The impact of schools and school programs upon adolescent sexual behavior

Because most youth are enrolled in school for many years before they initiate sex and when they initiate sex, schools have the potential for reducing adolescent sexual risk-taking. This paper reviews studies which examine the impact upon sexual risk-taking of school involvement, school characteristics, specific programs in school that do not address sexual behavior, and specific programs that do address sexual risk-taking. Multiple studies support several conclusions. First, involvement in and attachment to school and plans to attend higher education are all related to less sexual risk-taking and lower pregnancy rates. Second, students in schools with manifestations of poverty and disorganization are more likely to become pregnant. Third, some school programs specifically designed to increase attachment to school or reduce school dropout effectively delayed sex or reduced pregnancy rate, even when they did not address sexuality. Fourth, sex and HIV education programs do not increase sexual behavior, and some programs decrease sexual activity and increase condom or contraceptive use. Fifth, school-based clinics and school condom-availability programs do not increase sexual activity, and either may or may not increase condom or contraceptive use. Other studies reveal that there is very broad support for comprehensive sex- and HIV-education programs, and accordingly, most youth receive some amount of sex or HIV education. However, important topics are not covered in many schools.     

Investigating the Timing of First Sexual Intercourse Among Youth in EDO State,Nigeria in the Context of the Aids Epidemic

ABSTRACT

Objectives: This study examined the timing of sexual debut among youth in Edo state, Nigeria given the role that sexual abstinence plays in HIV prevention in sub-Saharan Africa. Methods: Survey data were collected from rural youth aged 11 to 17 years old enrolled in Junior Secondary Schools in Edo State, Nigeria. Discrete-time hazard techniques were used to examine the effects of theoretically relevant covariates on the timing of sexual debut among youth in Edo State. Results: Results indicate strong, significant relationships between psychosocial predictors and age at first sex for boys and girls. Youth with higher levels of knowledge about HIV as well as those who rejected common myths about HIV transmission delayed first sexual intercourse. Early sexual intercourse was strongly associated with experiencing pressure to engage in sex, while delay was associated with greater confidence that one could decline to participate in sex. On the other hand, youth with higher condom use self-efficacy engaged in first sexual intercourse at an earlier age. Conclusions: These results support the relevance of programs such as Nigeria's Family Life and HIV Education to contribute to delaying sexual intercourse focusing precisely on the forms of knowledge, myth rejection, motivation, and behavioral self-efficacy measured here. They provide policymakers with concrete evidence to increase support for such programming as a means to combat the spread of HIV among youth.     

Clinic-based service programs for increasing responsible sexual behavior

Three general classes of clinic-based programs to increase responsible sexual behavior are considered: (a) clinic-based educational/counseling programs, (b) school clinic-based condom distribution programs, and (c) clinic-based STD/HIV screening programs. Consistent condom use may double in response to clinic-based counseling. However, consistent use seldom exceeds 50% of coital exposures. Extensive and personalized counseling interventions reduce incident sexually transmitted infections by 5% to 10%. Increases in responsible sexual behavior following school-based condom distribution programs is reported in some but not in all studies. Screening programs for sexually transmitted infections are associated with decreases in rates of some infections. STD/HIV screening should be considered an important aspect of healthy sexuality and an adjunct to other counseling efforts.     

Condom Failure: Examining the Objective and Cultural Meanings Expressed in Interviews With African American Adolescents

The purpose of this study was to explore the meaning and context of self-reported “condom failure” among sexually active African American adolescents. Semistructured interviews regarding methods of protection from pregnancy and sexually transmitted disease (STD) with 124 youth (ages 14–19 years) were content analyzed. The findings suggested three meanings of condom failure. First, condom failure represents a legitimate and important risk related to sexual activity. Second, it can serve as an excuse repertoire for adolescents who engaged in unprotected sex and later experienced either pregnancy or a STD. Third, it may serve as an explanation for males who deceive their partners into having unprotected sex. The findings are discussed with regard to their implications for HIV or STD prevention and research.     

