Multilevel Barriers to Sexual Health Behavior Among Vulnerable Adolescent Girls in the USA

Introduction

Most sexual health interventions focus on individual-level predictors of sexual behavior. Given the considerable influence of environmental factors on adolescent girls' sexual health, current interventions may be insufficient to promote safer sex. In this study, we aimed to understand adolescent girls' anticipated barriers to engaging in safer sex behavior after completing a brief, web-based sexual health intervention called HEART.

Methods

This study used qualitative interviews with 50 adolescent girls who were recruited from community-based organizations that serve vulnerable youth. All participants were 12 to 19 years old (mean age=15.62, SD=1.83), and identified with a marginalized racial/ethnic group (58% Black; 18% Latinx; 24% Asian, biracial, or multiracial). Further, 24% identified as LGBTQ+, and 58% were sexually active.

Results

Guided by the social ecological model, we delineate six unique barriers to safer sex discussed by adolescents: partner manipulation, slut shaming, unclear sexual values, present time orientation, embarrassment, and access to sexual and reproductive health services.

Discussion

We conclude with recommendations for addressing these barriers to optimize adolescent girls' sexual health.

Sexual health practices of 16 to 19 year olds in New Zealand: an exploratory study

INTRODUCTION New Zealand sexual health surveillance data suggest that young people aged 15-19 years are at considerable risk of contracting sexually transmitted infections. Although there is an established body of international research around sexual behaviours and sexual health practices among teenagers, there is a dearth of local research focusing on this age group. AIM The aim of this study was to explore the sexual repertoires and sexual health practices among teenagers in New Zealand with a view to better understanding levels of risk in this age group. METHODS This study comprised a cross-sectional online survey designed to ask questions about sexual behaviours. A convenience sample of young people (n=52) aged 16-19 years living in New Zealand completed the survey. RESULTS Most participants (71.2%) were sexually active, reporting engagement in a range of sexual practices. The most commonly reported sexual behaviours were penis-in-vagina sex (86.5%) and oral sex with a person-with-a-penis (81.1%). Infrequent and inconsistent use of barrier protection across all types of sexual behaviour was also reported. DISCUSSION The findings of this study highlight the importance of ensuring that young people have access to sexual health education that routinely includes health information and advice addressing the full range of sexual practices, regardless of the identity classifications they may use, or that may be attributed to them.

ERPs Reveal Disengagement Processes Related to Condom Use Embarrassment in Intention-Behavior Inconsistent Young Adults

The use of barrier protections such as condoms has consistently been reported to reduce the acquisition of sexually transmitted infections. However, it has also been reported that the association between condom use intentions and behavior is, at best, often weak. Furthermore, embarrassment associated with purchasing condoms and negotiating their use has been shown to negatively impact the frequency of condom use. Using electroencephalography to analyze P300 event-related potential components known to measure early attention allocation, we examined electrophysiological evidence of early attention disengagement for embarrassing health information. Forty young adults-34 females and six males-participated in an adapted version of Posner's visual cueing paradigm. All were high in intention to use condoms, but half were intention-behavior consistent and half were intention-behavior inconsistent. Compared to intention-behavior consistent participants, those with intention-behavior inconsistency showed a reduced P300 component when attending to a visual target opposite to the field in which embarrassing self-relevant health information was presented, indicating more efficient early attention disengagement from such embarrassing health information. In conclusion, our electrophysiological data suggest that high intention alone may be not sufficient to predict adolescents' condom use behavior.

Dismantling the theory of planned behavior: evaluating the relative effectiveness of attempts to uniquely change attitudes, norms, and perceived behavioral control

The current study compares the effectiveness of interventions that attempted to uniquely influence hypothesized determinants of behavior in the Theory of Planned Behavior versus some optimal combination of constructs (three constructs vs. four) to increase condom use among intentions and behavior college students. 317 participants (M_age = 19.31; SD_age = 1.31; 53.3% female; 74.1% Caucasian) were randomly assigned to one of seven computer-based interventions. Interventions were designed using the Theory of Planned Behavior as the guiding theoretical framework. 196 (61.8%) completed behavioral follow-up assessments 3-month later. We found that the four construct intervention was marginally better at changing intentions (estimate = - .06, SE = .03, p = .06), but the single construct interventions were more strongly related to risky sexual behavior at follow-up (estimate = .04, SE = .02, p = .05). This study suggests that these constructs may work together synergistically to produce change (ClinicalTrials.gov Number NCT# 02855489).

