The influence of social determinants on sexual risk among out-of-school African American female adolescents

Condom Use at Last Sex and Sexual Negotiation Among Young African American Women in North Carolina: Context or Personal Agency

African American women are 10.8 times more likely to be diagnosed with HIV compared with White women. This descriptive study fills a gap by examining associations among social and contextual factors and sexual communication, condom use, and safer sex negotiation among African American women. Study participants between 18 and 25 years of age and who reported recent substance use were recruited from three North Carolina counties. A risk behavior survey was administered via audio computer-assisted self-interview, and logistic regression analyses were conducted to assess associations between social and contextual variables and condom use at last sex with a main partner. Education (AOR: 2.078; 95% CI: 1.214, 3.556), sexual communication with a main partner (AOR: 1.079; 95% CI: 1.050, 1.109), and condom use relationship scale (AOR: 1.059; 95% CI: 1.023, 1.098) were positively associated with condom use at last sex, whereas living with a main partner (AOR: 0.447; 95% CI: 0.210, 0.950) and the alcohol and drug problem scale (AOR: 0.971; 95% CI: 0.944, 0.998) were negatively associated with condom use (p < 0.05). The study findings show that among young African American women at risk for HIV, contextual and personal factors may influence condom use. A socio-ecological approach combining personal empowerment, interpersonal, structural, and biobehavioral strategies is necessary in implementing holistic gender-focused HIV prevention programs.

Exploring Substance Misuse Behaviors Among Black Girls in Detention: Intersections of Trauma, Sex, and Age

High risk substance misuse, trauma and gang involvement are prevalent in adolescents and often occur with youth involved with the youth punishment system. Evidence suggests that system involvement is related to trauma histories, substance misuse, as well as gang involvement. This study investigated the associations between individual and peer factors and their relationship to problem drug and alcohol use among Black girls involved with the youth punishment system. Data were collected from 188 Black girls in detention at baseline, as well as 3 and 6 month follow up periods. Measures assessed were abuse history, trauma history, sex while using drugs and alcohol, age, government assistance, and drug use. Significant findings from the multiple regression analyses indicated that younger girls were more likely to have a higher prevalence of having a drug problem than older girls at baseline. Having sex while on drugs and alcohol at the 3 month follow up period was correlated with drug use. These findings highlight how individual and peer factors can influence problem substance misuse, their behavior and peer relationships among Black girls in detention.

Alcohol, drug use, and sexual risk among young African American women in North Carolina: Is educational attainment protective?

Previous research shows that educational attainment is a protective factor for substance use and sexual risk among adolescents and young adults. Evidence also shows that this relationship may differ by race/ethnicity and gender. This study aimed to elucidate the relationship between educational attainment, substance use and sexual risk among African American women in emerging adulthood. This study uses cross-sectional data from 646 African American women (aged 18 to 25) enrolled in a randomized trial of a behavioral HIV risk-reduction intervention. At enrollment, participants completed a risk behavior assessment via audio-computer assisted self-interview and provided a urine sample for drug screening. Bivariate logistic regression analyses were conducted to examine substance use and sexual risk factors associated with educational attainment: completing some college or more vs. completing high school or less). Participants who completed some college or more (52%) were more likely to report heavy alcohol use (four or more drinks in one day) in the past 30 days (OR=1.48; p=0.014) and more likely to report alcohol or other drug use just before or during last sex (OR=1.43; p=0.026) compared with participants who completed high school or less. Completing some college or more was protective for having a positive urine screen for cocaine (OR=0.43; p=0.018) and reporting condomless sex at last sex (OR=0.71; p=0.041). Differences in positive marijuana screens, reporting a previous STI, or reporting their partner used alcohol or other drugs at last sex were not statistically significant. The findings reveal notable differences in the magnitude and direction of associations between educational attainment and substance use and sexual risk. Although educational attainment is subject to change because of the frequent pursuit of education during emerging adulthood, the findings may have important implications for tailoring HIV risk-reduction interventions to key populations, such as African American women.

