CROSBY, RICHARD A. PhD*†; DiCLEMENTE, RALPH J. PhD*†‡; WINGOOD, GINA M. ScD, MPH*†; ROSE, EVE MPH*; LANG, DELIA PhD, MPH*
SEXUALLY TRANSMITTED DISEASES (STDs) have escalated to epidemic proportions among African American adolescents. 1–3 African American females have been disproportionately affected, especially in the southern United States. 2,4 Because the sequelae of STD infection in females are especially problematic and costly, 3,5,6 enhanced prevention efforts specifically tailored for this population are particularly important. 3 While STDs pose a significant health threat to African American female adolescents, STD infection during pregnancy can be especially problematic, posing multiple risks to maternal and child health. 3,7–9
Unfortunately, few studies have reported STD prevalence or incidence among pregnant adolescents. Oh and colleagues 10 reported that 24% of pregnant adolescents tested positive at least once for Chlamydia trachomatis before delivery. One or more treatable STDs were diagnosed in nearly 39% of the sample. 10 More recently, Crosby and colleagues 11 found that 31% of pregnant adolescents tested positive for at least one of three STDs (chlamydia, gonorrhea, or trichomoniasis).
The risk of STD acquisition during pregnancy among African American adolescent females may be elevated by adolescents’ beliefs that condom use is primarily a protective behavior against becoming pregnant and therefore is not important during pregnancy. 12,13 Thus, STD prevention may be a subservient motivation for condom use among adolescents. This possibility is illustrated by findings from a recent study indicating that pregnant African American adolescent teens were significantly less likely than their nonpregnant peers to report condom use. 11 This risk may be further compounded by previously existing partner-related barriers to condom use. 13–15 Clinic- and community-based behavioral intervention programs designed to promote safer sex practices during pregnancy are urgently needed. Such programs should be based on current and accurate empirical data identifying and characterizing the social and behavioral antecedents of risky sex among pregnant adolescents. Yet, to the best of our knowledge, there are few published studies describing the factors associated with STD-related risk behaviors among pregnant African American adolescents.
While it is clear that pregnant adolescents have previously engaged in risky sexual behavior, it is important to investigate the correlates of continued engagement in risky sex during pregnancy. Accordingly, the purpose of this exploratory study was to identify correlates of engaging in relatively frequent penile-vaginal sex, unprotected by a condom, among inner-city African American adolescents during their first or second trimester of pregnancy. Because we were particularly interested in relationship-associated constructs that could influence risky sexual behavior, we restricted our investigation to adolescents who reported a current boyfriend. Due to the dearth of existing research, identification of these correlates could be useful for generating subsequent hypotheses that can be tested in prospective cohort trials and for informing the development and implementation of STD prevention programs designed for this at-risk population.
Data for this study were obtained from the baseline measures collected during a pilot study of a randomized controlled trial. The trial was designed to explore the efficacy of an STD/HIV prevention program tailored to be culturally sensitive and relevant for African American female adolescents. A consecutive sample of pregnant African American adolescent was recruited to participate in the project. Only adolescents whose pregnancy was at less than 21 weeks of gestation were eligible; this criterion allowed ample time for adolescents to complete the planned intervention sessions and for the study's follow-up period before labor and delivery. Recruitment was conducted at the prenatal clinic in a large urban hospital that served predominately low-income minority residents of Atlanta, Georgia.
From April 1999 through June 2000, project recruiters approached and screened 311 adolescent females to assess their eligibility for participation in the study. Adolescents were screened at their initial prenatal clinic visit to determine if they met the following criteria: African American, 14 to 20 years of age, sexually active in the previous 2 months, pregnant (less than 21 weeks’ gestation), single, planned to deliver at the hospital, and expressed willingness to attend planned intervention sessions and complete the two-stage baseline assessment protocol. The initial stage of the baseline assessment included a physical examination during which urine and serology specimens were collected for STD analysis and an in-depth interview was administered by trained interviewers to assess sexual risk behaviors. Subsequently, adolescents completed the second stage of the baseline assessment, which was a self-administered survey to assess theoretically derived psychosocial influences on adolescents’ sexual behavior.
