Sexually transmitted disease (STD) and human immunodeficiency virus (HIV) prevention efforts focus on increasing people's awareness of their risks for these infections. Prevention programs have relied on the concept that perceptions of risk for negative consequences are critical in motivating protective health behavior.1 Perceptions of risk for STD, defined here as the likelihood that a negative outcome (e.g., disease) will occur within 6 months after having unprotected sexual intercourse, are presumed to influence subsequent sexual behaviors. We have previously shown that adolescents make decisions regarding their sexual behavior based on their perceived risk for STDs (PRSTD), and that PRSTD can predict subsequent condom use with a main sex partner.2,3 The objective of this study was to determine whether PRSTD is correlated with perceptions about partners' STD-related risk behaviors. Prevention interventions include a focus on the role of sex partners in risk for acquiring an STD, and it would be useful to know whether PRSTD is affected by perceptions about partners.
Our sample consisted of adolescents who were participating in a longitudinal study at a municipal STD clinic. Eligibility criteria included: aged between 14 and 19 years old, English-speaking ability, engagement in vaginal or anal intercourse in the preceding 3 months, HIV negativity, and residence in the local metropolitan area.
The participation rate at the STD clinic was 81.9%. Participation varied by age, gender, and STD history. Older adolescents, males, and those with prior STD infections were less likely to participate. Participation rates for males and females were 77.5% and 85.3%, respectively; mean age of nonparticipants was 18.0 years, whereas for participants, it was 17.6 years; 16.3% of participants had an STD history, whereas 25.9% of nonparticipants had an STD history.
We limited our analysis to a total of 186 participants who reported having sex with a main partner during the last 6 months at the 6-month interview. The overall 6-month follow-up completion rate was 85.1%.
At the 6-month follow-up visit, research assistants asked participants about their most recent main partners' STD/HIV-related risk behaviors. They were also asked about their own perceptions of risk for STDs with the main sex partner.
We measured each individual's risk perception using a 5-item scale. Each item began with “If you have unprotected sex with your main partner in the next six months …” and completed 5 different options about the chance/likelihood/risk of contracting gonorrhea/chlamydia. We then summed the items and took the mean combined score as the measure of PRSTD; Cronbach's α on the PRSTD scale was 0.91. We defined a main sex partner as “someone you have sex with and you consider that person to be the person that you are serious about.” We assessed perceptions of risk for 2 STDs, gonorrhea and chlamydia. We described these as “diseases that cause discharge, burning, and mild pain.”
Participants were also asked to identify sexual risk behaviors of their most recent main sex partner. These behaviors are outlined in Table 1.
For each perceived behavior variable (6 total) and then for 2 relationship variables, we ran a series of models using PROC GLM (SAS v8.2). First, we tested the association between each perceived main partner behavior and PRSTD. We also controlled for presence of a casual partner within the last 6 months, as well as gender, and assessed interaction terms.
Among adolescents in our sample (N = 186), the mean age was 17.6 years (standard deviation [SD] = 1.4), and 66.1% were female. Fifty-seven percent had at least one parent with more than a high school education. Approximately 13% had an incident STD infection, and over 17% had a history of an STD, including gonorrhea, chlamydia, or nongonococcal urethritis (NGU). The mean partner age was years 20.8 (SD = 4.4), and the median length of relationship was just shy of 1 year, or 332 days.
Most adolescents perceived their partners to be involved in drug and alcohol use during the course of their relationships, and more than two thirds reported that they thought their partner had gotten an HIV test (see Table 1). Only one third reported that they perceived their partner to have a history of STD, and not quite one fifth thought their partners had other sex partners during the time they had been together. Five percent thought their partners had ever been involved in a same-sex relationship.
Also in Table 1, we show partial results of the initial generalized linear models. Those adolescents who perceived their partners to have ever engaged in gay sex had a higher perception of risk for STDs in the model with the risk behavior as the only main effect. Adding presence of casual partners and gender to the model, the relationship is still positive, but only approaches significance. The last coefficient in the polynomial model (A*B*C) approaches significance, signaling a possible 3-way interaction. In the models assessing the perception of concurrent sexual partners during the duration of the relationship, none showed an association with increased PRSTD, but there was a significant interaction between perception of concurrent partners and presence of an index casual partner within the last 6 months (F = 4.21, P <0.05). The perception that a partner had an HIV test, history of an STD, and ever used drugs or alcohol were not associated with PRSTD, nor was age of partner and length of relationship.
We further examined the significant interaction between presence of one or more casual partnerships among the index teens and the perception that their partners had had concurrent partnerships since they had been together. A stratified analysis by partner type shows a more pronounced association between perception of concurrent partners and higher PRSTD among those with a main partner only (6.16, P <0.01), whereas, not so surprisingly, the relationship disappears among the adolescents who had casual partners.
In the previous study of this cohort of adolescents, we were able to demonstrate that adolescents' perceptions of risk for STDs with a main sex partner are related to subsequent condom use with main sex partners but not casual sex partners.3 Although that study looked at PRSTD as a predictor of future protective behaviors, it did not explore the reasoning behind an adolescent's PRSTD with a main sex partner. This study looked at the correlates of PRSTD to better understand why some adolescents with main partners perceive their risk for STDs to be high.
Our data indicate that adolescents' perceptions of risk for contracting an STD are related to their perceptions that their main partner had concurrent partners. Nearly 20% of adolescents reported the perception that their partners were not monogamous. Theoretical models and studies in adults have shown that having partners who have concurrent sex partners is, in fact, associated with a higher likelihood of having and contracting an STD.8,12–15 Our findings suggests that adolescents are aware of the risk associated with having concurrent partners and that they perceive their risk of contracting an STD to be higher with a partner whom they believe is not monogamous.
An important observation in this study is that several known partner risk behaviors for STDs and HIV were not predictors of PRSTD in our adolescent population. Although these behaviors are proven risk factors,5–7,9,10,11 there was no observed relationship between PRSTD and report of partners' history of HIV testing, history of having an STD, drug use, or alcohol use. This suggests that adolescents may be underestimating their risk for STDs because more than two thirds of the sample perceived these factors to be present.
The data in our study should be interpreted carefully given certain limitations. First, the participants in the study were all patients at an STD clinic. Although this cohort affords us a population in which STDs are prevalent and STD prevention is critical, the results obtained from this cohort may lack generalizability to other populations. Another potential limitation is that older males with an STD were more likely to refuse to participate. To the extent that younger women with an STD attending STD clinics differ in determinants of PRSTD, caution should be used when generalizing these findings to all adolescent populations.
Perhaps the biggest limitation of our study was the small sample size. As a result of this factor, we were unable to gain further understanding into the potential effect modification of gender on the relationship between PRSTD and the perception that a partner had ever engaged in same-sex relations. Also, given the interactions and the need for a stratified analysis, a multivariate analysis was untenable in our sample.
The implications of our study may be important in the development of STD/HIV prevention programs, particularly for patients with low PRSTD. Although it is encouraging that PRSTD is influenced by perceptions that partners are not being monogamous, it is discouraging that other STD-related risk behaviors do not influence PRSTD. In addition, although this indicates that adolescents are not oblivious to their partners' risk status, it also shows that they are selective in what affects their PRSTD. Further research is warranted that examines why some risk factors are salient and others are not, and whether interventions focused on these salient factors increase PRSTD and subsequent STD-related risk behaviors.
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