Qualitative evaluation of historical and relational factors influencing pregnancy and sexually transmitted infection risks in foster youth

PurposeTo explore how attitudes, norms, behaviors, responses to early life experiences, and protective factors influence pregnancy and sexually transmitted infection risks from the perspectives of current and former foster youth to inform the development of prevention strategies.MethodsWe conducted semi-structured individual qualitative interviews with a diverse sample of 22 current/former foster youth aged 15–21 years (63% female; average age = 18.6 years). We then used Theoretical Thematic Analysis to systematically analyze the data for key themes related to sexual health in four categories: 1) norms and attitudes, 2) responses to early life experiences, 3) protective factors, and 4) youth-driven intervention ideas.ResultsParticipants reported a range of sexual experience levels, varied sexual orientations, and also reported varied life experiences prior to and during foster care. We detected several norms and attitudes that likely contribute to risks of early pregnancies and sexually transmitted infections. These included that one can tell by looking whether a partner is trustworthy or has a sexually transmitted infection, that condoms aren't necessary with long-term or infrequent partners or if birth control is used, and that teen pregnancy is an inevitable event. With respect to responses to early life experiences, youth frequently described difficulties dealing with strong emotions in the context of romantic and/or sexual relationships; many attributed these difficulties to early experiences with biological family members or in foster care. Participants linked emotion regulation difficulties with struggles in trust appraisal, effective communication, and impulsive behaviors. Youth also described a variety of protective factors that they felt helped them prevent sexual risk behaviors or improved their lives in other respects. Finally, participants endorsed factors likely to improve intervention acceptability and efficacy, including an open, non-judgmental group-based environment, involvement of peer mentors, and inclusion of caregiver and caseworker training components.ConclusionsTrauma-informed, tailored intervention strategies which address key norms and attitudes and provide broad-based assertiveness and emotion regulation skills are likely to be the most effective strategies to reduce risks of teen pregnancies and sexually transmitted infections among teens in foster care. Group-based interventions that involve peer mentors and caregiver and caseworker components may be especially acceptable and effective for teens in foster and/or kinship care.     

Parenting Under Pressure: Experiences of Parenting While Aging Out of Foster Care

Youth “aging out” of foster care experience higher rates of adolescent parenting than their peers who have not been in care. Due to their history of maltreatment, high adolescent pregnancy rates, and poor psychosocial outcomes, youth aging out who are parents are a vulnerable at-risk group. This study examines the parenting experiences of 33 youth aging out (21 mothers and 12 fathers) using data from a larger ethnography. Field notes of observation and transcribed interviews of youth aging out who are parents were analyzed using open coding strategies. Findings show parents encountered challenges while aging out and parenting, yet they found joy in their children and strived to be good parents despite having limited parenting skills, few resources, and little support. Desiring a better life for their children and fearing their children would enter foster care, parents were motivated to improve their lives for their children. Implications are discussed.     

Harsh Parenting,Deviant Peers,Adolescent Risky Behavior: Understanding the Meditational Effect of Attitudes and Intentions

Although research supports the influence of parents and peers on adolescent risky behavior, less is known about mechanisms proposed to explain this relation. This study examined the influence of adolescent attitudes and intentions about such behaviors. Prospective, longitudinal data came from rural youth who participated throughout adolescence (n = 451). Observed harsh parenting and relationship with deviant peers was assessed in early adolescence, attitudes and intentions were measured during middle adolescence, and risky behavior was assessed in late adolescence. Results indicated that parenting and deviant peers was related to engagement in tobacco use, alcohol use, and risky sexual behaviors. Moreover, attitudes and intentions mediated this relationship even after parent use and adolescent early involvement in these behaviors were taken into account.     

Sexual health behaviors and outcomes among current and former foster youth: A review of the literature

This review examines literature related to pregnancy, sexual health outcomes, and sexual risk behaviors for foster youth and youth who are aging/have aged out of foster care. Using the search terms foster youth, aging out, pregnancy, sexually transmitted diseases, sexually transmitted infections, sexual risk, sexual behavior, and sexual health, 26,376 sources were initially identified. After removing duplicate sources and those that did not meet inclusion criteria and adding others identified through the references of identified sources, 53 sources were included in the review. Outcome measures were grouped into broad categories of pregnancy, sexually transmitted infections, and risky sexual behaviors, with each having several subparts. Implications for social work practice and policy are presented and directions for future research are highlighted.     

