Environmental, social, and personal correlates of having ever had sexual intercourse among American Indian youths

Parenting in 2 Worlds: Testing improved parent-adolescent communication about sexuality in Urban American Indian families

Urban American Indian (AI) adolescents are more likely than non-Natives to have early sexual debut, teen pregnancies, sexually transmitted infections, and inadequate sexual health information. A RCT in three Arizona cities, with 585 parents of urban AI adolescents, tested whether a culturally tailored parenting intervention for urban AI families, Parenting in 2 Worlds (P2W), increased parent-adolescent communication about sexuality, compared to an informational family health intervention that was not culturally tailored. P2W produced significantly larger increases on two measures: communication about general sexual health and about sexual decision-making. The desired effects of P2W on the first measure were stronger short-term for cross-gender dyads, while for the second measure, they were stronger long-term for both mothers and fathers of adolescent sons.

Comparing American Indian/Alaska Native Adolescent Daughters' and Their Mothers' Awareness, Knowledge, Attitudes, and Behaviors Regarding Risk for Gestational Diabetes: Implications for Mother-Daughter Communication on Reproductive Health

PURPOSE

The purpose of the study was to describe, compare, and examine associations at baseline of reproductive health awareness, knowledge, health beliefs, communication and behaviors related to gestational diabetes (GDM) and GDM risk reduction in a vulnerable population of both American Indian/Alaska Native (AIAN) adolescent girls and their mothers.

METHODS

Descriptive/comparative/correlational analyses examined multitribal baseline data on 149 mother-daughter (M-D) dyads (N = 298; daughter age = 12-24 years) enrolled in a longitudinal study to adapt and evaluate a culturally relevant diabetes preconception counseling (PC) program (Stopping-GDM). The associations between GDM risk reduction awareness, knowledge, health beliefs, and behaviors (eg, daughters' eating, physical activity, reproductive-health [RH] choices/planning, M-D communication, daughters' discussions on PC) were examined. Data collected online from 5 national sites.

RESULTS

Many M-D lacked awareness/knowledge of GDM and risk reduction. Both M-D were unaware of the girl's risk for GDM. Mothers' knowledge and beliefs on GDM prevention/RH were significantly higher than daughters. Younger daughters had greater self-efficacy healthy living. Overall sample reported low to moderate scores for both M-D communication and daughters' GDM and RH risk-reduction behaviors.

CONCLUSIONS

Knowledge, communication, and behaviors to prevent GDM were low in AIAN M-D, especially daughters. More than daughters, mothers perceive greater risk of GDM for daughters. Early culturally responsive dyadic PC programs could help decrease risk of developing GDM. Implications for M-D communication is compelling.

Baseline results from NenŨnkUmbi/EdaHiYedo: A randomized clinical trial to improve sexual and reproductive health among American Indian adolescents

We report on baseline findings from NenUnkUmbi/EdaHiYedo, a community based participatory research randomized controlled trial with American Indian adolescents to reduce sexual and reproductive health disparities. American Indian adolescents aged 13-19 years participated in a baseline survey that was administered in five schools. We used zero-inflated negative binomial regression to evaluate how the count of protected sexual acts was associated with independent variables of interest. We stratified models by self-reported gender of adolescents and tested for a two-way interaction effect between gender and the independent variable of interest. Two hundred twenty-three girls and 222 boys (n = 445) were sampled. The average number of lifetime partners was 1.0 (standard deviation = 1.7). Each additional lifetime partner was associated with a 50% increase in the number of protected sexual acts incident rate ratio (IRR = 1.5, 95% confidence interval [CI] 1.1-1.9) and more than a twofold increase in the likelihood of not having protected sexual acts (adjusted odd ratio [aOR] = 2.6, 95% CI 1.3-5.1). Each additional number of substances used in adolescentss' lifetime was associated with an increased likelihood of not having protected sexual acts (aOR = 1.2, 95% CI 1.0-1.5). In boys, each one standard deviation increase in depression severity was associated with a 50% reduction in the number of times a condom was used adjusted IRR (aIRR = 0.5, 95% CI 0.4-0.6, p < .001). Each 1-unit increase in positive prospections of pregnancy was associated with a pronounced decrease likelihood of not having protected sexual acts (aOR = 0.01, 95% CI 0.0-0.1). Findings support the importance of tribally driven tailoring of sexual and reproducive health interventions and services for American Indian adolescents.