Associations Between Social Determinants of Health and Adolescent Contraceptive Use: An Analysis From the National Survey of Family Growth

This research assessed social determinants of contraceptive use among a nationally representative sample of adolescents. This study analyzed nationally representative, publicly available data from the 2013-2015 National Survey of Family Growth (NSFG). The sample consisted of sexually active males and females between the ages of 15 and 19 (n = 775). Independent variables were social determinant questions asked on the NSFG, selected based on the Healthy People Social Determinants of Health Framework. We tested associations between adolescents' social determinants of health and 2 outcomes, use of any contraceptive at last sex, and effectiveness level of contraceptive method at last sex. Results indicated high contraceptive use at last intercourse (91.5%) and a significant association between any use of contraceptive and family structure (adjusted odds ratio [AOR] = 2.05, 95% confidence interval [CI] = 1.04-4.03), employment (AOR = 2.00, 95% CI = 1.06-3.77), and education (AOR = 3.43, 95% CI = 1.06-11.13). Few participants reported use of a highly effective method of pregnancy prevention (4.3%). In regression analyses, access to health care (AOR = 0.34, 95% CI = 0.14-0.84) and language and literacy (AOR = 2.92, 95% CI = 1.03-8.26) were found to be associated with using moderately effective contraceptive method to prevent pregnancy compared with not using any method. Although adolescents report overall high rates of contraceptive use, not all contraceptives have the same rates of effectiveness, and adolescents are often choosing those with lower effectiveness. This study found low rates of highly effective contraceptives to prevent pregnancy use (ie, intrauterine device and implant). It is also important to further explore the associations between family structure (measured in this study as intact childhood family) and distal links to contraceptive use. Future research should also further distinguish pathways to adolescent decision-making to use contraceptive methods to protect against STIs and pregnancy.

A Systematic Review Exploring Racial Disparities, Social Determinants of Health, and Sexually Transmitted Infections in Black Women

OBJECTIVE

To explore and describe racial disparities, the role of social determinants of health, and individual risk behaviors among Black women as related to sexual health and/or sexually transmitted infections (STIs).

DATA SOURCES

Electronic resource databases used were PubMed, CINAHL, and Google Scholar. Peer-reviewed articles published during 2010 to 2020 were considered.

STUDY SELECTION

Thirty-two studies met the criteria and included data for a total of 18,904 Black women.

DATA EXTRACTION

Data were extracted from each study using the subheadings author (year), purpose, design, sample demographics and setting, key measures, key findings, and quality assessment. In addition, PRISMA-E and PROGRESS-Plus guided data extraction to illustrate health inequity.

DATA SYNTHESIS

Black women who were more likely to report having an STI over the course of their lifetime engaged in behaviors associated with greater risk, the most common of which were unprotected sex, disproportionate partner power, and substance abuse. The primary social determinants of health associated with increased risk were lower income and lower levels of education. Black women were less likely to discuss or feel comfortable discussing their sexual health with health care providers. By contrast, engagement in safe sexual practices stemmed from internal, social, and relationship factors.

CONCLUSION

Identifying Black women who are at risk of contracting an STI is essential in driving clinical decision-making. Health care providers should be cognizant of the long-standing mistrust that Black women have of health care providers and, therefore, work to establish positive respectful and trusting relationships with open communication.

Think Inside the Box: the Heterogeneity of "in Risk" Among "at Risk" Female African American Adolescents in North Carolina

INTRODUCTION

An abundance of research investigates the health of often referred to as "at risk" or "high risk" youth from underserved communities and usually racial/ethnic minorities. These ubiquitous terms relate to poverty, violence, and unsafe behaviors (e.g., sex without condoms, alcohol, and drug use).

METHODS

This analysis distinguished the heterogeneity of risks among African American female adolescents recruited for an intervention study from underserved communities in North Carolina. Eligibility included: ages 16-19, considered or dropped out of school, never completed high school, and during the past 3 months had sex with a male partner and used drugs or alcohol. A variable was created to represent the continuum of risk comprised of history of homelessness, or trading sex, or current heavy alcohol and marijuana use. Participants fell into 0, 1, or 2-3 categories. Ordinal logistic regression estimated the odds of adverse poor outcomes by category. Linear regression estimated reduction in material and emotional support by category.