Quasi-experimental evaluation of a national primary school HIV intervention in Kenya

This study examined the impact of a primary-school HIV education initiative on the knowledge, self-efficacy and sexual and condom use activities of upper primary-school pupils in Kenya. A quasi-experimental mixed qualitative-quantitative pre- and 18-month post-design using 40 intervention and 40 matched control schools demonstrated significant program impact on targeted objectives of (1) adequate program delivery and, for standard 6 and 7 pupils (ages 11-16 years), (2) increased HIV-related knowledge; (3) increased communication with parents and teachers about HIV and sexuality; (4) increased assistance to fellow pupils to avoid sexual activity; (5) increased self-efficacy related to abstinence and condom use; (6) decreased exposure to HIV through delayed first intercourse, decreased sexual activity and increased condom. Results support the conclusions that the existing infrastructure is adequate for national roll-out of the program; that the program has its most beneficial effect on sexually inexperienced youth and should therefore be implemented with the youngest age groups possible; and that gains are gender specific, with boys reporting increased condom use while girls are more likely to decrease or delay sexual activity. Based on these results, the program began national roll-out to all primary schools in 2005. By June 2006, the program was operating in 11,000 of the country's nearly 19,000 schools.     

Peer-led interventions to reduce HIV risk of youth: A review

One approach in HIV prevention programming targeting youth is to use peer leaders in what is referred to as peer education programming. This paper critically reviews and synthesizes the results and lessons learned from 24 evaluated peer-led programs with an HIV/AIDS risk reduction component that target youth in the communities where they live and are delivered in low- and middle-income countries. Interventions were identified through a comprehensive search of the peer reviewed AIDS-related literature as well as publication lists of major organizations in the UN family that address HIV and AIDS. Our synthesis of study results finds that these programs have demonstrated success in effecting positive change in knowledge and condom use and have demonstrated some success in changing community attitudes and norms. Effects on other sexual behaviors and STI rates were equivocal. We include an overview of characteristics of successful programs, a review of program limitations, and recommendations for the development and implementation of successful community-based peer-led programs in low-income countries.     

Asking Only “Did You Use a Condom?” Underestimates the Prevalence of Unprotected Sex Among Perinatally HIV Infected and Perinatally Exposed But Uninfected Youth

Among young adults who use condoms, incomplete condom use (putting a condom on after beginning or taking a condom off before finishing sex) and condom failure (condom breaking or slipping off during sex) are common. Therefore, sexual behavior surveys that ask only if a condom was used are likely to underestimate the actual prevalence of unprotected sex. This study examined data from 135 sexually active perinatally HIV-infected (PHIV+) youth and perinatally exposed but uninfected (PHIV?) youth, ages 13 to 24. Participants were asked whether they used a condom on their first and their most recent occasion of vaginal sex. Youth who reported using a condom were asked a follow-up question about whether there was any time during that occasion when sex was not protected by a condom. This follow-up question identified additional participants— almost double the proportions who initially said they did not use a condom—who had unprotected sex. Incomplete condom use was similar among PHIV+ and PHIV?youth, boys and girls, Latinos and African Americans, and younger and older youth. These findings illustrate the importance of asking specifically about whether any unprotected behavior occurred from start to finish of sex to achieve more valid estimates of sexual risk behavior.     

The 100% Condom Use Program: a demonstration in Wuhan, China

The 100% Condom Use Program (100% CUP) was evaluated in Wuhan, China. The program sought to increase knowledge of STI/HIV transmission, increase condom use rates, and reduce the prevalence of sexually transmitted infections (STIs) among sex workers (commercial sex workers (CSWs)), via condom availability and use policies in entertainment establishments and STI services including education and counseling. Entertainment establishment owners and CSWs participated in educational sessions and multiple community sectors were involved in the program. At baseline, 170 female CSWs were assessed, and 102 CSWs were assessed at the final 21-month follow-up. At 6-month follow-up, 95% of entertainment establishments were in compliance with 100% CUP policies. At 15 months, condoms were readily available in retail outlets, and condom use rates rose by 94.5%. Refractive rates of chlamydia and methodological limitations of the evaluation leave unanswered questions about the effectiveness of the program. Nonetheless, outcomes suggest that the 100% CUP may be a promising approach to HIV prevention in China.     

“Jimmy Cap Before You Tap”: Developing Condom Use Messages for African American Women

This study examined which characteristics of persuasive communications are most effective in changing African American women’s condom use attitudes. Focus groups were convened with 40 African American women (M_age = 25.54, SD = 4.67) to assess their opinions on current effective strategies used to promote condom use among their peers. Participants discussed effective characteristics of messaging campaigns (i.e., source, message type, channel) and how these could be used in future prevention messages. Findings revealed that making messages that are fun, catchy, and informative, delivered frequently through social media, TV, or radio by a peer or celebrity would be perceived as most effective in changing young African American women’s attitudes. Other themes that emerged were that condom use is more strongly associated with pregnancy prevention than HIV prevention and that sexual partners were perceived to have negative condom use attitudes. Recommendations centered on increasing exposure of HIV prevention messages by placing messages on the Internet and including a funny phrase or jingle in the message so that it is easy to remember and could potentially serve as a conversation starter for discussing safe sex with partners.     