Of those adolescents screened, 170 met all eligibility criteria and were enrolled in the study. Of those not eligible to participate in the study, most were not sexually active, could not plan to attend the intervention, or did not complete the entire baseline assessment protocol. Significant differences in biologically confirmed STD prevalence were not found between adolescents who completed the entire baseline assessment and those who completed initial enrollment procedures but did not complete the entire baseline assessment (P = 0.59).
Inclusion criteria for the current study.
Of the 170 adolescents completing baseline assessments, 144 (85%) reported current sexual activity within the context of a relationship with a boyfriend; analyses were restricted to these adolescents. The study protocol was approved by the Institutional Review Board before implementation.
Data collection was conducted at a large urban hospital prenatal clinic. At study enrollment, adolescents completed a face-to-face interview that assessed sexual risk behaviors. The interview was administered in private examination rooms. Interviewers were trained African American females in their early twenties. We employed young adult African American females to maximize adolescents’ sense of comfort and trust with the interviewers. Adolescents also completed an in-depth self-administered survey. A computerized readability assessment indicated a fifth-grade reading level for this survey instrument. The instrument was administered in a group setting with monitors providing assistance to adolescents with limited literacy and helping to assure them of the confidentiality of responses. Each completed questionnaire was reviewed by a project investigator to identify omissions and inconsistent responses. Any item that was incomplete or inconsistent with other items was referred to another interviewer, who met with the adolescent to review and complete these items. Adolescents were reimbursed $50.00 for completing these measures.
Selection of Measures
Due to the lack of literature identifying correlates of risky sex among pregnant inner-city African American adolescents, we selected exploratory measures on the basis of our underlying theoretical framework, the Theory of Gender and Power. Two important propositions (largely guiding the selection of measures) of this theory are that power differentials and social norms that favor males pose significant health risks for females. A recent article provides extensive descriptions of the theory's propositions, development, applications, and empirical support. 16 We also selected measures on the basis of empirical findings reported from studies of nonpregnant inner-city African American adolescent females 17–19 and from studies that included a mix of pregnant and nonpregnant inner-city African American adolescent females. 20–22
Sociodemographic information was collected by self-administered survey. Adolescents provided information about parity, age, school enrollment, current living arrangements, and whether anyone in their household received public assistance.
STD history and age at sexual initiation.
The self-administered survey also asked adolescents, “Have you ever had an STD such as gonorrhea, chlamydia, herpes, trichomoniasis, or genital warts?” Those responding “yes” to this question were subsequently presented with a question asking whether they had recently been treated for an STD. As part of the face-to-face interview, adolescents were asked to indicate how old they were the first time they willingly had sex.
The self-administered survey also assessed adolescents’ knowledge about HIV/STD, their attitudes towards condom use, perceived barriers to using condoms, and self-efficacy for negotiating condom use. A 23-item index measured adolescents’ knowledge about HIV infection/STD; inter-item reliability for this measure was satisfactory (α = 0.77). The Condom Attitude Scale for Adolescents (CAS-A) was also administered. This 10-item scale, adopted from that of St. Lawrence and colleagues, 23 has well-established reliability and validity (α = 0.72 in the current study). A 26-item scale was used to assess adolescents’ perceived barriers to condom use. Also adapted from that of St. Lawrence and colleagues, 24 this scale assesses partner-related barriers to condom use, lack of access to condoms, low motivation to use condoms, and perceptions that condoms ruin sexual pleasure. Previous research has established the reliability and validity of this instrument with populations of African American adolescent females 25 (α = 0.91 in the current study). The survey also assessed adolescents’ self-efficacy in negotiating condom use with a male partner, based on a four-item scale (α = 0.85).