RESULTS

Of the 237 participants, 59.5%, 27.8%, and 12.7% were in 0, 1, or 2-3 categories, respectively. Relative to adolescents in 0 categories, participants in other categories were more likely to report food insecurity (OR = 3.27, 95%CI [1.8, 5.94]); past arrest (OR = 3.56 [2.08, 6.09]); run away (OR = 3.30 [1.79, 6.10]); multiple sex partners (2.97 [1.61, 5.48]); and vaginal/anal sexual abuse (OR = 3.21[1.73, 5.96]). Material and emotional support was significantly lower for participants in 2-3 risk categories.

CONCLUSIONS

Vague use of "at risk" fails to recognize the heterogeneity of experiences and needs of underserved African American youth.

Integrating Individual and Contextual Factors to Explain Disparities in HIV/STI Among Heterosexual African American Youth: A Contemporary Literature Review and Social Ecological Model

Heterosexual African American youth face substantial disparities in sexual health consequences such as HIV and STI. Based on the social ecological framework, the current paper provides a comprehensive, narrative review of the past 14 years of literature examining HIV/STI risk, including risky sexual behavior, among heterosexual African American youth and a conceptual model of risk among this population. The review found that individual psychological and biological factors are insufficient to explain the sexual health disparities faced by this group; instead, structural disadvantage, interpersonal risk, and community dysfunction contribute to the disparity in HIV/STI outcomes directly and indirectly through individual psychological factors. The conceptual model presented suggests that for African American youth, (1) HIV/STI risk commonly begins at the structural level and trickles down to the community, social, and individual levels, (2) risk works in a positive feedback system such that downstream effects compound the influence of structural risks, and (3) contextual and individual risk factors must be considered within the advanced stage of the epidemic facing this population. Despite advanced HIV and STI epidemics among heterosexual African American youth, multisystemic interventions that target structural risk factors and their downstream effects are posited to reduce the disparity among this high-risk population.

Exploring Sexual Behaviour and Associated Factors among Adolescents in Saudi Arabia: A Call to End Ignorance

Little is known about sexual behaviour, attitudes, and associated factors among adolescents in Saudi Arabia. A cross-sectional study using a multistage sampling technique was conducted among 453 male adolescents selected from high schools in Riyadh, Saudi Arabia. About 54.1% of the adolescents practiced masturbation daily and 38% had experienced sexual contact, while 67% had friends who had experienced sexual contact. The majority of adolescents (72.2%) believed men engage in sexual experience before marriage, and only 11.5% discussed sexual health issues with their parents. Most adolescents believed in the effectiveness of sex education (92.3%) and the need for school-based sex education (85.6%). The logistic regression analyses showed adolescent sexual activity was independently associated with age [adjusted odds ratio (AOR) = 1.5, 95% confidence interval (CI): 1.3–1.8, p < 0.001), daily masturbation (AOR = 2.1, 95% CI: 1.3–3.2, p < 0.004), friends who engaged in sexual activity (AOR = 2.8, 95% CI: 1.4–4.6, p < 0.001), and belief that men experience sexual contact before marriage (AOR = 5.1, 95% CI: 2.8–9.3, p < 0.001). The findings indicated that male adolescents had negative attitudes toward sexual activity and were involved in risky sexual behaviour. To mitigate these issues, schools and community networks should be involved in the delivery of a culturally sensitive sexual health-promoting programme.

Racial Discrimination, Protective Processes, and Sexual Risk Behaviors Among Black Young Males

Racial discrimination is a documented risk factor for sexual risk behaviors among young Black men. Mechanisms of effect and protective processes remain to be investigated. This study examined the mediating effect of emotional distress, self-regulation, and substance use on the association between racial discrimination and sexual risk behaviors. Sexual risk behaviors included in this study were inconsistent condom use and sexual concurrency (sexual partnerships that overlap overtime). The protective effect of protective social ties was also investigated. A sample of 505 heterosexually active men aged 19-22 years were recruited and surveyed for 3 time points. Men answered questions on racial discrimination, sexual risk behaviors, emotional distress, self-regulation, and substance use. Mediation and moderation models were tested. Racial discrimination (T1) significantly and positively predicted emotional distress (T2). Emotional distress, substance use, and self-regulation partially mediated the association between racial discrimination and sexual risk behaviors. Protective social ties attenuated the effects of emotional distress on substance use and self-regulation. Racial discrimination is an important context for sexual risk behaviors. Minority stress may translate to sexual risk behavior through psychosocial mediators, such as emotional distress, self-regulation, and substance use. Protective social ties may buffer against emotional distress to reduce substance use and increase self-regulation. The findings of this study can provide new insights through the investigation of risk and protective processes that influence sexual risk behaviors among young Black men.

