Background: Socioeconomic status is often used to explain race differences in sexually transmitted diseases (STDs), yet the independent association of socioeconomic status and STDs among adolescents has been understudied.
Objective: To examine the associations between socioeconomic status and self-reported gonorrhea among black female adolescents, after controlling for sexual risk behaviors.
Methods: Interviews and surveys were completed by 522 sexually active black adolescent females residing in low-income urban neighborhoods.
Results: Adolescents whose parents were unemployed were more than twice as likely to report a history of gonorrhea, compared with those with employed parents. Adolescents living with two parents were less likely to report a history of gonorrhea.
Conclusions: The results of this study indicate that gonorrhea is associated with low socioeconomic status among black adolescent females regardless of the level of sexual risk behaviors. Lower socioeconomic status may be an marker for risky sociosexual environments.
From the *Department of Behavioral Sciences and Health Education, Rollins School of Public Health; the Departments of †Pediatrics and ‡Medicine, Division of Infectious Diseases, Emory University School of Medicine; the §Emory/Atlanta Center for AIDS Research; the ∥Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia; the ¶Department of Health Behavior, School of Public Health; and the Departments of #Medicine, Division of Infectious Diseases, and **Pediatrics, University of Alabama, Birmingham, Alabama
Supported by grant 1R01 MH54412 from the Center for Mental Health Research on AIDS, National Institute of Mental Health (to Dr. DiClemente). Drs. Sionéan and Crosby were supported under a cooperative agreement from the Centers for Disease Control and Prevention through the Association of Teachers of Preventive Medicine.
Reprint requests: Catlainn Sionéan, PhD, Department of Behavioral Sciences and Health Education, Rollins School of Public Health at Emory University, 1518 Clifton Road NE, Room 520, Atlanta, GA 30322. E-mail: firstname.lastname@example.org
Received for publication May 25, 2000, revised August 15, 2000, and accepted August 17, 2000.
A study of sexually active black adolescent females found that parental unemployment and non–two-parent household structure were associated with a self-reported history of gonorrhea.
ALTHOUGH OVERALL RATES OF GONORRHEA have decreased in the past decade, such declines were not observed in black populations, particularly among adolescent females and residents of the southern United States. 1–4 The persistent association of race and patterns of sexually transmitted diseases (STDs) has been the topic of frequent debate. 5–6 However, the relevance of race or ethnicity for patterns of STDs, including gonorrhea, is best understood in conjunction with socioeconomic status (SES) and other sociodemographic characteristics associated with sexual behaviors and STD risk. 7
As with other STDs, the risk for gonorrhea results from a complex interplay of physiologic (e.g., cervical ectopy), personal (e.g., sexual behaviors), and socioenvironmental (e.g., prevalence) factors. 4,8 Recent research has shown the importance of SES of individuals and their environments for health-related behaviors and outcomes. 9–11 Socioeconomic status may be associated with increased prevalence of gonorrhea because of higher rates of risk behaviors among individuals of lower SES. Among adolescents, lower SES has been shown to be associated with inconsistent condom use 12 and higher rates of other sexual risk behaviors, due in part to less parental involvement. 13–15 Alternatively, lower individual SES may be an indicator of residence in poorer neighborhoods, and hence, higher prevalence of gonorrhea within one’s pool of potential sexual partners. 16,17 Gonorrhea has been shown to cluster in poor and disorganized neighborhoods. 18–23 Two-parent families are less likely to live in poverty 24 and are more likely to live in more affluent neighborhoods 25,26; thus, adolescents in lower SES families may be more likely to have had gonorrhea due to residence in higher prevalence neighborhoods.
To date, few studies have examined associations between indicators of SES and self-reported STDs among adolescents. Results of two studies using national samples of adolescents are inconsistent. Goodman 27 reported no association between SES and self-reported STDs among a nationally representative sample of adolescents. However, Ellen and colleagues 28 found that at least one measure of SES, parental education, was associated with self-reported STDs among black adolescents. However, those studies examined adolescents’ reported history of any STD. The purpose of this study was to examine the associations between indicators of socioeconomic status and self-reported history of gonorrhea among a high-risk sample of black female adolescents, after controlling for sexual risk behaviors.
Between December 1996 and April 1999, 1,130 female adolescents in school health classes, adolescent medicine clinics, and health department clinics were screened for eligibility for participation in a randomized, controlled trial of a community-based, social skills STD and HIV prevention intervention. Recruitment sites were located in urban neighborhoods characterized by high rates of unemployment, substance use, violence, and STDs. To be eligible, adolescents needed to be black, between 14 and 18 years, sexually active in the previous 6 months, and provide written consent. The recruitment and study protocols were approved by the Institutional Review Board Committee on Human Research.