Rationale, Design, and Methods for Nen Unkumbi/Edahiyedo ("We Are Here Now"): A Multi-Level Randomized Controlled Trial to Improve Sexual and Reproductive Health Outcomes in a Northern Plains American Indian Reservation Community

American Indian (AI) youth in the United States experience disproportionate sexual and reproductive health (SRH) disparities relative to their non-Indigenous, white counterparts, including increased rates of sexually transmitted infections (STIs), earlier sexual debut, increased rates of teen birth, and reduced access to SRH services. Past research shows that to improve SRH outcomes for AI youth in reservation communities, interventions must address complex factors and multiple levels of community that influence sexual risk behaviors. Here, we describe development of a multi-level, multi-component randomized controlled trial (RCT) to intervene upon SRH outcomes in a Northern Plains American Indian reservation community. Our intervention is rooted in a community based participatory research framework and is evaluated with a stepped wedge design that integrates 5 reservation high schools into a 5-year, cluster-randomized RCT. Ecological Systems Theory was used to design the intervention that includes (1) an individual level component of culturally specific SRH curriculum in school, (2) a parental component of education to improve parent-child communication about SRH and healthy relationships, (3) a community component of cultural mentorship, and (4) a systems-level component to improve delivery of SRH services from reservation healthcare agencies. In this article we present the rationale and details of our research design, instrumentation, data collection protocol, analytical methods, and community participation in the intervention. Our intervention builds upon existing community strengths and integrates traditional Indigenous knowledge and values with current public health knowledge to reduce SRH disparities.

'Marriage is Going to Fix It': Indigenous Women's Experiences with Early Childbearing, Early Marriage and Intimate Partner Violence

Intimate partner violence (IPV), early childbearing (ECB) and early marriage (EM) are interconnected to the historical oppression of patriarchal colonialism imposed upon Indigenous peoples throughout the world by colonising nations, such as the UK. The artefacts of colonial oppression persist in both colonising nations and those that have been colonised through social norms of patriarchal oppression perpetuated upon women with far-reaching consequences. Indigenous women of the US experience higher rates of IPV, ECB and EM than any other ethnic group-which pose risks to women's physical, psychological, socioeconomic and educational status. The purpose of this study is to explore Indigenous women's experiences with ECB and EM through a critical ethnography with two US tribes. Through reconstructive analysis the following themes emerged: (i) ECB as a Precursor to Marriage; (ii) Unequal and Overburdened Marriages; (iii) ECB, EM and IPV; and (iv) Continued Harmful Effects of Multiple Abusive Relationships. Indigenous women's experiences of ECB and EM are connected to patriarchal historical oppression that systematically dehumanises and oppresses Indigenous women, who were once treated with respect and esteem. Decolonisation and re-visualisation to promote the status of women and girls are needed to offset women's constrained wellness, socio-political status and safety.

Intimate Partner and Sexual Violence, Reproductive Coercion, and Reproductive Health Among American Indian and Alaska Native Women: A Narrative Interview Study

Background: The disproportionately high prevalence of poor reproductive and sexual health outcomes among American Indian and Alaska Native (AI/AN) women is related to histories of colonization, oppression, and structural racism. Intimate partner violence (IPV) and sexual violence (SV) contribute to these health outcomes. Materials and Methods: Narrative interviews were conducted with AI/AN women from four tribal reservation communities. Interviews explored connections among sexual and reproductive health, IPV, SV, reproductive coercion (RC), and pregnancy experiences as well as women's experiences of healing and recovery. Results: Among the 56 women interviewed (aged 17-55 years, 77% were aged 40 years and younger), all described multiple exposures to violence and highlighted lack of disclosure related to sexuality, childhood abuse, SV, and historical trauma. Access to confidential reproductive health services and contraceptive education was limited. Almost half (45%) reported experiencing RC in their lifetime. Use of substances occurred in both the context of SV and for surviving after exposure to violence. Women underscored the extent to which IPV, SV, and RC are embedded in histories of colonization, racism, and ongoing oppression. Interventions that incorporate AI/AN traditions, access to culturally responsive reproductive health and advocacy services, organizations, and services that have AI/AN personnel supporting survivors, public discussion about racism, abuse, sexuality, and more accountable community responses to violence (including law enforcement) are promising pathways to healing and recovery. Conclusions: Findings may advance understanding of AI/AN women's reproductive health in the context of historical trauma and oppression. Intervention strategies that enhance resiliency of AI/AN women may promote reproductive health.