Risky sexual behavior in low‐income African American women: The impact of sexual health variables

In a sample of 163 low‐income African American women, we used logistic regression analyses to test for associations between (a) 5 operationalized constructs theorized in the Sexual Health Model to impact one's overall sexual health (barriers to healthy sexuality, sexual anatomy and functioning, positive sexuality, sexual health care, and cultural identity) and (b) several measures of risky sexual behavior (consistent condom use, multiple concurrent partnerships, and overall sexual risk). No significant relationship was found between acculturation and risky sexual behaviors. Having sexual difficulties was positively associated with overall sexual risk and multiple concurrent partnerships. Favorable attitudes toward condoms were positively associated with consistent condom use. Desiring or intending pregnancy was positively associated with inconsistent condom use and overall sexual risk behavior. This is only the second study linking sexual difficulties and risky sexual behavior. The exact nature of this correlational relationship needs to be studied and replicated in different and more heterogeneous populations.     

Mentoring and social skills training: ensuring better outcomes for youth in foster care

Youth in foster care face significant life challenges that make it more likely that they will face negative outcomes (i.e., school failure, homelessness, and incarceration). While the reason(s) for out-of-home placement (i.e., family violence, abuse, neglect and/or abandonment) provide some context for negative outcomes, such negative outcomes need not be a foregone conclusion. In fact, interventions created to serve at-risk youth could ostensibly address the needs of youth in foster care as well, given that they often face similar social, emotional, and other challenges. Specifically, the author posits that supporting foster care youth through the use ofmentoring and social skills training could reduce the negative outcomes far too common for many of these youth.     

Foster Parenting the Sexually Abused

The number of foster children with histories of sexual abuse has increased over the past decade. These children often demonstrate symptomatology which can tax the resources of foster parents. We describe a program designed to enhance parental sense of competence in dealing with abused children via the integration of parenting skills training with education on normative sexual development and child sexual abuse. Foster parents demonstrated a significant increase in knowledge and comfort with sexual development, behaviors associated with sexual abuse, and an increase in parental sense of competence. Additional analyses suggest a relationship between a child's sexual history and its impact on current foster parenting attitudes.     

Placement Instability and Risky Behaviors of Youth Aging Out of Foster Care

Youth who age out of foster care are at risk of poor outcomes and risky behaviors in young adulthood. Yet, little is known about what child welfare workers can do to decrease these risks. The effect of foster care placement instability on substance use and risky sexual behaviors is examined using data from 114 young adults who aged out of care. When controlling for variables commonly associated with these behaviors, a history of foster care placement instability increased the young adults’ likelihood to use substances. Child welfare practitioners could potentially reduce the vulnerability of this population by providing them greater stability during adolescence.     

Baseline Characteristics of Dependent Youth Who Have Been Commercially Sexually Exploited: Findings From a Specialized Treatment Program

ABSTRACT

Commercial sexual exploitation of children has emerged as a critical issue within child welfare, but little is currently known about this population or effective treatment approaches to address their unique needs. Children in foster care and runaways are reported to be vulnerable to exploitation because they frequently have unmet needs for family relationships, and they have had inadequate supervision and histories of trauma of which traffickers take advantage. The current article presents data on the demographic characteristics, trauma history, mental and behavioral health needs, physical health needs, and strengths collected on a sample of 87 commercially sexually exploited youth. These youth were served in a specialized treatment program in Miami-Dade County, Florida, for exploited youth involved with the child welfare system. Findings revealed that the youth in this study have high rates of previous sexual abuse (86% of the youth) and other traumatic experiences prior to their exploitation. Youth also exhibited considerable mental and behavioral health needs. Given that few programs emphasize the unique needs of children who have been sexually exploited, recommendations are offered for providing a continuum of specialized housing and treatment services to meet the needs of sexually exploited youth, based on the authors’ experiences working with this population.     

The invisibility of adolescent sexual development in foster care: Seriously addressing sexually transmitted infections and access to services

Adolescents residing in foster care are at higher risk for acquiring sexually transmitted infections (STIs) and human immune deficiency virus (HIV) compared to their non-foster care peers. A literature review was conducted to determine whether youth residing in foster care face different barriers to sexual health care compared to their peers in the general population and, if so, what those barriers are. The review revealed barriers common to adolescents in general as well as additional barriers specific to the ecosystem of adolescents in foster care. Systemic issues that decreased access to sexual health services included child welfare policies that were either missing or implemented without fidelity; complicated financial factors; barriers to service utilization; lack of collaboration between child welfare and medical professionals; and limited information provided to foster youth on their sexual health and development. Consent and confidentiality issues that foster youth face in seeking sensitive health services also need to be resolved. More research is needed on how to facilitate development of coherent policies and effective practices that promote sexual health care access for adolescents in foster care.     