Data were collected by a self-administered survey and a structured interview. All adolescents completed confidential self-administered surveys in a group setting. Trained research associates monitored the administration and provided assistance to participants with limited literacy. Each adolescent then completed an individually conducted structured interview in a private room by a trained black female interviewer.
The survey assessed sociodemographic variables, including household receipt of Temporary Assistance to Needy Families (TANF), employment status of the responsible adult, family structure, and parental monitoring. Adolescents reported the employment status and number of hours worked for the adult in the household who was responsible for monitoring the adolescent’s activities; typically, this was their mother. Employment status was categorized as unemployed or employed. Family structure was assessed with a single item, “Who do you usually live with?” Adolescents reporting they lived with both their mother and father were categorized as living in two-parent families. All other adolescents were categorized as living in single-parent families. A recent study indicates that these measures have both criterion and construct validity. 29
History of gonorrhea, the outcome variable used in the current study, was assessed by asking adolescents if they had ever been told by a doctor or nurse that they had gonorrhea. The interview also assessed sexual risk factors including consistency of condom use, frequency of sexual intercourse, having multiple sex partners during the previous 6 months, perceiving that their sex male partner has had other sex partners during the previous 6 months (a risky partner), and age of typical sex partners.
Statistical analyses were conducted in several sequential steps. First, we conducted separate analyses comparing self-reported history of gonorrhea between those reporting and not reporting household receipt of TANF. We repeated these analyses for parental employment status and family structure. Prevalence ratios and corresponding 95% confidence intervals were used to assess direction, strength, and statistical significance of associations. Second, to identify potential covariates, we examined associations between each indicator of SES and the sexual risk factors and parental monitoring. Covariates associated with any of the indicators of SES (P < 0.10) were included in three separate logistic regression analyses, examining the independent association between each indicator of SES and self-reported gonorrhea. 30
Of those screened, 609 adolescents were eligible to participate in the study. Of those adolescents not eligible to participate (n = 521), the majority (98%) were not sexually active. The current study consists of 522 (85.7%) eligible adolescents who were enrolled and completed baseline assessments. The majority of eligible teens who did not participate in the study were unavailable because of conflicts with their employment schedules.
Adolescents were 14 to 18 years, with a mean of 16.0 years (SD, 1.2 years). Approximately one fifth (18.4%) of the adolescents reported living in a household with someone receiving TANF. Forty-two percent reported that their parent was unemployed, and 22% reported living with two parents. Eight percent of the sample reported ever being diagnosed with gonorrhea.
In the bivariate analyses, two of the indicators of socioeconomic status (parental employment status, family structure), were associated with a history of gonorrhea (Table 1). In addition, consistency of condom use, frequency of unprotected intercourse, having a risky partner, and higher parental monitoring were identified as covariates.
In the logistic regression analyses, controlling for the observed covariates, adult employment status and family structure each were associated with self-reported history of gonorrhea. Adolescents whose parents were unemployed were more than twice as likely to report a history of gonorrhea, compared with those residing with employed parents. Adolescents living with two parents were less likely to report a history of gonorrhea (Table 1).
The results of this study indicate that self-reported history of gonorrhea is associated with low socioeconomic status among high-risk black adolescent females. Specifically, parental unemployment and single-parent family structure were associated with increased risk for gonorrhea. These associations persisted after controlling for the potential confounding effects of parental monitoring, adolescents’ sexual risk behaviors, and having a risky sex partner.
Our findings extend those of previous studies of socioeconomic status and self-reported STDs among adolescents. An association between SES and adolescents’ self-reported STD has not been found consistently in previous studies 27,28,31 and may depend on the characteristics of the sample or the specific STD examined. In high-prevalence populations, individuals’ sexual risk behaviors may be less important influences on their risk of infection than the characteristics of their sexual partners. 16,32,33 Thus, rather than an indicator of high-risk behavior, low SES may be a marker for involvement in high-risk sexual networks, and a subsequent greater likelihood of exposure to an infected partner.
Sexual networks may be associated with the SES of individuals, communities, or both. In our study, indicators of adolescents’ low SES were associated with having a sexual partner who had other partners and with a history of gonorrhea. However, having a risky partner did not account for the association between SES and gonorrhea.
