Adolescents' Perceived Ability to Say "No" to Unwanted Sex

Systematic review of digital interventions to support refusal self-efficacy in child and adolescent health promotion

Refusal self-efficacy protects against risky health behavior. Digital interventions have the potential to support self-efficacy due to the enactive experience provided by digital technologies. The aim of this systematic literature review was to evaluate the evidence of digital interventions to support refusal self-efficacy in child and adolescent health promotion. Following the Cochrane Collaboration guidelines, five electronic databases were searched from 2009 to 2020. The studies were assessed by two independent reviewers according to the eligibility criteria. Eligible studies were included in the review, assessed for risk of bias, synthesized narratively and assessed for evidence quality with the GRADE approach. Twenty-three studies, that examined 18 different interventions, were included in the review. The interventions included various digital elements as means to support the child and adolescent refusal self-efficacy (e.g. games, videos, feedback and activities for regulating feelings). The interventions improving refusal self-efficacy were more often used at home setting and addressed the four sources of self-efficacy with different digital elements regardless of intervention duration and intensity. Although the results on intervention effects varied and the evidence quality remained low, the overall evidence concerning these interventions was encouraging. Based on the subgroup analysis, the results were mainly encouraging among girls. When these interventions are implemented in health promotion, their benefits and weaknesses need to be considered comprehensively. The results provide information for designing and developing digital interventions to support child and adolescent refusal self-efficacy. Further research with larger sample sizes and more rigorous study designs is needed to strengthen the evidence of these interventions.

Assessing How Gender, Relationship Status, and Item Wording Influence Cues Used by College Students to Decline Different Sexual Behaviors

Researchers rarely examine college students' event-level refusals and how refusals may change based on sexual behavior, gender, or relationship status. As such, we assessed how sexual behavior and demographic characteristics influence cues students use to decline sexual activity. As an exploratory aim, we examined the influence of item wording (such as reading the words, not willing/non-consent vs. refusal) on how students reported declining sexual activity. A sample of 615 college students from Canada and the U.S. completed a survey; students were randomly assigned to one of two conditions that manipulated item wording (not willing/non-consent vs. refusal). Students were then prompted with four open-ended questions that asked how they refused/communicated non-consent for four sexual behaviors. An inductive coding procedure was used and five overarching themes emerged. Three themes included explicit and implicit verbal cues and two themes included explicit and implicit non-verbal cues. Wording condition (i.e., not willing/non-consent v. refusal) did not influence the types of cues reported by students. Refusal communication varied by sexual behavior and relationship status but not gender. Sexual assault prevention initiatives should include more information about the variety of refusal cues used by college students in their programming, as many of these cues are currently absent.

Depressive symptoms as a longitudinal predictor of sexual risk behaviors among African-American adolescents

OBJECTIVE

Understanding individual level factors associated with sexual risk behaviors among African-American adolescents remains an important public health priority. The current secondary data analysis examined the longitudinal association between a baseline assessment of depressive symptoms and sexual risk behaviors reported 6 months later; the purpose was to determine whether the association of depressive symptoms to risky sex varies as a function of gender. A secondary aim was to examine self-efficacy for sex refusal and condom use assessed at a 3-month follow-up as mediators of the depressive symptoms-sexual risk relationship.

METHODS

The sample consisted of 782 sexually active African-American adolescents (Mage = 15.3 years, SD = 1.08; 54% female) recruited to participate in a sexual health intervention trial. Data analyses focused on vaginal sex, and outcomes included: (a) sexual activity with 2 or more partners in the previous 3 months; (b) the relative frequency of condom use in the previous 3 months; (c) noncondom use at last occasion of sex; and (d) positive sexually transmitted infection (STI) screening.

RESULTS

Depressive symptoms predicted sex with 2 more partners for female participants, but no other risk markers for the sample as a whole. However, there was a significant indirect effect of depressive symptoms on condomless sex via decreased condom use self-efficacy for both male and female adolescents.

CONCLUSIONS

These findings have important implications for HIV/STI prevention, in which behavioral interventions may benefit from modules that include a focus on the influence of mood on self-efficacy for safer sex practices. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

African-American sexual minority adolescents and sexual health disparities: An exploratory cross-sectional study

PURPOSE

To better understand sexual health disparities among African-American sexual minority adolescents.

