Predisposing factors related to adolescent sexuality Kristin McIntosh, MPH, CHES Justin B. Moore, PhD, MS Lloyd F. Novick, MD, MPH Omur Cinar Elci, MD, PhD Division of Community Health and Preventive Medicine Brody School of Medicine East Carolina University

Background In 2005, YRBSS data indicate: 46.8% of adolescents report having ever had intercourse1 33.9% of adolescents are currently sexually active1 23.3% reported alcohol or drug use before last intercourse1 Approximately on in three young women become pregnant before the age of twenty2 Few studies examine predisposing factors Due to detrimental public health outcomes of adolescents engaging in early sexual activity, there is a pressing need to explore predisposing factors associated with risky adolescent sexual behaviors. The aim of the study was to investigate predisposing factors which may contribute to adolescents’ early sexual behavior, focusing upon adolescents who where enrolled in an urban or rural school-based health center located in an Eastern North Carolina county. According to the Youth Risk Behavior Survey (YRBSS), 47% of adolescents across the U.S. have engaged in sexual intercourse at least once. Consequences for adolescents engaging in early sexual activity includes pregnancy and STDs. Additionally, adolescent sexual activity is often related to substance use experimentation; a history of physical, sexual, or emotional/verbal abuse; peer pressure and sexually active friends, or home environment – in relation to parental control. Early sexual activity amongst U.S. teens continues to be a problem for Public Health officials and communities throughout the United States and the rural south. In the United States, 1 million teenagers become pregnant each year. Approximately 47 pregnancies occur each day in North Carolina. 25% of STDs occur to teenagers each year – calculating to 1 out of every 4 teens. Many studies reviewed prior to conducting this particular study, explored single predisposing factors (i.e. early sexual activity vs. sexual abuse), not a combination of factors – as in this study. {CLICK for next slide} 1Centers for Disease Control and Prevention. Youth Risk Behavior Surveillance --- United States, 2005. Surveillance Summaries, June 9, 2006 / 55(SS05); 1-108 2National Campaign to Prevent Teen Pregnancy analysis of Teen Pregnancy Data. (2006).

Teen pregnancy & STD rates (yr. 2000) [explain slide] {CLICK for next slide} Source: CDC; NC SCHS; HIV/STD Prevention & Care

Goals & Objectives Goal: Objective: To describe predisposing factors which may be associated with adolescents’ early sexual behavior, teenage pregnancy, and STD transmission. Objective: To identify risk factors that predispose teens to early sexual behaviors in Wayne Co, NC. The major goal of this study was to examine what predisposing factors are associated with early engagement in sexual behavior, teenage pregnancy, and STD transmission amongst adolescents. The primary outcome or objective was to identify risk factors that predispose adolescents to engage in early sexual activity or behaviors in Wayne County, North Carolina. {CLICK for next slide}

Wayne County, NC Carteret Onslow Hyde Jones Craven Duplin Lenoir Dare Tyrrell Pamlico Wayne Greene Beaufort Washington Martin Pitt Edgecombe Wilson Nash Gates Northampton Halifax Perquimans Chowan Bertie Hertford Pasquotank Camden Currituck This slide shows where Wayne County lies within the context of the eastern portion of North Carolina; and the county which the study took place. {CLICK for next slide} Source: Constance Mason, Dr. Elci

Study Population Target population: Sample population: Rural & urban Wayne Co. students Enrolled in Wayne Co. SBHCs, during 2005-06 & 2006-07 Ages 10-19 yrs. (5th – 12th grades) Sample population: Randomly selected 411 students Systematic sampling A target population consisted of 3,441 rural and urban students who have attended 1 of 6 school-based health centers in Wayne County, NC and have completed a Guidelines for Adolescent Preventative Services (GAPS) questionnaire during the school years 2005-06 and 2006-07. Utilizing a systematic sampling method, a randomized sample of 411 students, ages 10-19 years (5th – 12th grade), were selected as a study population. Enrollment in a school-based health center and completion of the GAPS questionnaire was accepted as consent to participate in the study. {CLICK for next slide}

Sample The sample population was calculated and implemented as shown on this slide. {CLICK for next slide}

Study Instrument Each of the Wayne County school-based health centers require each enrolled student to complete a GAPS questionnaire. The GAPS questionnaire was designed by the American Medical Association (AMA) as a screening tool to be utilized in conjunction with the Guidelines for Adolescent Preventative Services. These guidelines were intended as a model for the implementation of comprehensive adolescent health care in a clinical setting. The 72-item standard GAPS questionnaire consists of various questions regarding sexual health, substance use, parental communication regarding health issues/concerns, family structure, suicidal thoughts, history of abuse, and having ever lived or spent time in a shelter, group home, jail or juvenile detention center. The questionnaire also requests students to provide demographic information (age, gender, race/ethnicity, grade level, primary language spoken). Students who filled out the questionnaire were to respond to the questions by placing a checkmark in a box marked “yes”, “no”, or “not sure”; or by the appropriate available choices when multiple answers were given. The GAPS questionnaire is widely utilized in clinical practice and school-based health clinics, and responses on the GAPS have been corroborated during clinical visits. Approval for this study was obtained from the Institutional Review Board at the Brody School of Medicine at East Carolina University, the Wayne County school-based health centers’ director, and a Wayne County Public School Administrator prior to the start of the study. [Provide copies of GAPS to those who would like to see a copy]. {CLICK for next slide}