A frequency measure of sexual communication between adolescents and their boyfriends was assessed. This construct was assessed as part of the self-administered questionnaire. Adolescents were asked, “During the past 6 months, how many times have you and your sex partner discussed how to prevent STDs?” Response alternatives were “never” (0 times), “sometimes” (1–3 times), “often” (4–6 times), and “a lot” (7 or more times). The question was then rephrased to assess frequency of discussing how to use condoms and how to prevent the AIDS virus. A final question asked adolescents how often they and their partner discussed their partner's sex history. These four items were the basis of a sexual communication scale that yielded an internal reliability coefficient of 0.86.
As part of the face-to-face interview, adolescents were also asked (1) whether they believe their current boyfriend is having sex with other partners, (2) how many hours during the typical week they spend with their boyfriend, and (3) the duration of their current relationship.
Substance abuse issues.
As part of the face-to-face interview, adolescents were asked if they had ever used marijuana and alcohol and to indicate how often in the past 30 days they had used these substances. Use of other substances was also assessed.
Sexual risk assessment.
The face-to-face interview collected information about adolescents’ recent sexual risk behavior. The frequency of adolescents’ engaging in penile-vaginal sex, unprotected by a male condom, during the past 30 days was assessed by asking how many times they engaged in vaginal sex (defined as “when the man puts his penis in your vagina—the place where you put a tampon”) and how many of these times involved condom use. The value obtained from the latter measure was subtracted from the former to yield a measure of frequency of unprotected vaginal sex. The value of using measures of unprotected sex as opposed to measures that assess proportion of condom use has been described by numerous researchers. 26–28
The distributions of all measures were evaluated for normality by calculating skewness and kurtosis ratios with use of SPSS, version 9.0. As recommended by SPSS, ratios exceeding an absolute value of 2.0 are an indication that the distributions are not normal. Because parametric analyses assume that variable distributions are normal, nonparametric analyses were used for these variables. All nonnormal distributions were dichotomized by performing a median split. The outcome measure (unprotected vaginal sex [UVS]) was dichotomized by performing an upper-tertile split (i.e., adolescents in the upper one third of this frequency measure were compared to those in the lower two thirds).
T tests were computed for continuous variables and contingency table analyses for dichotomous variables to assess bivariate associations between the selected correlates and UVS. Correlates achieving significance (P < 0.05) were entered into a forward stepwise logistic regression model to assess the independent effect of each correlate in the presence of the others. Adjusted odds ratios, their 95% confidence intervals, and respective P values were calculated for each variable retaining significance in the multivariate model.
Characteristics of the Sample
Average age of the adolescents was 17.8 years (standard deviation = 1.6 years). The majority (57.1%) were not enrolled in school. About 55% lived with at least one parent. More than one quarter (26.1%) of the adolescents reported living in a household that received public assistance. About two thirds (69.0%) were nulliparous. The majority (93.1%) reported that they had conceived with their current steady sex partner. The average age of sexual debut was 14.8 years (standard deviation = 1.9 years). Just over one half (51.5%) indicated that they had been diagnosed with at least one STD in the past, and 18.2% indicated they had been treated for an STD in the past 6 months. About one fifth (21.5%) of the adolescents tested positive for at least one of the three STDs assessed during the enrollment process. Marijuana use in the past 30 days was reported by 14.7% of the adolescents. Recent use of alcohol and other substances was reported by less than 6% and 3%, respectively; these values were too small for meaningful analyses.
The mean frequency of UVS in the past 30 days was 6.5 (standard deviation = 9.2); the distribution had a strong positive skew, such that about two thirds of the adolescents reported engaging in UVS during four or fewer occasions in the past 30 days. After this distribution was split as close as possible to the upper tertile, 35.4% were classified as “high risk” (five or more episodes of UVS in the past 30 days).
Adolescents classified as low risk and high risk did not differ in terms of mean weeks of gestation, as assessed by ultrasound (13.0 weeks versus 13.3 weeks;t = 0.43; df = 139;P = 0.67). However, adolescents classified as low risk were significantly younger than those classified as high risk (17.6 years versus 18.3 years;t = 2.45; df = 142;P = < 0.02).