Positive Psychological Characteristics and Substance Use in First Nation Adolescents

BackgroundNorth American Indigenous (NAI) adolescents experience disproportionate harm related to substance use compared to non-Indigenous adolescents. Strengths-based approaches to substance use prevention and treatment are consistent with Indigenous conceptualizations of health, which tend to be holistic and incorporate more spirituality and community than mainstream Western conceptualizations. Despite this, little is known about how positive psychological characteristics that might confer protection relate to substance use among NAI adolescents. Thus, the present study aims to examine the relations among life satisfaction, subjective happiness, self-compassion, and cigarette, marijuana, alcohol, and other drug use. MethodsParticipants were 106 reserve-dwelling First Nation adolescents located in Eastern Canada (M_age= 14.6 years, 50.0% female) who completed a paper-and-pencil survey regarding their substance use and psychological characteristics for a larger community-based participatory research project. ResultsGreater life satisfaction was significantly associated with decreased odds of lifetime (OR = 0.88, 95%CI [0.81, 0.96]) and current cigarette smoking (OR = 0.90, 95%CI [0.82, 0.99]). Greater subjective happiness was significantly associated with decreased odds of current marijuana use (OR = 0.83, 95%CI [0.71, 0.97]). Although significantly correlated with lower lifetime use of other drugs, self-compassion was not significantly associated with lifetime or current odds of substance use after controlling for age, gender, and other positive characteristics. DiscussionThis is one of the first studies to evaluate positive characteristics and substance use in NAI adolescents. Results point to positive characteristics that may be useful in substance use prevention and suggest the need for further research to further elucidate these associations.

Impacts of the respecting the circle of life teen pregnancy prevention program on risk and protective factors for early substance use among native American youth

BACKGROUND

Early substance use disproportionately impacts Native American (Native) youth and increases their risk for future abuse and dependence. The literature urges for interventions to move beyond focusing on single risk behaviors (e.g. substance use) and instead have capacity to improve health risk behaviors co-occuring during adolescence, particularly among Native populations for whom few evidence-based interventions (EBI) exist. We evaluated the effectiveness of the Respecting the Circle of Life program (RCL) on risk and protective factors for early substance use. RCL is a culturally tailored EBI shown to improve sexual health outcomes among Native youth.

METHODS

We conducted secondary analyses of data collected through a community-based randomized controlled trial of RCL evaluated among Native youth (ages 11-19) residing on a rural reservation between 2015-2020 (N = 534, 47.4 % male). We used linear regression, controlling for baseline age and sex, to test between study group differences in outcomes at 3-, 9-, and 12-month post-intervention. Models were stratified by sex and age (11-12, 13-14, and 15+ years of age) to examine differences within these subgroups.

RESULTS

Youth receiving RCL reported lower intention to use substances through 12-months follow-up (p = 0.006). Statistically significant improvements were also observed across peer, parent, and sexual partner risk and protective factors to delay substance use initiation, with notable differences among boys and participants ages 13-14.

CONCLUSIONS

RCL is a primary prevention, skills-based program effective in preventing risks for substance use. This evaluation underscores the value in developing programs that influence concurrent adolescent risk behaviors, especially for Native communities who endure multiple health disparities.

Assessment of the Reach, Usability, and Perceived Impact of "Talking Is Power": A Parental Sexual Health Text-Messaging Service and Web-Based Resource to Empower Sensitive Conversations with American Indian and Alaska Native Teens

BACKGROUND

Early sexual debut among American Indian and Alaska Native (AI/AN) adolescents has been associated with an increased risk of teenage pregnancies and sexually transmitted infections, along with an increased risk of having multiple lifetime sexual partners, and engaging in greater frequency of sex, substance abuse, and lack of condom use. A major protective factor against early sexual debut among AI/AN youth is the familial system. Interventions aiming to improve parent-child communication and parental warmth toward adolescent sexual health topics were reported to contribute to positive youth sexual health outcomes, specifically among minority youth. Healthy Native Youth thus developed the Talking is Power text-messaging service to guide parents and caring adults on how to initiate sensitive topics with youth and how to support them in making informed decisions regarding sex and healthy relationships.