Do Associations Between Pleasure Ratings and Condom Use During Penile-Vaginal Intercourse Vary by Relationship Type?: A Study of Canadian University Students

Research suggests the relationship between pleasure and condom use during penile-vaginal intercourse (PVI) is associated with relationship status. This online study examined pleasure ratings and condom use at last PVI, stratifying by partner type, among a national sample of Canadian university students. Participants were 715 undergraduates (60.7% women, 39.3% men) who reported on their most recent sexual experience. Condom use decreased with level of relationship commitment, whereas ratings of pleasure increased. Overall, participants were more likely to rate their most recent PVI as Very pleasurable when condoms were not used compared to when condoms were used. However, when stratified by partner type, these differences largely disappeared. For women, with one exception, there were no differences in pleasure between PVI with and without condoms across most partner-type categories. Women in committed dating relationships were more likely to report their last PVI as very pleasurable if condoms were not used than women in these same relationships who had used condoms. Across relationship categories, men who did and did not use condoms did not differ in terms of their pleasure ratings. The results of this study suggest relationship context should be taken into account when assessing condom use experiences.

Teen Perceptions of Sexual Activity: Influences, consequences, realities, and thoughts on safe sexual health practices

Teens' engagement in sexual activity and safe sexual practices is an important public health issue in the US today. This descriptive survey study explored teens' thoughts about the influences, consequences, and realities associated with teen sexual activity and pregnancy and their perceptions of access to sexual health education and contraception. Surveys were administered to 856 Delaware youth in 39 high school health classes from 16 schools. Of the 31 survey items, 25 offered significantly different responses; participants agreed with 16 and disagreed with 9 items (p < .005), revealing important findings concerning teen perceptions as the basis for meaningful interventions.

Risky Business: condom failures as experienced by female sex workers in Mombasa, Kenya

Limited research exists about condom failure as experienced by female sex workers. We conducted a qualitative study to examine how female sex workers in Mombasa, Kenya contextualise and explain the occurrence of condom failure. In-depth, semi-structured interviews were conducted with thirty female sex workers to ascertain their condom failure experiences. We qualitatively analysed interview transcripts to determine how the women mitigate risk and cope with condom failure. Condom failure was not uncommon, but women mitigated the risk by learning about correct use, and by supplying and applying condoms themselves. Many female sex workers felt that men intentionally rupture condoms. Few women were aware of or felt empowered to prevent HIV, STIs, and pregnancy after condom failure. Interventions to equip female sex workers with strategies for minimising the risk of HIV, STIs, and pregnancy in the aftermath of a condom failure should be investigated.

The Role of Condom Use Self-Efficacy on Intended and Actual Condom Use Among University Students in Ghana

Little attention has been paid to the dimensions that help to predict and understand condom use among university students within an African context. A cross-sectional study involving 518 university students in Accra, Ghana was conducted to determine how the Condom Use self-Efficacy Scale-Ghana (CUSES-G) can predict both actual condom use and future condom use. Of all the participants, 84% were sexually active but less than half of the sample (48%) reported to have used condom during their last sexual intercourse. A hierarchical regression analysis showed that components of the Condom Use Self-Efficacy Scale (CUESE-G) such as appropriation, assertiveness, pleasure and intoxication, and STDs predicted condom use and condom use intentions. Behavioural change campaigns targeting university students should encourage condom use self-efficacy, as this would strengthen condom use, which is economically cheap and practically effective means of preventing STIs including HIV.

Condom use: The discrepancy between practice and behavioral expectations

Aim: The overall aim of this paper is to examine sexually active young people’s behavioral expectations of condom use. Methods: We collected data at nine youth clinics and one sexually transmitted infections (STI) clinic in Sweden. We included participants whom had been sexually active during the past 12 months: A total of 1022 participants between the ages of 15 and 31 were included. We analyzed the data separately, for different types of sexual practices and types of sexual partners. Multinomial logistic regression was used to analyze age and gender differences for discrepancies. Results: The behavioral expectation of condom use differed, depending on the type of sexual practice and the type of partner. For all types of sex, the overall pattern showed that the participants were most likely to use a condom with a casual unknown partner, followed by a casual known partner, regular partner and lastly, a main partner. Our results also demonstrated that there is a discrepancy between the behavioral expectation of condom use and the self-reported condom use. The lowest discrepancy was for oral sex, especially with a main partner, and the largest discrepancy was for anal sex and vaginal sex with a casual partner. Conclusions: Our results imply that the participants had a greater expectation of condom use than actually occurs, especially for casual unknown partners. There is a lack of knowledge about the risks associated with oral sex, which is evident in the results of the participants’ behavioral expectations of condom use under those conditions.