METHODS

African-American adolescents (N = 1120; mean age = 15.24 years) were recruited from 4 cities (Columbia, SC; Macon, GA; Providence, RI; Syracuse, NY) to a larger trial. The current analyses used data from the 18-month follow-up when adolescents reported on their sexual partnerships, condom use knowledge, self-efficacy and outcome expectancies for condom use, sexual risk behavior, and STI testing history.

RESULTS

Compared with heterosexual adolescents, sexual minority adolescents reported more concerns about potential relationship harms resulting from safer sex negotiation. Sexual minority adolescents were also more likely to engage in riskier sexual behaviors, with females reporting more sexual partners and drug use prior to sex, and males reporting inconsistent condom use and higher rates of HIV.

CONCLUSIONS

African-American sexual minority adolescents evidence disparities in sexual risk behavior and STI history that appear to result from interpersonal and relationship concerns. These concerns need to be targeted in sexual health interventions for sexual minority adolescents.

Beyond "Just Saying No": A Preliminary Evaluation of Strategies College Students Use to Refuse Sexual Activity

Preventing sexual assault is a core goal for universities as prevalence rates of sexual assault remain high, particularly among college students. A key mechanism thought to decrease rates of sexual assault is teaching college students how to give clear, explicit, verbal refusals. However, there is a paucity of research regarding how college students refuse sex. Thus, the purpose of this study was to understand different behavioral strategies college students would use to refuse sex. A sample of 773 heterosexual college students (523 women, 250 men) were recruited from two large southern universities in the USA to complete a survey on sexual communication. Thirty-eight items assessing verbal and behavioral cues that college students would use to refuse vaginal-penile sex were written based on previous, formative research. Items were assessed by the research team through an exploratory factor analyses, followed by a confirmatory factor analysis (CFA). The results yielded a three-factor structure: direct nonverbal refusals, direct verbal refusals, and indirect nonverbal refusals; CFA results suggested a good fit index for the model. Two independent sample t tests were conducted to examine differences in refusal cues across gender and relationship status; significant differences in refusals emerged for both. The three-factor structure depicting refusal cues was similar to previous work depicting cues college students use to communicate sexual consent; such information could inform sexual assault prevention programming.

Knowledge, attitudes, and practices regarding antiretroviral management, reproductive health, sexually transmitted infections, and sexual risk behavior among perinatally HIV-infected youth in Thailand

More than 30% of perinatally HIV-infected children in Thailand are 12 years and older. As these youth become sexually active, there is a risk that they will transmit HIV to their partners. Data on the knowledge, attitudes, and practices (KAP) of HIV-infected youth in Thailand are limited. Therefore, we assessed the KAP of perinatally HIV-infected youth and youth reporting sexual risk behaviors receiving care at two tertiary care hospitals in Bangkok, Thailand and living in an orphanage in Lopburi, Thailand. From October 2010 to July 2011, 197 HIV-infected youth completed an audio computer-assisted self-interview to assess their KAP regarding antiretroviral (ARV) management, reproductive health, sexual risk behaviors, and sexually transmitted infections (STIs). A majority of youth in this study correctly answered questions about HIV transmission and prevention and the importance of taking ARVs regularly. More than half of the youth in this study demonstrated a lack of family planning, reproductive health, and STI knowledge. Girls had more appropriate attitudes toward safe sex and risk behaviors than boys. Although only 5% of the youth reported that they had engaged in sexual intercourse, about a third reported sexual risk behaviors (e.g., having or kissing boy/girlfriend or consuming an alcoholic beverage). We found low condom use and other family planning practices, increasing the risk of HIV and/or STI transmission to sexual partners. Additional resources are needed to improve reproductive health knowledge and reduce risk behavior among HIV-infected youth in Thailand.

Information-enhancement and goal setting techniques for increasing adaptive motivation and decreasing urges to drink alcohol

OBJECTIVE

The aim of the study was to determine whether experimental manipulation of sense of control would change moderate drinkers' (N=106) task-specific motivational structure and explicit and implicit determinants of their urge to drink alcohol.