Individuals and their sexual networks exist within larger communities. Adolescents in non–two-parent families and those with unemployed parents are more likely to live in poorer and more disorganized neighborhoods. 24–26 Lack of screening and treatment services, commercial sex, and high rates of substance use may increase and maintain disease prevalence in disadvantaged communities. 7,8,19 Because persons tend to have sexual partners who live in close proximity, 23 those living in disadvantaged communities may be at greater risk for gonorrhea because of a higher prevalence in their “pool” of potential sexual partners. 18–20
Community-level SES may affect the risk of gonorrhea for all members of a particular community; alternatively, it may interact with individual SES to create a “double jeopardy” of risk for poorer individuals in poorer communities. Further research is needed to disentangle the effects of community and individual SES on individuals’ risk for gonorrhea and other STDs.
This study has several limitations. First, the study used relatively gross measures of SES. Many studies focusing on SES have used measures that assess parental education and occupation; however, such measures may be less appropriate for predominantly lower SES families. 34 Second, the use of self-reported data may have underestimated the extent of gonorrhea in this population if some adolescents had undiagnosed infections or were underreporting their infections. However, the use of self-reported history of gonorrhea provided more complete estimates of gonorrhea prevalence in this population because biologically confirmed cases would include only those cases not yet treated. Moreover, recent studies have reported substantial agreement between medical chart reviews and adolescents’ self-reports of any STD, 35 particularly gonorrhea. 36 Finally, the adolescents in this study were all black females from relatively disadvantaged backgrounds; their behaviors and STD history may not be representative of the general adolescent female population. Nevertheless, this population is important to study because its adolescents are at increased risk for STDs relative to adolescents in the general population.
The results of this study are consistent with a growing body of literature regarding the importance of sociosexual environmental factors for STDs, particularly gonorrhea. 7,17,19,23 In addition, the results of this study support the Institute of Medicine Report recommendation that multilevel interventions be designed and implemented to reduce the prevalence and incidence of STDs among adolescents. 2 The challenge of STD prevention lies in the integration of individual- and group-level theories of sexual health and risk behavior, and the development and implementation of methods of investigating risk within a multilevel, multicausal framework.
1. Division of STD Prevention. Sexually Transmitted Disease Surveillance, 1998. Department of Health and Human Services. Atlanta: Centers for Disease Control and Prevention. September 1999.
2. Eng T, Butler W. The Hidden Epidemic: Confronting Sexually Transmitted Diseases. Washington, DC: National Academy Press, 1997.
3. Fox KK, Whittington WL, Levine WC, Moran JS, Zaidi AA, Nakashima AK. Gonorrhea in the United States, 1981–1996: demographic and geographic trends. Sex Transm Dis 1998; 25: 386–393.
4. Wasserheit JN. Effect of changes in human ecology and behavior on patterns of sexually transmitted diseases, including human immunodeficiency virus infection. Proc Natl Acad Sci U S A 1994; 91: 2430–2435.
5. Fullilove RE. Race and sexually transmitted diseases. Sex Transm Dis 1998; 25: 130–131.
6. Zenilman JM. Gonorrhea, chlamydia and the sexual network: Pushing the envelope. Sex Transm Dis. 2000; 27: 224–225.
7. Aral SO, Wasserheit JN. Interactions among HIV, other sexually transmitted diseases, socioeconomic status, and poverty in women. In: O’Leary A, Jemmott LS, eds. Women at Risk: Issues in the Primary Prevention of AIDS. New York: Plenum Press, 1995: 13–41.
8. Wasserheit JN, Aral SO. The dynamic topology of sexually transmitted disease epidemics: implications for prevention strategies. J Infect Dis 1996; 174: S201–S213.
9. Diez-Roux AV, Nieto FJ, Muntaner C, Tyroler HA, Comstock GW, et al. Neighborhood environments and coronary heart disease: a multilevel analysis. Am J Epidemiol 1997; 146: 48–63.
10. O’Campo P, Xue X, Wang M-C, Caughy MOB. Neighborhood risk factors for low birthweight in Baltimore: a multilevel analysis. Am J Public Health 1997; 87: 1113–1118.
11. Robert SA. Neighborhood socioeconomic context and adult health. The mediating role of individual health behaviors and psychosocial factors. Ann N Y Acad Sci 1999; 896: 465–468.
12. Sionéan C, Zimmerman RS. Moderating and mediating effects of socioeconomic status, perceived peer condom use, and condom negotiation on sexual risk behavior among African-American and white adolescent females. Ann N Y Acad Sci 1999; 896: 474–476.
13. Hogan DP, Astone NM, Kitagawa EM. Social and environmental factors influencing the contraceptive use among black adolescents. Fam Plann Perspect 1985; 17: 165–169.