Assessing Child Well-Being in Non-Relative Foster Care with a New Outcome Measurement Tool

ABSTRACT

The Child Health and Illness Profile–Adolescent Edition (CHIP-AE), a recently developed standardized instrument, was administered to 49 adolescents living in non-relative family foster care under the auspices of the child welfare system in Illinois. Youth reported high levels of satisfaction with their health, academic progress, resiliency and risk resistance, but low levels of work performance. These youth also reported higher levels of psychosocial problems, major and minor adverse effects from injuries, migraines, and chronic medical conditions such as epilepsy, diabetes and sickle-cell anemia. This study demonstrated the potential usefulness of the CHIP-AE as a tool for involving youth living in non-relative foster care in assessing their own health and well-being. Suggestions for future use of the CHIP-AE are discussed.     

Sexual and reproductive health policies for foster youth in California: A qualitative study of child welfare professionals' experiences and perceptions of policies

Child welfare professionals and foster parents increasingly suggest the importance of establishing clear and consistent policies and procedures to address the sexual and reproductive health of youth in foster care. The present study examines the content and context of such policies across 18 California counties through a search of publically available county policy documents, and surveys and expert interviews with child welfare professionals (N = 22). A policy framework for agenda setting and policymaking was used to guide the data collection and analysis process. Child welfare professionals were aware of multiple sources of information, support and services for foster youths' sexual and reproductive health, though few practiced in counties with formal policies that outline the resources and support that youth should receive. Participants demonstrated widespread recognition that issues of youth sexual and reproductive health were significant; posing challenges to youth, foster parents and child welfare staff. Identified policy solutions included: 1) training for social workers and foster parents; 2) collaborative partnerships with public health nurses and community providers; 3) data tracking and monitoring of outcomes to assess youth needs and evaluate the impact of programs and policies; and 4) involvement by advocacy organizations in defining problems and advocating for improved services and support for youth in care. Social workers largely perceived that support from child welfare administrators and policy leaders is necessary to prioritize this issue and initiate policy formation. Additional research is needed to further examine the impact of policy mandates on social workers, foster parents and youth in foster care.     

School contextual factors and race differences in adolescent sexual behaviors

Abstract

Although there exist a voluminous number of studies examining predictors of adolescent sexual behavior, few studies have explored the role of the school social context in influencing teen sexual activity generally and specifically, the role that school contextual factors play in helping understand race differences in risky sexual behaviors. Using data from a nationally representative school-based survey of American youth in Grades 7–12, we find support for our core hypothesis that school contextual factors are associated with risky sexual behavior, number of sexual partners, and ever having sex, albeit it nuanced ways and that such factors cannot account for much of the race gap in adolescent sexual behavior. We interpret these findings to be more supportive of a social contagion model (versus a school climate model).     

Pregnancy risk among older youth transitioning out of foster care

Youth served in the foster care system have higher rates of pregnancy than general population youth; yet we have little information about risk and protective factors to target in order to prevent early pregnancy in this population. We assessed early pregnancy risk and protective factors known for general population adolescents for their relevance to youth in the foster care system. Using data from a longitudinal study of 325 older youth from the foster care system, we examined bivariate and multivariate relationships between these factors and pregnancy between ages 17 and 19 using logistic regression. Models examined the risk for early parenting separately by gender. The pregnancy rate increased by 300% between ages 17 and 19. At 19, 55% of females had been pregnant, while 23% of males had fathered a child. Although this study assessed multiple known factors, few were significant for this high risk group. Females who were not sexually active at age 17 were less likely to become pregnant, but those who reported using birth control were as likely to become pregnant as those who did not. Also, females with a history of arrest were more likely to have a pregnancy between 17 and 19. Males who left the foster care system before their 19th birthday were more likely to make someone pregnant. Youth from the foster care system are at exceptional risk of early pregnancy, regardless of their maltreatment history, religiosity, school connectedness, or academic achievement, particularly in the years between 17 and 19. This high risk group needs pregnancy prevention interventions and access to effective birth control.     

Using the bridges transition framework for youth in foster care: Measurement development and preliminary outcomes

Youth in foster care often undergo multiple transitions before reaching adulthood, and these transitions often create significant stress and can exacerbate emotional and behavioral problems. A measurement instrument (the Youth Experience of Transitions, or YET) was designed to assess foster care youths' understanding of transitions, and this instrument was tested on a group of youth undergoing an intervention program designed to assist them in coping with the stress of these transitions while in foster care. The intervention was based on the Transitions Framework by William Bridges and was implemented in multiple community agencies with funding from the Andrus Family Fund. Using factor analysis, we found that the YET contained two factors representing (1) openness and (2) determination. For youth in the participating foster care programs, growth in openness from baseline to 6 months was linked to a significant decrease in internalizing symptoms; no significant links were found for externalizing symptoms. Implications for foster care intervention programs are discussed.     