mHealth versus face-to-face: study protocol for a randomized trial to test a gender-focused intervention for young African American women at risk for HIV in North Carolina

Background

Disparities in the prevalence of HIV persist in the southern United States, and young African American women have a disproportionate burden of HIV as compared with young women of other racial/ethnic backgrounds. As a result, engaging young African American women in the HIV care continuum through HIV testing is imperative. This study is designed to reach this key population at risk for HIV. The study seeks to test the efficacy of two formats of a gender-focused, evidence-based, HIV-risk reduction intervention—the Young Women’s CoOp (YWC)—relative to HIV counseling and testing (HCT) among young African American women between the ages of 18 and 25 who use substances and have not recently been tested for HIV.

Methods

Using a seek-and-test framework, this three-arm cross-over randomized trial is being conducted in three county health departments in North Carolina. Each county is assigned to one of three study arms in each cycle: in-person (face-to-face) YWC, mobile Health (mHealth) YWC, or HCT. At study enrollment, participants complete a risk behavior survey via audio computer-assisted self-interview, and drug, alcohol, and pregnancy screening tests, and are then referred to HIV, gonorrhea, and chlamydia testing through their respective health departments. Participants in either of the YWC arms are asked to return approximately 1 week later to either begin the first of two in-person individual intervention sessions or to pick up the mHealth intervention preloaded on a tablet after a brief introduction to using the app. Participants in all arms are asked to return for a 6-month follow-up and 12-month follow-up, and repeat the survey and biological testing from baseline.

Discussion

The findings from this study will demonstrate which delivery format (mHealth or face-to-face) is efficacious in reducing substance use and sexual risk behaviors. If found to be efficacious, the intervention has potential for wider dissemination and reach.

Trial registration

ClinicalTrials.gov: NCT02965014. Registered November 16, 2016.

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.

Social determinants of adult sex ratios and racial/ethnic disparities in transmission of HIV and other sexually transmitted infections in the USA

In Black population centres in the USA, adult sex ratios (ASRs) are strongly female-biased primarily due to high male incarceration and early mortality rates. I explore the system of social determinants that shape these ASRs, and describe their apparent consequences. Evidence suggests that female-biased ASRs play a role, along with racial residential segregation, to increase mixing between core and peripheral members of sexual networks, facilitating transmission of human immunodeficiency virus and other sexually transmitted infections. Unique historical factors underlie Black male incarceration and mortality rates in the USA, making comparisons with other groups or other countries challenging.This article is part of the themed issue 'Adult sex ratios and reproductive decisions: a critical re-examination of sex differences in human and animal societies'.

Efficacy of the Young Women's CoOp: An HIV Risk-Reduction Intervention for Substance-Using African-American Female Adolescents in the South

HIV/sexually transmitted infection (STI) risk-reduction interventions are needed to address the complex risk behaviors among African-American female adolescents in disadvantaged communities in North Carolina. In a two-group randomized trial, we reached 237 sexually active, substance-using African-American female adolescents, to test a risk-reduction intervention, the Young Women's CoOp (YWC), relative to a nutrition control. In efficacy analyses adjusting for baseline condom use, at three-month follow-up participants in the YWC were significantly less likely to report sex without a condom at last sex relative to control. There were mixed findings for within-group differences over follow-up, underscoring the challenges for intervening with substance-using female youths.

