of research focus.

METHODS

Anonymous survey data were collected using audio computer-assisted self-interviews in community venues in urban, low-income, STI prevalent, US neighborhoods to reach AYAs, aged 12 to 24 years. Conventional descriptive statistics, bivariate analysis, and multiple logistical regression models were used to assess indicators of a self-reported lifetime prevalence of STIs.

RESULTS

Participants (N = 1540) were on average 20.6 years; 57.2% were women, the majority were racial and ethnic minorities (92%), and almost half (49.2%) identified as sexual minorities. Nearly one third (32.%) had 1 or more STIs. As expected, gender differences were identified. For AYA men, being African American/Black, moving residences more than 4 times since kindergarten, and having a history of human immunodeficiency virus testing were each positively associated with STIs. Also, those who strongly disagreed that many young people in their community exchanged sex for money had a significantly lower likelihood of having an STI. For AYA women, exchanging sex for drugs or money, lacking money, which prevented activities, and using marijuana were each associated with STIs.

CONCLUSIONS

This research extends our understanding of social and environmental contextual influences on AYAs' risk for STIs. It highlights differences in risk exposures that are distinctly different for AYA women and men, suggesting the need for tailored interventions to address their unique economic needs and social challenges.

Interaction Effects of Neighborhood Disadvantage and Individual Social Support on Frequency of Alcohol Use in Youth Living with HIV

Youth living with HIV (YLH) experience multiple disease-related stresses along with the same structural and developmental challenges faced by their uninfected peers; alcohol use among YLH represents a risk behavior by virtue of potential effects on youth health and increased likelihood of engaging in unprotected sex while drinking alcohol. Research aimed at better understanding the interplay of individual- and neighborhood-level influences on alcohol use for YLH is needed to inform interventions. This study examined whether socioeconomic disadvantage (SED) and social support influence, independently and through interaction, alcohol use in YLH. Data from the Adolescent Medicine Trials Network for HIV/AIDS Interventions (ATN) consisted of YLH across 538 neighborhoods in the United States who acquired HIV behaviorally. Neighborhood-specific data were compiled from the 2010 U.S. Census Bureau and matched with individual-level data from the ATN (N = 1,357) to examine effects that contribute to variation in frequency of alcohol use. Other drug use, being male, being non-Black, and older age were associated with greater alcohol use. Higher social support was negatively associated with alcohol use frequency. A cross-level interaction indicated that the association found between decreasing social support and increasing alcohol use frequency was weakened in areas with lower SED. Implications are discussed.

Sexual intercourse, age of initiation and contraception among adolescents in Ireland: findings from the Health Behaviour in School-aged Children (HBSC) Ireland study

Background

The need to tackle sexual health problems and promote positive sexual health has been acknowledged in Irish health policy. Young people’s sexual behaviour however remains under-researched with limited national data available.

Methods

This study presents the first nationally representative and internationally comparable data on young people’s sexual health behaviours in Ireland. Self-complete questionnaire data were collected from 4494 schoolchildren aged 15–18 years as part of a broader examination of health behaviour and their context. The prevalence of sexual initiation, very early sexual initiation (< 14 years) and non-condom use at last intercourse are reported and used as outcomes in separate multilevel logistic regression models examining associations between sociodemographic characteristics, lifestyle characteristics and young people’s sexual behaviours.

Results

Overall, 25.7% of boys and 21.2% of girls were sexually initiated. Older age was consistently predictive of initiation for both boys and girls, as were alcohol, tobacco and cannabis involvement, living in poorer neighbourhoods and having good communication with friends. Involvement in music and drama was protective. Very early sexual initiation (< 14 years) was reported by 22.8% of sexually initiated boys and 13.4% of sexually initiated girls, and was consistently associated with rural living, cannabis involvement and bullying others for both. Boys’ very early initiation was predicted by alcohol involvement, receiving unhealthy food from parents and taking medication for psychological symptoms, whereas better communication with friends and more experience of negative health symptoms were protective. Girls’ very early initiation was predicted by being bullied and belonging to a non-Traveller community, whereas taking medication for physical symptoms and attending regular health checks was protective. Condom use was reported by 80% of sexually initiated students at last intercourse. Boys’ condom use was associated with older age, higher family affluence, bullying others, more frequent physical activity and health protective behaviours. For girls, condom use was predicted by belonging to a non-Traveller community, healthy food consumption, higher quality of life and being bullied, whereas taking medication for physical and psychological symptoms was associated with non-condom use.

Conclusions

These nationally representative research findings highlight the importance of focusing on young people as a distinct population subgroup with unique influences on their sexual health requiring targeted interventions and policy.

Electronic supplementary material

The online version of this article (10.1186/s12889-018-5217-z) contains supplementary material, which is available to authorized users.

The Context of Sexual Decisions and Intrapersonal and Interpersonal Factors Related to Sexual Initiation Among Female Military-Dependent Youth

Despite the sizable population of military-dependent youth (MDY) in the United States and the military stressors they experience (e.g., relocations, parental deployment), little is known about MDY's sexual behavior, especially about the perceived role that military stressors play in their sexual decisions, such as the decision to initiate sex. We conducted 25 semistructured, in-depth interviews with sexually experienced female MDY aged 15 to 19 years to (a) describe MDY's general perceptions of military life and (b) identify intrapersonal and interpersonal characteristics related to MDY's sexual initiation, including the perceived impact of military stressors. We analyzed life history grids and transcripts to identify common and unique themes across participants' experiences. Most participants reported having positive experiences related to military life, and most did not believe that military stressors influenced their decision to initiate sex. Common intrapersonal and interpersonal characteristics related to sexual initiation were having an older first sexual partner, being in a dating relationship, receiving sexual health education prior to their first sexual experience, and discussing sex with a parent prior to their first sexual experience. These intrapersonal and interpersonal characteristics should be considered when developing sexual health programs for MDY, which should focus on building supportive peer and parental relationships.