METHODS

Descriptive statistics were used to demonstrate website analytics and reach per views and time spent on each page, and for displaying participants' responses to the questions on the usability of the Talking is Power text-messaging series. To assess the perceived impact of the series, the differences in mean percentage scores of the question assessing parental comfort in engaging in sexual health topics with youth between pre- and post-intervention were calculated using two-sample t-tests of equal variances. Descriptive content analysis was adopted to highlight emerging themes from open-ended items.

RESULTS

When looking at reach, 862 entrances were recorded during the specified time period (5.8% of total entrances to HNY website), while the bounce rate was set at 73.1% (22.6% greater than the industry average), and the exit rate was 54.3% (15.2% greater than the industry average). Series usability was highly ranked on the 5-Likert scale in terms of signing up for a similar series on a different topic, quality of images, texts, and links, relating to prompts, and change in sparking sensitive conversations with youth. High likelihood of recommending the series to a friend or colleague was also reported by participants (0-10). No significant difference in parental comfort levels was reported (p = 0.78 > 0.05). Main themes provided suggestions for improving the series mode of delivery, while others included positive feedback about the material, with the possibility of expanding the series to other adolescent health topics.

CONCLUSION

Lessons learned during the design, dissemination, and evaluation of the resource's usability, reach, and perceived impact may be of interest to other Indigenous communities who are in the process of adapting and/or implementing similar approaches.

Effectiveness of Native STAND: A Five-Year Study of a Culturally Relevant Sexual Health Intervention

Culturally relevant interventions have the potential to improve adolescent health and protective factors associated with sexual risk taking. We evaluated the impact of the Native STAND curriculum with American Indian and Alaska Native (AI/AN or Native) high school students living across the U.S. using a pre-post evaluation design. Native STAND is a comprehensive sexual health curriculum for Native high school students that focuses on sexually transmitted infections, HIV/AIDS, and teen pregnancy prevention, while also covering drug and alcohol use, suicide, and dating violence. The curriculum was implemented in 48 AI/AN communities from 2014 to 2019. A significantly higher percentage of youth reported at post-test having a serious conversation about sex with their friends (post 36% vs. pre 28%, p < 0.001), thinking about lessons learned (post 24% vs. pre 7%, p < 0.0001), and sharing lessons learned during the conversation (post 21% vs. pre 4%, p < 0.001). A lower percentage of AI/AN youth reported being bullied in the last year (post 31% vs. pre 37%, p < 0.001). Family social support was moderated by dose, with subscale scores of 3.75 at post-with <27 sessions vs. 3.96 at post-with all 27 sessions (p = 0.02). The results demonstrate the effectiveness of Native STAND when delivered in a variety of settings. Efforts are now underway to update Native STAND for medical accuracy, improve alignment with typical class periods, and promote its use and an effective EBI for AI/AN youth.

Empowering our people: Predictors of retention in an STI risk reduction program among rural Native Americans with binge substance use

PURPOSE

Substance use and sexual risk-taking have been shown to co-occur. Programs focused on sexually transmitted infections (STIs) reduction may benefit substance-using, particularly binge substance-using, adults. This is especially true for rural Native American communities who endure sexual and substance use disparities and have few STI risk reduction programs. This study explores factors predicting retention in an STI risk reduction program among rural Native adults engaged in binge substance use.

METHODS

We analyzed data from 150 Native adults ages 18-55 participating in an evaluation of "EMPWR," a 2-session STI risk reduction program in a rural, reservation-based community. Multivariate logistic regression models were used to estimate associations between independent variables and program completion across demographics, sexual behaviors, substance use behaviors, mental health, recent health care utilization, and perceived enculturation and discrimination.

FINDINGS

The sample was 49.2% (n = 59) female with a mean age of 33.61 years (SD = 8.25). Twenty-six completed only the first EMPWR session, 94 completed both EMPWR sessions, and 30 were randomized but completed 0 sessions. Being married/cohabiting (adjusted odds ratio [AOR] = 6.40, P = .0063) and living with an older generation (AOR = 4.86, P = .0058) were significantly associated with higher odds of completing EMPWR.

CONCLUSIONS

Findings provide insight on factors driving retention of Natives with recent binge substance use in STI risk reduction programming. An important contribution to Native health literature is that living with an older generation positively predicted EMPWR program completion, suggesting that STI risk reduction programs should harness the strength of families to ensure program attendance and optimize impacts in rural reservation contexts.