The remainder of the bivariate associations were assessed by contingency table analyses; these findings are displayed in Table 1. As shown, 7 of the 17 variables achieved significance. Adolescents were significantly more likely to be classified as high risk if they (1) were parous, (2) were not enrolled in school, (3) did not reside with at least one parent, (4) reported infrequent sexual communication with their partner, (5) spent 30 hours or more each week with their partner, (6) reported that the current relationship was at least 2 years old, and (7) reported using marijuana in the past 30 days.
Three variables retained significance in the multivariate model (Table 2). The model was significant (chi-square with 3 df = 24.5;P < 0.0001) and had excellent fit (goodness of fit chi-square with 6 df = 1.52;P = 0.96). Compared to adolescents residing with at least one parent, those not residing with a parent were about 2.2 times more likely to be classified as high risk. Adolescents who reported spending at least 30 hours each week with their boyfriends were 3.7 times more likely to be classified as high risk than those spending less time with their boyfriend. Finally, adolescents scoring lower on the frequency measure of sexual communication with their partners were about 2.9 times more likely to be classified as high risk than those scoring higher on the communication measure.
This exploratory study identified several correlates of engaging in penile-vaginal sex, unprotected by a condom, among inner-city adolescents during their first or second trimester of pregnancy. The identified correlates can be useful for generating hypotheses that guide the design of expanded research efforts in the context of observational or experimental studies. Correlates that retained significance in the multivariate model are especially important; the strongest of these was spending 30 hours or more with the boyfriend each week. The finding suggests the possibility that increased familiarity with a sex partner may foster beliefs regarding the STD safety of these sex partners, a hypothesis articulated in the reports of at least two recent studies. 22,29
Not residing with at least one parent was also an important multivariate correlate of continued risky sex. This finding suggests the hypothesis that parent-associated functions (e.g., parental monitoring, parent-adolescent exchanges about avoiding sexual risk, and parent support/approval for practicing risk reduction) may serve as protective factors for pregnant inner-city African American adolescents. A growing body of evidence suggests that parent-associated factors are protective against sexual risk behavior among African American adolescent females, regardless of their pregnancy status. 30–35
A final hypothesis suggested by the multivariate findings of this exploratory study of pregnant inner-city African American adolescents is that infrequent communication about sex and sex-related issues between pregnant adolescents and their partners may be an important antecedent of sexual risk behavior. Clearly, communication between sex partners forms the basis for subsequent collaboration with regard to behaviors protective against STDs. The current finding supports and extends previous research findings suggesting that communication between sex partners is an important protective factor, regardless of pregnancy staus. 20,30,36
Several of the null bivariate findings deserve comment. For example, it is important to note that adolescents’ history of STD diagnosis and recent treatment for STDs did not differentiate between those classified as low and high risk for UVS in the past 30 days. This observation suggests that STD diagnosis and treatment may not be a sufficiently salient experience to motivate condom use during pregnancy. Also, none of the psychological assessments (STD/AIDS-associated knowledge, attitudes toward condom use, perceived barriers to condom use, and perceived self-efficacy for condom-use negotiation) achieved bivariate significance. Given that past studies have found significant associations between various combinations of these measures and risky sex among nonpregnant adolescent females, 14,37–39 our null findings suggest the possibility that the dynamics of practicing safer sex may differ according to pregnancy status. Finally, it was intriguing that differences in UVS were not found between adolescents who did and did not believe their boyfriend had current relationships with other women. Although concurrent sexual risk behavior of male partners should be a warning sign to female partners regarding inflated odds of STD acquisition, our data suggest that pregnant adolescents do not take added precautions.
Findings are limited by several factors, including the inherent limitations of a cross-sectional study design. Nonetheless, it is important to note that cross-sectional analyses of baseline data collected in the context of randomized controlled trials can be a valuable source of information about study populations, particularly because the baseline data are not confounded by planned interventions. In the current study, the baseline data provided a unique opportunity to identify correlates of risk behavior among a vastly understudied population of adolescents.