14. Hogan DP, Kitagawa EM. The impact of social status, family structure and neighborhood on the fertility of Black adolescents. Am J Sociol 1985; 90: 825–855.
15. Ramirez-Valles J, Zimmerman MA, Newcomb MD. Sexual risk behavior among youth: modeling the influence of prosocial activities and socioeconomic factors. J Health Soc Behav 1998; 39: 237–253.
16. Aral SO, Hughes JP, Stoner B, et al. Sexual mixing patterns in the spread of gonococcal and chlamydial infections. Am J Pub Health 1999; 89: 825–833.
17. Stoner BP, Whittington WL, Hughes JP Aral SO, Holmes KK. Comparative epidemiology of heterosexual gonococcal and chlamydial networks: implications for transmission patterns. Sex Transm Dis 2000; 27: 215–223.
18. Becker KM, Glass GE, Brathwaite W, Zenilman JM. Geographic epidemiology of gonorrhea in Baltimore, Maryland, using a geographic information system. Am J Epidemiol 1998; 147: 709–716.
19. Cohen D, Spear S, Scribner R, et al. “Broken windows” and the risk of gonorrhea. Am J Public Health 1999; 90: 230–236.
20. Ellen JM, Hessol NA, Kohn RP, Bolan GA. An investigation of geographic clustering of repeat cases of gonorrhea and chlamydial infection in San Francisco, 1989–1993: evidence for core groups. J Infect Dis 1997; 175: 1519–1522.
21. Hook EW, Handsfield HH. Gonococcal infections in the adult. In: Holmes KK, Sparling PF, Mardh P, et al, eds. Sexually Transmitted Diseases. 3rd ed. New York: McGraw Hill, 1999:451–466.
22. Scribner RA, Cohen DA, Farley TA. A geographic relation between alcohol availability and gonorrhea rates. Sex Transm Dis 1998; 25: 544–8.
23. Zenilman JM, Ellish N, Fresia A, Glass G. The geography of sexual partnerships in Baltimore: applications of core theory dynamics using a geographic information system. Sex Transm Dis 1999; 26: 75–81.
24. Dalaker J. US Census Bureau, Current Population Reports, Series P60–207, Poverty in the United States: 1998. Washington, DC: US Government Printing Office, 1999.
25. Jenks C, Mayer SE. The social consequences of growing up in a poor neighborhood. In: Lynn L, McGeary M, eds. Inner-city Poverty in the United States. Washington, DC: National Academy Press, 1990: 111–186.
26. Sells WC, Blum RW. Morbidity and mortality among US adolescents: an overview of data and trends. Am J Public Health 1996; 86: 513–519.
27. Goodman E. The role of socioeconomic status gradients in explaining differences in US adolescents’ health. Am J Public Health 1999; 89: 1522–1528.
28. Ellen JM, Aral SO, Madger LS. Do differences in sexual behaviors account for the racial/ethnic differences in adolescents’ self-reported history of a sexually transmitted disease? Sex Transm Dis 1998; 25: 125–129.
29. Ensminger ME, Forrest CB, Riley AW, et al. The validity of measures of socioeconomic status of adolescents. J Adolesc Res. 2000; 15: 392–420.
30. Hosmer DW, Lemeshow S. Applied Logistic Regression. New York: John Wiley & Sons, 1989.
31. Crosby RA, Leichliter JS, Brackbill R. Longitudinal prediction of sexually transmitted diseases among adolescents: results from a national survey. Am J Prev Med 2000; 18: 312–317.
32. Laumann EO, Youm Y. Racial/ethnic group differences in the prevalence of sexually transmitted diseases in the United States: a network explanation. Sex Transm Dis 1999; 26: 250–261.
33. Gunn RA, Fitzgerald S, Aral SO. Sexually transmitted disease clinic clients at risk for subsequent gonorrhea and chlamydia infection: possible “core” transmitters. Sex Transm Dis 2000; 27: 243–349.
34. Entwisle DR, Astone NM. Some practical guidelines for measuring youth’s race/ethnicity and socioeconomic status. Child Dev 1994; 65: 1521–1540.
35. Millstein SG, Moscicki AB. Sexually-transmitted disease in female adolescents: effects of psychosocial factors and high risk behaviors. J Adolesc Health 1995; 17: 83–90.
36. Hornberger LL, Rosenthal SL, Biro FM, Stanberry LR. Sexual histories of adolescent girls: comparison between interview and chart review. J Adolesc Health 1995; 16: 235–239.