Data Collection No identifying markers were collected or reported. Questionnaires were coded numerically for identification purposes. Data was retrieved from 410 questionnaires. Dependent variables for cross-sectional study If a student had ever had sex Ever been pregnant Ever had a STD Possible risk factors were explored Upon completion of 410 questionnaires, data was retrieved. Validity of the student responses were reviewed by the school-based health center nurse and student. No identifying markers were collected or reported to identify participating students. Each questionnaire was coded numerically to identify each questionnaire. Primary dependent variables for this cross-sectional study were: if a student had ever had sex, ever been pregnant, or ever had a STD. Possible risk factors that were examined in this study included: substance use (tobacco use, alcohol use, marijuana use, and other drug use), parental communication, having sexually active friends, and a history of (physical, sexual, or emotional/verbal) abuse; along with race, age, gender, family structure (both parents, single parent, no parents), and the location of residence (rural vs. urban) to predict predisposing factors related to adolescent sexual health. {CLICK for next slide}

Analyses Descriptive statistics Categorical data analysis methods The relationship between sexual activity and risk factors. Unconditional logistic regression models controlled with age race gender family dynamics (living with both parents, single parent, no parents) Descriptive and categorical statistics were utilized in data analysis. Age and gender adjusted unconditional logistic regression models were fit to calculate odds ratios at 95% confidence intervals to examine the relationship between sexual activity and risk factors. This study also controlled for confounding variables [as listed on slide]. {CLICK for next slide}

Results This table shows some of the results calculated from the data collected, shown here in frequencies and percentages. Observations from these results concluded that: Of the 410 students who contributed data to this study, 65.9% live in a rural area, compared to 34.1% living in urban areas. Black students make up 67.6% of the study population. 65% of students reside in a single parent household. Among the black population, 75.3% reside in single parent households. NOTE (%s): blacks, rural areas, single parents, & the risk factors listed on right side of table. {CLICK for next slide}

Sexual activity by age 26% of students were sexually active From this table, we concluded that: 25% of the sample population reported being sexually active. And that there is a linear trend by age; meaning that as age increased, so did the number of teens engaging in sex. {CLICK for next slide} 26% of students were sexually active Linear trend by age

Ever had sex From this table, you can see that with further analysis showed that black teens coming from single parent families, which represented a majority of the observed pregnancies in the study population, were two times more likely to report having ever had sex (OR: 2.0, 95% CI: 1.1-4.1). A positive relationship was observed between the variables ever having had sex and having a history of abuse, and having a history of substance use and sexually active friends. However, there was no significant association between parental communication on having sex, pregnancy, or STDs (p>0.05). In age and gender adjusted logistic regression models, an observation with a similar risk spectrum for having sex among urban and rural teenagers was made. There was no relationship found between the gender of the student and if they have ever had sex. {CLICK for next slide} Students engaged in early sexual activities were 2 times more likely to come from black, single parent households [OR: 2.0 (95% CI: 1.0-4.1)].

Sexual activity in urban vs. rural This slide breaks down the sample population into Urban vs. Rural geographical areas by those students who have reported ever having had sex. We have observed that there is a trend by age in both geographical areas (rural & urban). NOTE: there no reports of race under urban due to “no whites in the urban sample population”. But based on this study, in comparing rural students to ethnicity- blacks have an EXCESS risk of engaging in early sexual activities. {CLICK for next slide}

Parental communication & family structure* In comparing parental communication and family structure to early sexual behaviors among teens, those students who reported having parental communication and who live in urban geographical areas have an EXCESS risk. Also urban area students living in single parent households also have an ELEVATED risk of engaging in early sexual behaviors. {CLICK for next slide} *controlled w/students who reported “ever having had sex”.

Other risk factors In comparing other risk factors to students who reported engaging in early sexual behaviors, results show that substance abuse is a problem in both geographical areas (rural and urban), but more so in rural areas. Also students who reported having a history of abuse (physical, sexual, emotional/verbal) also was observed as a problem in rural areas vs. urban areas. {CLICK for next slide}

Conclusion Higher risk of early sexual activity Black students Urban students Students from a single parent families Students with history of abuse Students who used substances Parental communication…what is being said? Too little too late? This is one of the very few studies that has examined rural & urban adolescents in relation to risk factors for sexual initiation, pregnancy & STD infections. Compared with others, black students from single parent families have a higher risk for early sexual activity. When comparing rural and urban school-based health centers, no significant differences regarding early adolescent sexual activity were observed. This study observed that parental communication does not have protective effects against early sexual activity among adolescents. This is one of the very few studies that has examined rural and urban adolescents in relation to risk factors for sexual initiation, pregnancy, and STD infections. Further studies should focus on interventions addressing these risk factors and include parental education and involvement to reduce the risk of early sexual activity among adolescents. {CLICK for next slide}

Questions?