Competing Priorities: Partner-Specific Relationship Characteristics and Motives for Condom Use Among At-Risk Young Adults

Condoms protect against human immunodeficiency virus (HIV)/sexually transmitted infections (STIs) and unintended pregnancy and are essential to sexual health efforts targeting young adults, who are disproportionately affected by both outcomes. Understanding condom use motives is critical to increasing condom use. Research in this area is limited, particularly regarding the roles of partners and relationship factors. Using a longitudinal sample of 441 young adults and 684 reported partnerships we examined associations between relationship factors and condom use motives (pregnancy prevention, disease prevention, or dual protection). Simultaneous multilevel models identified variables associated with motives; level-specific models identified the levels (individual, partnership, time) variables impacted motives. Participants reported choosing condoms for pregnancy prevention, disease prevention, and dual protection in 51%, 17%, and 33% of partnerships, respectively. Partner-specific factors varied, to a differing degree, across the three levels. Seven variables (duration, condom self-efficacy, commitment, sexual decision-making, power, and vulnerability to harm [HIV/STIs] and pregnancy) distinguished condom use motives. The level of this association varied but was most pronounced at the partner and individual levels. Researchers and practitioners should consider the impact of both individual- and partner-level factors on condom use motives, in both research and sexual health programs.     

Work and Sexual Trajectories Among African American Youth

The beneficial or deleterious effects of employment on youth and well-being have been highly contested. This study explores whether work influences youths' sexual risk correlates in a sample of African Americans (N = 562; 55% females; M = 14.5 years, SD = 0.6 years) followed longitudinally from adolescence to early adulthood. The study used growth curve modeling to test the association between number of hours worked and condom use, sex partners' age differences, and number of partners over time. Working a greater number of hours was associated with less condom use, with the effect varying by youths' grade point average. Working a greater number of hours was associated with older sex partners among female youth. No association was found between work and number of partners. The findings suggest that working during adolescence and early adulthood increased participants' sexual activity, thus lending some support for the work consequences perspective. The implications for future research and youth development programs are discussed.     

Understanding Condom Use Decision Making Among Homeless Youth Using Event-Level Data

This is one of the first qualitative event-based studies to understand the various mechanisms through which multiple factors influence condom use decision making among homeless youth. Event-level interviews that explore characteristics of the environment surrounding sexual events were conducted with 29 youth who were asked to describe two recent sexual encounters. In thematic analyses of data across events, reasons that youth gave for engaging in unprotected sex included the expectation of having sex and use of alternative methods of protection against pregnancy. Other nonevent factors that influenced condom use decision making were related to attributes of the partnership (e.g., testing, trust and love, and assessments of risk) and attributes of the youth (e.g., perceptions of diseases, concerns over pregnancy, and discomfort using condoms). Additional event analyses conducted within the same individuals found that decision making was influenced by multiple interacting factors, with different pathways operating for event and nonevent factors. Future interventions should consider taking a multilevel and individualized approach that focuses on event-based determinants of risky sex in this population.     

Cultural Factors and Program Implications

ABSTRACT

Despite the effectiveness of condoms in HIV prevention, programs and services encouraging HIV prevention have failed to increase condom use among U.S. Latino populations. The authors identify six “myths” preventing condom use among Latinos. It is suggested that programs address these myths surrounding condom use in HIV prevention strategies targeting Latino communities in order to make interventions more salient to Latino populations and, therefore, more effective.     

A model-based evaluation of a cultural mediator outreach program for HIV+ Ethiopian immigrants in Israel

This article presents a model-based evaluation of a program designed to reduce HIV transmission from HIV-infected Ethiopian immigrants in Israel. Rather than rely on self-reported variables such as condom use, this study's approach focuses on pregnancy rate reduction, estimated from administrative periodic reporting data, as a measure of unprotected sexual exposure. The models show that among both HIV+ women and the female sex partners of HIV+ men, the ongoing pregnancy rates estimated during the intervention were significantly lower than the estimated baseline pregnancy rates, suggesting reductions in unprotected sexual exposures among those participating in the program.     