METHOD

The effects of various levels of information-enhancement and goal-setting on participants' performance on experimental tasks were assessed. Participants were randomly assigned to a high-sense-of-control, low-sense-of-control, or no-intervention group. Dependent measures were indices derived from a task-specific version of the Personal Concerns Inventory and the Shapiro Control Inventory, Alcohol Urge Questionnaire, and alcohol Stroop test.

RESULTS

At baseline, there were no differences among the groups on any of the measures; however, post-experimentally, induced sense of control had led to increases in adaptive motivation and decreases in explicit and implicit measures of the urge to drink.

CONCLUSIONS

The results show that sense of control can be experimentally induced. This finding has important clinical implications.

Impact of Abuse History on Adolescent African-American Women's Current HIV/STD-associated Behaviors and Psychosocial Mediators of HIV/STD Risk

This study examined if relationship power, sex refusal self-efficacy, and/or fear of condom negotiation mediated the relationship between abuse history and consistent condom use (CCU) among African-American female adolescents (n=593). Participants with an abuse history (58%) were less likely to report CCU (p=.003). Women with an abuse history reported less relationship power (p=.006) and self-efficacy for refusing sex (p<.001), and more fear of condom negotiation (p=.003), none of which independently or jointly mediated the association between abuse and CCU. Notably, history of abuse was associated with CCU across mediator models (p=.037 to p=.067), despite inclusion of psychosocial mediators. This study demonstrates the importance of understanding adolescents' condom use behaviors within the context of their life experiences, especially past abuse history.

Predicting discordance between self-reports of sexual behavior and incident sexually transmitted infections with African American female adolescents: results from a 4-city study

This study examined correlates of the discordance between sexual behavior self-reports and Incident Sexually Transmitted Infections. African American adolescent females (N = 964) from four U.S. cities were recruited for an HIV/STI prevention trial. Self-reported sexual behaviors, demographics, and hypothesized psychosocial antecedents of sexual risk behavior were collected at baseline, 6-, 12-, and 18-month follow-up assessments. Urine specimens were collected and tested for three prevalent STIs (chlamydia, gonorrhea, trichomonas) at each assessment. Seventeen percent of participants with a laboratory-confirmed STI reported either lifetime abstinence or recent abstinence from vaginal sex (discordant self-report). Lower STI knowledge, belief that fewer peers were engaging in sex, and belief that more peers will wait until marriage to have sex were associated with discordant reports. Discordance between self-reported abstinence and incident STIs was marked among African American female adolescents. Lack of STI knowledge and sexual behavior peer norms may result in underreporting of sexual behaviors.

Sexually transmitted infections, sexual risk behavior, and intimate partner violence among African American adolescent females with a male sex partner recently released from incarceration

PURPOSE

Social networks directly and indirectly influence sexually transmitted infections (STIs) risk. The objective was to explore associations between sex with a male recently released from incarceration and sexual risk and intimate partner violence (IPV) among African American adolescent females.

METHODS

Sociodemographic, psychosocial, and sexual behavior data were collected at baseline, 6, and 12 months from African American females, aged 15-21 years, participating in an HIV/STI prevention trial. Among 653 participants with ≥1 follow-up assessments, generalized estimating equations tested associations during follow-up between having a recently released partner and STI acquisition, sexual risk behaviors, and IPV, adjusting for age, treatment assignment, and corresponding baseline measure.

RESULTS

Eighty-three (13.6%) participants had a recently released partner at 6 months and 56 (9.3%) at 12 months. Participants with a recently released partner were more likely to have the following: vaginal (adjusted odds ratio [AOR]: 5.48), anal (AOR: 2.43), and oral (AOR: 1.51) sex, a casual partner (AOR: 1.66), sex while high/drunk (AOR: 1.57) or with a high/drunk partner (AOR: 2.27); use condoms inconsistently (AOR: .58); acquire Chlamydia (AOR: 1.80), and experience emotional (AOR: 4.09), physical (AOR: 2.59), or sexual abuse (AOR: 4.10) by a boyfriend. They had a greater number of sex partners, lower partner communication and refusal self-efficacy, were high/drunk during sex more frequently, and used condoms during oral sex less frequently.