Gender matters: condom use and nonuse among behaviorally bisexual men

Although frequently cited as being at high risk for HIV/STI transmission, little is known about behaviorally bisexual men's patterns and experiences of condom use and nonuse with male and female sexual partners. Using a variety of recruitment techniques informed by a Community Advisory Committee, a total of 77 behaviorally bisexual men were recruited from Indianapolis, Indiana to participate in semi-structured interviews focused on sexual health. Qualitative data were collected containing detailed information on their patterns and experiences of condom use and nonuse with both male and female partners. Participants described numerous commonly reported barriers for consistent condom use, as well as distinct bisexual-specific barriers. The majority reported consistent condom use with male and female casual partners, but many who did not use condoms described doing so in the context of ongoing relationships. In addition, participants provided reasons for condom use and nonuse that varied based on the gender of the partner and the type of relationship with the partner. Future interventions focused on increasing condom use among behaviorally bisexual men should take into account the unique complexities of gender and relationship configurations in this distinct population.

Reproductive health decision-making in perinatally HIV-infected adolescents and young adults

With widespread access to antiretroviral therapy in the United States, many perinatally HIV-infected (PHIV+) children are surviving into adolescence and adulthood, becoming sexually active and making decisions about their reproductive health. The literature focusing on the reproductive decisions of individuals behaviorally infected with HIV can serve as a springboard for understanding the decision-making process of PHIV+ youth. Yet, there are many differences that critically distinguish reproductive health and related decision-making of PHIV+ youth. Given the potential public health implications of their reproductive decisions, better understanding of factors influencing the decision-making process is needed to help inform the development of salient treatment and prevention interventions. To begin addressing this understudied area, a "think tank" session, comprised of clinicians, medical providers, and researchers with expertise in the area of adolescent HIV, was held in Bethesda, MD, on September 21, 2011. The focus was to explore what is known about factors that influence the reproductive decision-making of PHIV+ adolescents and young adults, determine what important data are needed in order to develop appropriate intervention for PHIV+ youth having children, and to recommend future directions for the field in terms of designing and carrying out collaborative studies. In this report, we summarize the findings from this meeting. The paper is organized around the key themes that emerged, including utilizing a developmental perspective to create an operational definition of reproductive decision-making, integration of psychosocial services with medical management, and how to design future research studies. Case examples are presented and model program components proposed.

Condom use motivations and selected behaviours with new versus established sex partners

Objective To compare condom use motives and behaviours in the context of penile–vaginal intercourse (PVI) with new versus established sexual partners, using daily event-level data among a clinic-recruited sample. Methods: Participants (ages 15–65 years old) were recruited from five sexually transmissible infection (STI) clinics in three United States cities. They were provided with personal digital assistants and instructed to respond to daily questionnaire items regarding PVI events from the past 24 h. Generalised estimations equations were used to make inferences on age-adjusted estimated odds ratios, comparing events occurring with established versus new partners. Results: For males, pregnancy prevention was a more common motivation for condom use in new relationships (P < 0.001). Males with new sex partners were more likely to report condom use (P < 0.005) and also reported fewer errors or problems in condom use with new sex partners (P < 0.001). For females, pregnancy prevention (P = 0.03), STI acquisition (P < 0.001) and STI transmission (P = 0.005) were more likely to be motives for condom use with new versus established partners. Also, females with new sex partners were more likely to report condom use (P < 0.001) as well as using multiple condoms during a single event (P = 0.03). Conclusion: Event-level findings suggest that condom use motivations and behaviours vary depending on whether PVI occurs between established versus new sex partners. Condom use is more likely for PVI with new partners, but other condom-associated behaviours and motivations differ between females and males.

Condom use by partner type among military and police personnel in Peru

The aim of this study was to analyze the rates of condom use among military and police populations in Peru, focusing on differences in use by type of partner. A Knowledge Attitudes and Practices survey was conducted among 6,808 military and police personnel in 18 Peruvian cities between August-September 2006 and September-October 2007. A total of 90.2% of the survey respondents were male; mean age was 37.8 years and 77.9% were married/cohabiting. In all, 99.5% reported having had sex; 89% of the participants had their last sexual contact with their stable partner, 9.7% with a nonstable partner, and 0.8% with a sex worker. Overall, 20.4% used a condom during their most recent sexual contact. Reasons for nonuse of condoms included the following: perception that a condom was not necessary (31.3%) and using another birth control method (26.7%). Prevention efforts against sexually transmitted diseases should focus on strengthening condom use, especially among individuals with nonstable partners.