Welfare and adolescent sex: The effects of family history,benefit levels,and community context

To examine whether welfare serves as an incentive to early childbearing, this article explores the first steps in the process of becoming a teenage parent: risk of first voluntary sexual intercourse at an early age and, among teens having sex, contraceptive use at first intercourse. Alternative operationalizations of welfare include the AFDC benefit level in the state of residence, the ratio of the benefit level to family income, community-level welfare receipt, and family history of welfare receipt. Results do not support the hypothesis that higher welfare benefits provide an incentive that hastens sex or reduces contraceptive use. Analyses provide moderate support for a culture of poverty perspective among girls. Intergenerational welfare receipt has a borderline significant effect on the timing of first sex, and maternal welfare receipt predicts nonuse of contraception at first sex for girls. Strong support is found for a stressful life experiences perspective, in which both parental marital disruption and nonvoluntary sex predict earlier voluntary sex. Analyses were supported by a grant from the Office of Population Affairs, Department of Health and Human Services, under Grant # APR 00000959. Her research interests include teenage childbearing, family processes, public policy, and survey methodology. She received her Ph.D. from the University of Michigan. Donna Ruane Morrison is a Senior Research Associate, and her research interests include the effects of family structure and processes on the well-being of children. She received her Ph.D. in sociology from Johns Hopkins University. Dana A. Glei is a Research Analyst, and her research interests include employment, gender, and teen pregnancy and childbearing. She received her M.A. from the University of Virginia.     

The Influences of Sociosexuality and Attachment Style on Reactions to Emotional Versus Sexual Infidelity

Perinatally HIV-infected (PHIV+) youth are surviving into adolescence and young adulthood. Understanding the sexual development of PHIV+ youth is vital to providing them with developmentally appropriate HIV-prevention programs. Using pooled data (N = 417) from two longitudinal studies focused on HIV among youth (51% female; 39% HIV+) and their caregivers (92% female; 46% HIV+), the rate of sexual onset during adolescence across four youth–caregiver combinations was compared: PHIV+ youth with HIV+caregivers (12%), PHIV+ youth with HIV– caregivers (27%), HIV– youth with HIV+caregivers (34%), and HIV– youth with HIV– caregivers (27%). Youth with HIV– caregivers were more likely than other youth–caregiver groups to have had their sexual onset. Youth with HIV+ caregivers reported a slower rate of onset of penetrative sex across the adolescent years. Findings are discussed by highlighting the role that both youth and caregiver HIV status play in the onset of sexual behavior across adolescence.     

The Good Life: Moral and Ethical Sexual Considerations

There are an enormous number of studies surrounding predictors of condom use, and an equally impressive number of prevention programs in place to decrease the rate of HIV transmission. Despite such attention, the incidence of HIV infection remains high. One contributing factor to the continued spread of HIV may be the relative absence of recognition by researchers that condoms are imbued with a social meaning that threatens two salient goals for interactants: the desires to maintain positive identities and close relationships. Recent evidence suggests that requests to use a condom may be interpreted in ways that threaten both goals. This investigation examines the roles of identity and relational maintenance goals as influences on safe‐sex decisions. Results from an experimental design confirm the importance of these goals to safe‐sex behavior. Implications are noted and suggestions for changes in prevention programs offered.     

Sexual decision making and safer sex behavior among young female injection drug users and female partners of IDUs

Data from interviews with 94 young women who were injection drug users (IDUs) or partners of IDUs were analyzed to examine associations between self-reported sexual decision making and condom use, contraceptive use, and relationship characteristics. Most women (73-85%) reported participating in decisions about condom use, contraception, and when to have sex. Adjusting for potential covariates, respondents who reported participating in decisions about condom use and when to have sex were 7 and 19 times, respectively, more likely than others to report recently using condoms. Respondents who reported participating in decisions about contraception were 20 times more likely than others to report recently using contraceptives. Longer sexual relationships were associated with decreased likelihood of condom or contraceptive use.     

A prospective study of the onset of sexual behavior and sexual risk in youth perinatally infected with HIV

Perinatally HIV-infected (PHIV+) youth are surviving into adolescence and young adulthood. Understanding the sexual development of PHIV+ youth is vital to providing them with developmentally appropriate HIV-prevention programs. Using pooled data (N = 417) from two longitudinal studies focused on HIV among youth (51% female; 39% HIV+) and their caregivers (92% female; 46% HIV+), the rate of sexual onset during adolescence across four youth-caregiver combinations was compared: PHIV+ youth with HIV+caregivers (12%), PHIV+ youth with HIV- caregivers (27%), HIV- youth with HIV+caregivers (34%), and HIV- youth with HIV- caregivers (27%). Youth with HIV- caregivers were more likely than other youth-caregiver groups to have had their sexual onset. Youth with HIV+ caregivers reported a slower rate of onset of penetrative sex across the adolescent years. Findings are discussed by highlighting the role that both youth and caregiver HIV status play in the onset of sexual behavior across adolescence.