"There Is a Lot of Practice in Not Thinking about That": Structural, Interpersonal, and Individual-Level Barriers to HIV/STI Prevention among Reservation Based American Indians

American Indians (AI) face significant disparities in HIV/STI morbidity and mortality, and historical, structural, interpersonal, and individual level barriers stymie prevention efforts. The objective of this paper is to examine barriers to HIV/STI prevention among reservation-based AI. We conducted face-to-face qualitative interviews with 17 reservation-based AI community leaders and community members in Southern California on HIV/STI knowledge and attitudes and barriers to prevention. The disruption of traditional coping mechanisms and healing processes were compromised by historical trauma, and this allowed stigmas to exist where they did not exist before. This impacted access to healthcare services and trust in medicine, and is linked to individuals adopting negative coping behaviors that confer risk for HIV/STI transmission (e.g., substance use and sexual behaviors). Most of the participants reported that HIV/STIs were not discussed in their reservation-based communities, and many participants had a misperception of transmission risk. Stigma was also linked to a lack of knowledge and awareness of HIV/STI's. Limited available services, remoteness of communities, perceived lack of privacy, and low cultural competency among providers further hindered the access and use of HIV/STI prevention services. These findings highlight the need to address the historical, structural, and interpersonal factors impacting individual-level behaviors that can increase HIV/STI transmission among reservation-based AIs. Prevention work should build on community strengths to increase HIV/STI knowledge, reduce stigma, and increase access to preventative care while using culturally grounded methodologies.

The factor structure of self-esteem and its association with alcohol use in American Indian (AI) adolescents

American Indian (AI) adolescents experience disproportionately higher rates of alcohol use and related consequences. While self-esteem has been found to be associated with alcohol use in non-AI samples, little is known about this relationship in AI adolescents. Further, there is a dearth of literature examining the psychometric properties of self-esteem measures for AI adolescents. The current study aims to examine the factor structure of the self-esteem items of the American Drug and Alcohol Survey (ADAS) and to better understand the relationships among self-esteem, alcohol use, and alcohol-related problems in AI adolescents. The present study represents secondary analyses of cross-sectional data collected between 2009 and 2013. Participants (n = 3,498) were AI adolescents (Mage = 14.8, 47.7% female) attending schools on or near reservations across 11 states. Participants completed the American Drug and Alcohol Survey. Factor analytic results suggested 2 factors, representing intrapersonal (from intrinsic sources) and interpersonal self-esteem (from extrinsic sources). Multilevel regression analyses revealed that, with both factors entered into the model, intrapersonal self-esteem was negatively associated with alcohol consumption and alcohol-related problems, while interpersonal self-esteem was positively associated with alcohol consumption and alcohol-related problems. Results suggest the importance of examining the properties of assessment tools before they are used with a community for whom they were not developed. Further, self-esteem does not appear to be universally protective. Rather, interventions should aim to consider sources from which AI adolescents are drawing self-esteem and focus on promoting more intrinsic sources rather than aiming to increase self-esteem in general. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Recommendations from an expert panel of health professionals regarding a gestational diabetes risk reduction intervention for American Indian/Alaska Native Teens

BACKGROUND

American Indian/Alaska Native (AI/AN) adolescents are at higher risk for gestational diabetes (GDM), type 2 diabetes, and pregnancy complications than the general population.

OBJECTIVE

To inform cultural adaptation of a validated evidence-based intervention (VEBI) originally designed to deliver preconception counseling and diabetes education to non-AI/AN teens with diabetes.

DESIGN

Qualitative data were collected using focus group and individual interview methods with health care professionals and experts (n = 16) in AI/AN health, GDM, adolescent health, and/or mother-daughter communication. A semistructured discussion guide elicited responses about provision of care for AI/AN girls at risk for GDM, experience with successful programs for AI/AN teens, comfort of mother/daughter dyads in talking about diabetes and reproductive health and reactions to video clips and booklet selections from the VEBI. All interviews were recorded and transcribed verbatim, and data analysis included inductive coding and identification of emergent themes.

RESULTS

Providers felt teens and their moms would be comfortable talking about the VEBI topics and that teens who did not feel comfortable talking to their mom would likely rely on another adult female. Participants suggested including: AI/AN images/motifs, education with a community focus, and avoiding directive language. Concerns included: socioeconomic issues that affect AI/AN people such as: food and housing insecurity, abuse, and historical trauma.

CONCLUSIONS

Perspectives from these participants have been used to guide the development of a culturally tailored GDM risk reduction program for AI/AN girls. This program will be available to health care providers who serve the AI/AN population.