Achieving Safety: Safer Sex, Communication, and Desire among Young Gay Men

Conceptualizations of safer sex practices among young gay men (YGM) are frequently structured around communication between partners and the subsequent utilization or absence of condoms in a sexual encounter. Drawing on a sample of 34 in-depth interviews with YGM, ages 18 to 24, we explore the ways in which conceptualizations and definitions of safer sex are discussed and enacted. Placing attention on their safer sex practices, we analyze the conversations that do and do not occur among YGM and their partners, including the strategies (e.g., negotiated safety, condom communication and negotiation) that are commonly perceived as most useful by YGM. We provide recommendations regarding how to craft safer sex messages for YGM by considering their competing demands.

Unwanted unprotected sex: condom coercion by male partners and self-silencing of condom negotiation among adolescent girls

This exploratory study used the theory of reasoned action and the theory of gender and power to guide elicitation of partner-related impediments to condom use among 64 adolescent girls living in poor urban areas with high rates of HIV and partner abuse. About 53% indicated that they had experienced unwanted, unprotected vaginal sex and 25% indicated that they were unable to discuss condom use with a partner. Novel qualitative findings related to condom coercion, condom sabotage, and self-silencing of condom negotiation are discussed in the context of connecting partner abuse to interpersonal control over condom use. Implications for intervention design are discussed.

Neighborhood disadvantage and changes in condom use among African American adolescents

Neighborhood context may influence youth sexual decision-making. We examined the association between neighborhood characteristics and condom use in a sample of African American youth followed across the high school years (N = 681; 51% female). Using a three-level hierarchical linear model, we modeled inconsistent condom use over time and then examined its association with youth's sexual risk trajectories (sexual intercourse frequency, number of partners, and pregnancy concerns) and individual-level characteristics (sex, age, SES, and household composition), and neighborhood disadvantage. While sexual intercourse frequency was associated with inconsistent condom use over time, youth reporting greater pregnancy concerns and number of partners reported more consistent condom use over time. Females were more likely to report more inconsistent condom use over time. Neighborhood disadvantage characteristics were associated with less baseline condom use, but did not have an association with changes in youth's condom use over the high school years. We discuss the implications for community-based HIV/AIDS prevention for youth.

Understanding high fertility desires and intentions among a sample of urban women living with HIV in the United States

To assess childbearing motivations, fertility desires and intentions, and their relationship with key factors, we conducted a cross-sectional survey among 181 HIV-infected women of reproductive age (15-44 years) receiving clinical care at two urban health clinics. Fertility desires (59%) and intentions (66% of those who desired a child) were high among this predominately African American sample of women, while the proportion with accurate knowledge of mother-to-child transmission (MTCT) was low (15%). Multivariate regression analyses identified factors significantly associated with the intention to have a child. Notably, age and parity did not remain significant in the adjusted model. The discrepancies between expressed desires and intentions for future childbearing, and the strong role of perceived partner desire for childbearing emphasize the need for universal reproductive counseling to help women living with HIV navigate their reproductive decisions and facilitate safe pregnancies and healthy children.

Recent and past intimate partner abuse and HIV risk among young women

OBJECTIVE

To examine the associations between past intimate partner abuse experienced during adolescence (verbal and physical), recent intimate partner abuse (verbal, physical, and sexual), and HIV risk (as indicated by lack of condom use) for sexually active young adult women in relationships with male partners.

DESIGN

Secondary data analysis of waves II and III of the National Longitudinal Study of Adolescent Health (Add Health).

SETTING

The Add Health Study is a longitudinal, in-home survey of a nationally representative sample of adolescents.

SAMPLE

Analyses involved 2,058 sexually active young adult women.

MAIN OUTCOME MEASURES

HIV risk was measured by consistent condom use over the past 12 months.

RESULTS

Physical and verbal abuse experienced in adolescence were associated with physical/verbal abuse experienced in young adulthood. Young, sexually active women experiencing no abuse in their relationships were more likely to consistently use condoms in the past 12 months than were their abused counterparts.

CONCLUSION

A causal pathway may exist between prior abuse, current abuse, and HIV risk.

A Qualitative Study of Southern Baptist Mothers' and Their Daughters' Attitudes Toward Sexuality

This qualitative study of 14 Southern Baptist mother-daughter dyads uses grounded theory to explore the attitudes these mothers and daughters hold toward sexuality, religiosity, and spirituality, in addition to how they communicate with each other about these topics. Themes that emerge from the data include abstinence before marriage, lack of interest in sexual behavior, peer influence, parental monitoring, extracurricular activities, the parent-child relationship, shame versus self-respect, and an orientation to the future. This research provides a description of the way in which Southern Baptist mothers and daughters communicate about spirituality and sexuality and reveals the effect this communication has on these adolescent girls. Implications for further research as well as the clinical implications of this study provide guidance for professionals in this area.