Assessing Spatial Relationships between Race, Inequality, Crime, and Gonorrhea and Chlamydia in the United States

Incidence rates of chlamydia and gonorrhea reached unprecedented levels in 2015 and are concentrated in southern counties of the USA. Using incidence data from the Center for Disease Control, Moran's I analyses assessed the data for statistically significant clusters of chlamydia and gonorrhea at the county level in 46 states of the USA. Lagrange multiplier diagnostics justified selection of the spatial Durbin regression model for chlamydia and the spatial error model for gonorrhea. Rates of chlamydia (Moran's I = .37, p < .001) and gonorrhea (Moran's I = .38, p < .001) were highly clustered particularly in the southern region of the USA. Logged percent in poverty (B = .49, p < .001 and B = .48, p < .001) and racial composition of African-Americans (B = .16, p < .001 and B = .40, p < .001); Native Americans (B = .12, p < .001 and B = .20, p < .001); and Asians (B = .14, p < .001 and B = .09, p < .001) were significantly associated with greater rates of chlamydia and gonorrhea, respectively, after accounting for spatial dependence in the data. Logged rates of rates violent crimes were associated with chlamydia (B = .053, p < .001) and gonorrhea (B = .10, p < .001). Logged rates of drug crimes (.052, p < .001) were only associated with chlamydia. Metropolitan census designation was associated with logged rates of chlamydia (B = .12, p < .001) and gonorrhea (B = .24, p < .001). Spatial heterogeneity in the distribution of rates of chlamydia and gonorrhea provide important insights for strategic public health interventions in the USA and inform the allocation of limited resources for the prevention of chlamydia and gonorrhea.

Perceived, anticipated and experienced stigma: exploring manifestations and implications for young people's sexual and reproductive health and access to care in North-Western Tanzania

Young people - particularly girls and young women in sub-Saharan Africa - face significant challenges accessing sexual and reproductive health information and services. These challenges are shaped in part by sociocultural factors, including stigma. This paper presents findings from a qualitative study that explored the micro-level social process of stigma surrounding young people's sexual and reproductive health in two communities in Tanzania. Respondents described an environment of pervasive stigma surrounding the sexual and reproductive health of unmarried young people. Stigma manifested itself in multiple forms, ranging from verbal harassment and social isolation to physical punishment by families, community members, peers and healthcare providers. Respondents perceived that stigma was a barrier to young people accessing sexual and reproductive health services and identified excessive questioning, scolding and requirements to bring sexual partners or parents to receive services at health facilities as obstacles to accessing care. The pervasiveness and complexities of stigma surrounding young people's sexual and reproductive health in the two study communities and its potential consequences for health suggest both a need for care in using the term stigma as well as further studies on the feasibility of incorporating stigma-reduction strategies into young people's sexual and reproductive health programmes.

Two-Year Trajectories of Sexual Risk Behaviors Among Drug-Using Adolescents and Emerging Adults in an Urban Community

Among 14-24 year-olds who used drugs and were recruited from an emergency department, we examined 2-year trajectories of sexual risk behaviors. We hypothesized that those in higher risk trajectories would have more severe substance use, mental health concerns, and dating violence involvement at baseline. Analyses identified three behavioral trajectories. Individuals in the highest risk trajectory had a more severe profile of baseline alcohol use, marijuana use, dating violence involvement, and mental health problems. Future research will examine longitudinal differences in risk factors across trajectories. Understanding risk factors for sexual risk behavior trajectories can inform the delivery and tailoring of prevention interventions.

HIV/AIDS Communication Inequalities and Associated Cognitive and Affective Outcomes: A Call for a Socioecological Approach to AIDS Communication in Sub-Saharan Africa

Three-and-a-half decades on, no cure or vaccine is yet on the horizon for HIV, making effective behavior change communication (BCC) the key preventive strategy. Despite considerable success, HIV/AIDS BCC efforts have long been criticized for their primary focus on the individual-level field of influence, drawing on the more reductionist view of causation at the individual level. In view of this, we conducted a series of studies that employed a household survey, field experiment, and textual content analysis, and explored the macro-social-level effects of HIV/AIDS-related media and messages on HIV/AIDS cognitive and affective outcomes in Ethiopia. Against a backdrop of epidemiological and socioecological differences, urban versus rural residence has emerged as an important community-level factor that impacts HIV/AIDS-related media and message consumption processes and associated outcomes. The central thread crossing through the six studies included in this paper demonstrates that urban and rural people in high HIV prevalence contexts differ in their concern about and information needs on HIV/AIDS, HIV/AIDS-related media use, and HIV/AIDS-related cognitive and affective outcomes, as well as in their reaction to differently designed/framed HIV prevention messages. This paper proposes that HIV prevention media and message effects in high epidemic situations should be considered from a larger community-level perspective and calls for a socioecological approach to AIDS communication in the hard-hit sub-Saharan Africa. With a number of concrete recommendations to current and future HIV/AIDS BCC efforts in the region, the study joins an emerging body of health communication literature and theorizing that suggests the need to consider media and message effects from a macro-social perspective.