Instability in the lives of foster and nonfoster youth: Mental health impediments and attachment insecurities

Foster youth are at risk for negative mental health and psychosocial outcomes, including when they are on the brink of emancipation from care into self-sustained adulthood. Factors believed to affect outcomes among foster youth include residential and school instability. Although frequent moves to new homes and schools are common for youth living in poverty, instability for foster youth involves not only changing homes and schools but often also changes in caregivers, thus putting foster youth at risk for disrupted attachment relationships. For the current study, structural equation models examined links between instability, mental health problems, and attachment insecurities in foster and at-risk nonfoster youth. A model containing instability provided a better fit to the data than a model containing foster care status only. Group comparisons revealed that instability was associated with posttraumatic stress disorder symptoms for foster but not nonfoster youth. Implications of instability in the lives of foster youth are discussed.     

Foster parenting together: Assessing foster parent applicant couples

This study examined family and marital context, parenting knowledge and attitudes, and mental/emotional health in a sample of 99 heterosexual foster parent applicant couples to determine whether there were distinct sub-groups in the sample with regard to marital/family context, psychological symptoms, and parenting attitudes and knowledge; to describe those sub-groups; and to examine whether those sub-groups experienced different rates of approval to foster and placement of children in their homes. The sample included only applicant couples who completed all questionnaires and 30 h of MAPP training over 10 sessions. Due to sample size, we estimated one Latent Class model for marital/family context and psychological symptoms, and another for parenting attitudes and knowledge. Analysis revealed two distinct classes of applicant couples for marital/family context and psychological symptoms, designated as Problematic Family Context (PFC), 60% of the sample and Nonproblematic Family Context (NFP), 40%. Significantly more NFP were approved to foster and had children placed in their homes 14 months later. Latent Class Analysis also revealed Problematic (35%) and Non-problematic (65%) sub-classes for parenting attitudes and knowledge; however, both classes were about equally likely to be approved to foster and to have children placed in their homes. These findings underscore the importance of screening during foster parent training and suggest that the MAPP training was partially successful in selecting applicants with the most foster parenting potential.     

Latent classes of older foster youth: Prospective associations with outcomes and exits from the foster care system during the transition to adulthood

Youth in the foster care system face considerable challenges during the transition to adulthood. However, there is significant variability within this population. This study uses person-oriented methods and a longitudinal dataset of youth aging out of foster care to examine differences in how subgroups of foster youth fare during the transition to adulthood. We identified four distinct latent classes, consistent with prior person-oriented studies of this population, and validated these classes by examining differences on additional relevant factors at age 17. After establishing these classes, we tested their predictive validity by examining differences in outcomes at age 19 in domains relevant to the transition to adulthood, including education and employment, problem behaviors, and mental health problems. Finally, given the importance of extended foster care in promoting better outcomes, we used survival analysis to prospectively examine whether class membership was associated with differences in the rates at which youth left foster care between ages 17 and 19. One large group of youth exhibited moderate behavior problems and left care quickly, while another large group of resilient youth had favorable outcomes and left care relatively slowly. A small group exhibited considerable behavior and mental health problems, but left care more slowly, and a very small group was characterized by a history of pregnancy. Findings suggest considerable variability in service need among older foster youth. Implications for service provision during the transition to adulthood are discussed.     

An Approach to Community Outreach Practice in the 21st Century

ABSTRACT

This article presents the findings of a study about knowledge, attitudes and beliefs about AIDS held by older Hispanic adults. Members of the convenience sample provided responses that identify concerns about effective practice in outeach and information provision to older adults with regard to risky sexual practices. Intervention to prevent the spread of HIV/AIDS among older adults needs to be culturally competent and to be attuned to social practices, traditions, community concerns, and generational perspectives with regard to serious health problems related to sexual behavior. The sample composition was primarily Hispanic (97.4%); Catholic, (92.1%) and female (84.2%) with a mean age of 73.7 years. Approximately 28.2% of those surveyed stated that they felt that AIDS was an important problem for older adults. The majority, (76.3%) were aware of locations where health information and services were available if AIDS were a problem. Even though the majority indicated knowledge that AIDS is spread through sexual intercourse, more than one third, (36.8%) thought that sexually active adults 55 and over never use condoms. A discussion of the implications for disease prevention programs and community practice is presented emphasizing the importance of empowerment strategies in health promotion programs and the strengthening of multidisciplinary collaborative efforts to effect positive community health changes.