CONCLUSIONS

A recently released sex partner is associated with sexual risk and IPV among African American adolescent females. Prevention programs should inform adolescents about potential risks associated with recently released partners as well as provide adolescents with skills to establish and maintain healthy sexual relationships.

Exploring Factors Associated with Nonchange in Condom Use Behavior following Participation in an STI/HIV Prevention Intervention for African-American Adolescent Females

To enhance future STI/HIV prevention efforts, this study examined factors associated with adolescents' failure to improve their condom use behaviors after participating in an STI/HIV prevention intervention. African-American adolescent females (N = 205; M age = 17.9) in an STI/HIV prevention intervention trial completed ACASI interviews and provided self-collected vaginal swabs to assess two prevalent STIs at baseline and 6 months after intervention. Analyses compared those who increased condom use after intervention (change group) to those whose condom use did not increase (nonchange group). 43.4% did not increase their condom use after the intervention and were more likely to have an STI at followup (χ² = 4.64, P = .03). In a multivariate logistic regression model, the nonchange group was more likely to have (a) higher sensation seeking (AOR = .91, P = .023), (b) a boyfriend (AOR = .32, P = .046), and/or (c) a physical abuse history (AOR = .56, P = .057). There were also differences in the extent to which psychosocial mediators changed between the two groups. Findings highlight the need to tailor STI/HIV interventions to adolescents with a greater degree of sensation seeking and address key relationship characteristics and trauma histories to bolster intervention efficacy.

Characteristics of African American adolescent females who perceive their current boyfriends have concurrent sexual partners

PURPOSE

Perceived partner concurrency, reporting that a current sexual partner has other sexual partners, may pose sexual health risks to adolescents. We examined the contextual characteristics of African American female adolescents who reported their current boyfriend was having concurrent sexual relationships.

METHODS

Participants were African American adolescent females (N = 511; mean age = 17.6) recruited from sexual health clinics. Before participating in an STD/HIV prevention trial, the participants completed audio computer-assisted self-interviews with measures of perceived partner concurrency and individual- (e.g., depression, substance use), interpersonal- (e.g., social support, interpersonal stress), and community-level factors (i.e., neighborhood quality).

RESULTS

Twenty-seven percent of participants reported their belief that their current boyfriend had concurrent sexual partners during their relationship. In a logistic regression analysis, participants endorsing perceived partner concurrency reported less relational power (adjusted odds ratio [AOR] = .94, 95% confidence interval [CI] = .89-.98, p < .01), decreased relationship commitment (AOR = .88, 95% CI = .80-.96, p < .01), elevated perceived interpersonal stress (AOR = 1.02, 95% CI = 1.003-1.04, p < .05), and previous STD diagnoses (AOR = 2.07, 95% CI = 1.31-3.28, p < .01; overall model: χ(2) = 67.25; p < .001).

CONCLUSIONS

Results suggest that the efficacy of sexual risk reduction interventions may be improved by emphasizing the increased HIV/STD risks associated with having a boyfriend with concurrent sex partners. In addition, interventions may benefit from incorporating stress management training and addressing key relationship dynamics, particularly among adolescents with a history of STDs.

The relationship of character strengths to sexual behaviors and related risks among African American adolescents

BACKGROUND

Relatively few studies have examined positive character traits that are associated with lower HIV/STD risks.

PURPOSE

In the present study, the relationships of character strengths with sexual behaviors and attitudes were assessed among 383 African-American adolescents.

METHOD

Character strengths were measured using the Values in Action Inventory of Strengths. Because the strengths were highly inter-correlated, stepwise discriminant function analyses were utilized to assess their independent associations with sexual behaviors and attitudes.

RESULTS

Greater Love of Learning was related to self-reported abstinence from sexual intercourse for boys and self-reported abstinence from drug use for boys and girls. Greater Love of Learning and Curiosity were related to the belief in no premarital sex for boys, whereas only Curiosity was significant for girls. Prudence was related to reported abstinence from sexual intimacy (e.g., touching or kissing). Judgment was related to sexual initiation efficacy for girls and boys, whereas Leadership was only significant for girls.