Sexual risk, substance use, mental health, and trauma experiences of gang-involved homeless youth

This study examined the associations of sexual risk behaviors, substance use, mental health, and trauma with varying levels of gang involvement in a sample of Los Angeles-based homeless youths. Data were collected from 505 homeless youths who self-reported various health information and whether they have ever identified as or been closely affiliated with a gang member. Multivariable logistic regression assessed associations of lifetime gang involvement with risk taking behaviors and negative health outcomes. Results revealed seventeen percent of youths have ever identified as a gang member and 46% as gang affiliated. Both gang members and affiliates were at greater risk of many negative behaviors than non-gang involved youths. Gang members and affiliates were more likely to report recent methamphetamine use, cocaine use, chronic marijuana use, having sex while intoxicated, and symptoms of depression, symptoms of posttraumatic stress disorder. They were also more likely to have experienced childhood sexual abuse and witnessing family violence. Gang members were more likely to ever attempt suicide, experience recent partner violence, and report physical abuse during childhood. Results suggest that lifetime gang involvement is related to a trajectory of negative outcomes and amplified risk for youths experiencing homelessness. Additionally, being closely connected to a gang member appears to have just as much as an impact on risk as personally identifying as a gang member. Given the lack of knowledge regarding the intersection between youth homelessness and gang involvement, future research is needed to inform policies and programs that can address the specific needs of this population.

A Randomized Controlled Trial to Compare Computer-assisted Motivational Intervention with Didactic Educational Counseling to Reduce Unprotected Sex in Female Adolescents

STUDY OBJECTIVE

To examine a computer-assisted, counselor-guided motivational intervention (CAMI) aimed at reducing the risk of unprotected sexual intercourse. DESIGN, SETTING, PARTICIPANTS, INTERVENTIONS, AND MAIN OUTCOME MEASURES: We conducted a 9-month, longitudinal randomized controlled trial with a multisite recruitment strategy including clinic, university, and social referrals, and compared the CAMI with didactic educational counseling in 572 female adolescents with a mean age of 17 years (SD = 2.2 years; range = 13-21 years; 59% African American) who were at risk for pregnancy and sexually transmitted diseases. The primary outcome was the acceptability of the CAMI according to self-reported rating scales. The secondary outcome was the reduction of pregnancy and sexually transmitted disease risk using a 9-month, self-report timeline follow-back calendar of unprotected sex.

RESULTS

The CAMI was rated easy to use. Compared with the didactic educational counseling, there was a significant effect of the intervention which suggested that the CAMI helped reduce unprotected sex among participants who completed the study. However, because of the high attrition rate, the intent to treat analysis did not demonstrate a significant effect of the CAMI on reducing the rate of unprotected sex.

CONCLUSION

Among those who completed the intervention, the CAMI reduced unprotected sex among an at-risk, predominantly minority sample of female adolescents. Modification of the CAMI to address methodological issues that contributed to a high drop-out rate are needed to make the intervention more acceptable and feasible for use among sexually active predominantly minority, at-risk, female adolescents.

Gang membership and marijuana use among African American female adolescents in North Carolina

The southeastern US sustains the highest high school dropout rates, and gangs persist in underserved communities. African American female adolescents who drop out of school and are gang members are at substantial risk of exposure to severe violence, physical abuse, and sexual exploitation. In this study of 237 female African American adolescents 16-19 years of age from North Carolina who dropped out or considered dropping out, 11% were current or past gang members. Adolescents who reported gang membership began smoking marijuana at a mean age of 13, whereas those who reported no gang membership began at a mean age of 15 years (P<0.001). The mean ages of first alcohol use were 14 years and 15 years for gang members and non-gang members, respectively (P=0.04). Problem alcohol use was high in both groups: 40% and 65% for non-gang and gang members, respectively (P=0.02). Controlling for frequent marijuana use and problem alcohol use, adolescents who reported gang membership were more likely than non-gang members to experience sexual abuse (odds ratio [OR] =2.60, 95% confidence interval [CI] [1.06, 6.40]), experience physical abuse (OR =7.33, 95% CI [2.90, 18.5]), report emotional abuse from their main partner (OR =3.55, 95% CI [1.44, 8.72]), run away from home (OR =4.65, 95% CI [1.90, 11.4]), get arrested (OR =2.61, 95% CI [1.05, 6.47]), and report violence in their neighborhood including murder (OR =3.27, 95% CI [1.35, 7.96]) and fights with weapons (OR =3.06, 95% CI [1.15, 8.11]). Gang members were less likely to receive emotional support (OR =0.89, 95% CI [0.81, 0.97]). These findings reinforce the urgent need to reach young African American women in disadvantaged communities affiliated with gangs to address the complexity of context and interconnected risk behaviors.