Another important limitation is reliance on the validity of adolescents’ self-reported measures, particularly their reports relevant to frequency of sex and condom use. Also, classification of adolescents as low or high risk solely on the basis of frequency of UVS in the past 30 days is problematic. Although other factors (e.g., multiple partners and sex with casual partners) could also have been considered in determination of risk, the frequency of these behaviors was too low for meaningful analysis.
Finally, we employed a convenience sample for this exploratory study. A limitation with any convenience sample is that participation bias may systematically influence the findings. In this study, adolescents who could not plan to attend the intervention sessions or who did not complete the entire baseline assessment protocol were excluded from the convenience sample, thereby further limiting the generalizability of the exploratory findings. Thus, our findings may not be generalizable to other populations of pregnant African American females. Finally, the results may not be generalizable to adolescents of other ethnic/racial groups. Further research will be needed to corroborate these findings with other ethnic/racial groups.
Implications for Prevention
Clearly, the design of effective STD/HIV prevention interventions for pregnant minority adolescents may be informed by observational studies such as this one. Further research should discern differences in STD/HIV prevention needs between pregnant and nonpregnant adolescents, thereby enhancing the empirical basis for modifying existing STD/HIV intervention programs for delivery to pregnant adolescents. One important implication of these findings is that clinic- and community-based STD prevention programs specifically designed for pregnant adolescents could be an important asset to urban communities. Given the potential for serious adverse sequelae as a result of STD acquisition during pregnancy, combined with existing disproportionate STD risk among African American adolescent females, STD prevention efforts could also augment routine prenatal care for this population. Thus, these findings, although exploratory, suggest that incorporating STD prevention activities within the context of a prenatal program may be an efficient strategy for specifically emphasizing the importance of practicing safer sex during pregnancy to reduce the risk of STD acquisition, thereby avoiding problematic outcomes.
The multivariate findings suggest that counseling and prevention education programs designed for pregnant adolescents may benefit from addressing two factors. First, programs could provide pregnant adolescents with skills and encouragement regarding open communication with male partners about STD prevention. Although initiating this communication may otherwise be problematic for adolescent females and their partners, tying the practice to “prenatal care” and “having a healthy baby” may facilitate acceptance and motivate adolescents to engage in sexual communication with their male partners. Second, programs could seek to dispel adolescents’ misconceptions with regards to beliefs that the long-term male sex partner is not a potential source of STD infection. This myth may be dispelled by briefly describing the asymptomatic nature of prevalent STDs and by emphasizing that the male partner may not be aware that he has an STD.
Finally, the multivariate findings suggest that pregnant inner-city African American adolescents who do not reside with a parent may be particularly likely to engage in frequent UVS. Thus, clinic- and community-based STD-prevention programs may be especially important for these adolescents. Obstetricians providing prenatal care to adolescents not residing with a parent may want to extend additional counseling efforts, designed to discourage continued risky sex, to this vulnerable population. Evidence from a recent multisite study suggests that clinic-based STD prevention counseling for adolescents may be particularly effective when the content is tailored through interactive discussion between the provider and client. 40 Similarly, obstetricians may refer these adolescents to community-based programs designed to facilitate adolescents’ adoption of safer sex practices. Community-based interventions that incorporate multiple sessions in a small group format have also demonstrated efficacy among populations of minority adolescent females. 41–43 Thus, clinicians need to be alert to the amplified risk associated with not residing with a parent and should consider carefully assessing adolescents’ sexual risk practices and referring adolescents to existing appropriate community prevention programs.
Conclusions and Recommendations
Pregnant inner-city African American adolescent females may be particularly likely to engage in continued risky sex if they spend at least 30 hours each week with their boyfriends, do not reside with a parent, or do not engage in frequent communication with their boyfriends about sex-related issues such as STD prevention. Given the potential for serious adverse sequelae associated with STDs acquisition during pregnancy, clinic- and community-based programs designed to promote safer sex among pregnant adolescents could be beneficial. Larger-scale, prospective studies of this vulnerable population are needed to further test these hypotheses.
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