CONCLUSIONS

The findings suggest that character strengths may be associated with lower levels of sexual behaviors and sex-related beliefs among a sample of African-American adolescents.

Test-retest reliability of self-reported HIV/STD-related measures among African-American adolescents in four U.S. cities

PURPOSE

To evaluate the test-retest reliability of self-reported sexuality-related data in a sample of African American adolescents residing in four U.S. cities.

METHODS

Using audio computer-assisted self-interviewing (ACASI), 156 African American teens (mean age = 15.5 years) provided data on lifetime and recent sexual behavior, HIV/sexually transmitted disease (STD) testing, and theoretical antecedents of sexual risk behavior on two occasions separated by 2 weeks.

RESULTS

Most self-reports of lifetime sexual behavior and STD/HIV testing were stable across the two assessment points. Test-retest agreement was substantial for dichotomous indices of lifetime sexual behaviors and STD testing (kappas ranging from .61-.87), and for 3-month recall of vaginal sex (kappa = .72) and number of sexual partners (intraclass correlation coefficient [ICC] = .68). Lower reliability estimates emerged for count data of unprotected vaginal sex occasions (ICC = .44). Test-retest reliability estimates for antecedents of sexual risk behavior were highest for a validated measure of HIV-related knowledge (r = .73), but somewhat lower for peer norms (r = .58) and condom use self-efficacy (r = .50).

CONCLUSIONS

Although variability in the stability of self-report data was observed, findings confirm that most sexual behavior, STD and HIV testing history, and psychosocial measures can be assessed reliably among adolescents. Research should continue to identify strategies to enhance the reliability of self-report sexual behavior data from youth at risk for HIV and other sexually transmitted infections.

Peer influence on risk taking, risk preference, and risky decision making in adolescence and adulthood: an experimental study

In this study, 306 individuals in 3 age groups--adolescents (13-16), youths (18-22), and adults (24 and older)--completed 2 questionnaire measures assessing risk preference and risky decision making, and 1 behavioral task measuring risk taking. Participants in each age group were randomly assigned to complete the measures either alone or with 2 same-aged peers. Analyses indicated that (a) risk taking and risky decision making decreased with age; (b) participants took more risks, focused more on the benefits than the costs of risky behavior, and made riskier decisions when in peer groups than alone; and (c) peer effects on risk taking and risky decision making were stronger among adolescents and youths than adults. These findings support the idea that adolescents are more inclined toward risky behavior and risky decision making than are adults and that peer influence plays an important role in explaining risky behavior during adolescence.

Risk and protective factors for sexual risk taking among adolescents involved in Prime Time

This article describes a preliminary qualitative evaluation of risk and protective factors associated with consistent contraceptive use and healthy sexual decision-making among ten of the first participants in the Prime Time intervention study. Prime Time is an 18-month intervention including one-on-one case management and peer educator training targeting sexually active 13-17-year-old girls who are recruited from health care clinics. Using an approach grounded in findings from previous research, social cognitive theory, and the social development model, Prime Time aims to improve participants' contraceptive use consistency, reduce number of sexual partners, and reduce unwanted sexual activity. Findings from this preliminary evaluation alert health care providers to the complex and dynamic nature of adolescent girls' sexual behaviors and to a broad range of risk and protective factors within individuals and their environments that may influence adolescent girls' sexual behaviors and contraceptive use. Findings suggest that an ongoing, supportive relationship with a case manager who is able to pace and tailor an intervention to the individual young person can have positive effects on adolescent girls' sexual behaviors and contraceptive use.

Coital debut: the role of religiosity and sex attitudes in the Add Health Survey

Recent reviews suggest that religiosity is associated with the delay of adolescent coital debut (Rostosky, Wilcox, Wright, Randall, in press; Wilcox, Rostosky, Randall, Wright, 2001). Few studies, however, have examined this association using longitudinal data to test theoretically driven models. We analyzed data from 3,691 adolescents (ages 15-21), testing the hypothesis that adolescent religiosity and sex attitudes (at Wave 1) predict later coital debut (at Wave 2) and that these predictive relationships vary by gender. Findings indicated that beyond demographic factors and number of romantic partners, religiosity reduced the likelihood of coital debut for both males and females. After accounting for the effects of religiosity, anticipation of negative emotions after coital debut (sex attitude factor 1) further reduced its likelihood for females and males. Finally, adolescent girls - but not boys - who anticipated positive emotions following sexual intercourse (sex attitude factor 2) were more likely to debut. While virginity pledge status was associated with coital debut for boys and girls, more conservative beliefs about sex appeared to mediate its effect. Finally, a significant interaction between race and religiosity indicated that African American adolescent males who had either signed a virginity pledge or were more religious were significantly more likely to debut than both White non-Hispanic males and African American males who were less religious and/or who had not signed a pledge. The implications of these results for adolescent pregnancy prevention programming are discussed.

Adolescent development in social and community context: a program of research

Search Institute's integrated program of research on the linkages among community, developmental assets, and health outcomes is discussed. Recommendations are made for building a science that is dedicated to exploring pathways to developmental success.

Reliability and validity of a self-efficacy instrument specific to sickle cell disease

The psychometric properties of a new, 9-item scale measuring disease-specific perceptions of self-efficacy were investigated in a community-based sample of adults (N = 83) with sickle cell disease (SCD). The Sickle Cell Self-Efficacy Scale (SCSES) was comprised of nine questions relating to participants' perceptions of their ability to function on a day-to-day basis and to manage SCD symptomatology (e.g. episodes of pain). The SCSES demonstrated good internal consistency, discriminant validity, and convergent and predictive validity, both with previously validated measures of related constructs as well as with reported SCD symptomatology. Overall, the instrument appears to be reliable and valid for assessing clients' self-efficacy for engaging successfully in day-to-day activities despite having SCD. Future investigators may wish to examine temporal and causal links between alterations in self-efficacy and changes in adjustment to sickle cell disease; the SCSES provides a psychometrically sound tool with which to investigate these phenomena.

Cultural, contextual, and intrapersonal predictors of risky sexual attitudes among urban African American girls in early adolescence

The role of cultural factors in explaining sexual attitudes among African American urban girls, aged 10-13 years, was investigated in this study. The authors predicted that girls with higher school interest, family cohesion, religiosity, and behavioral self-esteem would endorse less risky sexual attitudes. Also, older girls were expected to have more risky sexual attitudes than younger girls, and girls from 1- rather than 2-parent households were expected to have more risky sexual attitudes. The authors hypothesized that ethnic identity and gender role orientations would contribute to explaining variability in sexual attitudes after controlling for contextual and intrapersonal variables. A questionnaire containing measures of the study constructs was administered to 214 girls who were participants in a substance abuse prevention program. Pretest data were used in analyses. A final regression model accounted for 23% of the variance in sexual attitudes. Age and behavioral self-esteem were significant predictors, with younger teens and teens with higher behavioral self-esteem having less risky sexual attitudes. Cultural variables contributed to explaining variation in sexual attitudes after other variables were controlled for. Higher levels of ethnic identity were associated with less risky sexual attitudes. A masculine gender role orientation was associated with more risky sexual attitudes.

Reliability and validity of a self-efficacy instrument for protective sexual behaviors

The authors investigated the psychometric properties of a 22-item scale that measured respondents' perceptions of their ability to refuse sexual intercourse, question potential sexual partners, and use condoms. Two hundred twenty-one male and female undergraduates completed an anonymous questionnaire that measured a wide range of constructs. The scale exhibited good internal consistency, and convergent validity was demonstrated for 5 sexual behavior items (number of sexual partners ever and in the past 3 months, condom use in past 3 months, at last intercourse, and in the future). The instrument appeared to be free of social desirability bias and was reliable and valid for assessing college students' self-efficacy for protective sexual behaviors. College healthcare professionals could administer the instrument to help students determine their levels of self-efficacy for engaging in self-protective behaviors and identify domains in which they may need to improve their skills to reduce their risks of acquiring a sexually transmitted disease or having or causing an unplanned pregnancy.