Community Perceptions of Alcohol Exposed Pregnancy Prevention Program for American Indian and Alaska Native Teens

A community needs assessment during a tribally-led Changing High-Risk Alcohol Use and Increasing Contraception Effectiveness Study (CHOICES) intervention highlighted the need to reduce the risk for alcohol exposed pregnancy (AEP) among American Indian and Alaska Native (AIAN) adolescent girls. The CHOICES for American Indian Teens (CHAT) Program aims to reduce the risk of AEP among AIAN teens in one Northern Plains tribal community. The CHAT team adopted an iterative process to modify the tribally-led CHOICES curriculum for AIAN teens. This paper describes the iterative process as well as the community perception towards AEP prevention among AIAN teens. The CHAT team conducted several levels of formative and qualitative research, including one-on-one interviews (n = 15) with community members, AIAN elders and school counsellors; and three focus groups with AIAN adolescent girls (n = 15). A qualitative data analysis identified several recommendations that centered on making the information regarding alcohol and birth control appealing to teens; ensuring the confidentiality of the participants; making the program culturally relevant; and including boys in the program. This study outlines various components prioritized by community members in creating a culturally-relevant and age-appropriate AEP prevention program and provides community perceptions of AEP prevention for the teens in this community.

The Association between Substance Abuse and Sexual Misconduct among Macau Youths

This study investigates how peer influence, school attachment, and substance abuse are related to sexual behavior, with particular interest in exploring the relationship between substance abuse and sexual misconduct, while using a stratified random sample of adolescents in Macau. Mediation analyses were employed. The results show that substance abuse, apart from susceptibility to peer influence and school attachment/commitment, was significantly related to sexual misconduct. Substance abuse was the best predictor of sexual misconduct, and it significantly mediated the relationship between susceptibility to peer influence, as well as school attachment and sexual misconduct. This reflects that the use of substances, including drugs, alcohol, and cigarettes, can be viewed as a catalyst for triggering engagement in sexual misconduct. The implications of this study involve taking measures to reduce the rate of substance abuse as a way of decreasing sexual misconduct in adolescents. Future research directions in exploring the relationship between adolescent substance abuse and risky sexual behavior are discussed.

Applying core theory and spatial analysis to identify hepatitis C virus infection "core areas" in British Columbia, Canada

"Core areas" of transmission for bacterial sexually transmitted infections have been identified. However, it is unclear whether core areas apply to viral infections, such as hepatitis C virus (HCV). We used geographic mapping and spatial analysis to identify distinct core areas of HCV infection in British Columbia (BC) using the BC Hepatitis Testers Cohort (BC-HTC), 1990-2013. The BC-HTC includes all BC residents tested for HCV (~1.5 million; 1990-2013). Core HCV infection areas were identified spatially and temporally for five time periods (1990-1993, 1994-1998, 1999-2003, 2004-2008 and 2009-2013) through thematic mapping, Kernel Density Estimation, Hotspot analysis and cluster analysis at the Census dissemination area level in ArcGIS and SatScan. HCV infection core areas were consistently identified. HCV core areas expanded from the downtown of major cities in different regions of BC (Metro Vancouver, Vancouver Island, and Northern BC; 1990-1998), to smaller cities in Metro Vancouver and Interior BC (2000 onwards). Statistically significant clusters, or hotspots, were also observed for downtown Vancouver, Northern BC (Prince George) and Vancouver Island from 1990 to 2008 with expansion to other urban areas in Metro Vancouver from 1990-2013. Statistically significant clusters persisted after adjustment for injection drug use, number of HCV tests, age, sex, material and social deprivation. Persistence of areas with high HCV diagnoses rates in Vancouver and Prince George supports the theory of core areas of HCV transmission. Identification of core areas can inform prevention, care and treatment programme interventions and evaluate their impact over time.

Risk and Protective Factors Associated With Lifetime Sexual Experience Among Rural, Reservation-Based American Indian Youth

Early sexual initiation is a catalyst for sexually transmitted infection and unintended pregnancy. American Indian/Alaska Native (AI/AN) youth initiate sex prior to age 13 more often than other U.S. youth, contributing to current inequalities in sexual health. Identifying what factors were associated with lifetime sexual experience among AI/AN youth can inform the development of primary prevention programming to delay sexual initiation, alleviate the costs of early sexual activity, and improve sexual health outcomes in this population. We analyzed cross-sectional data from 267 AI youth ages 13-19, recruited from a rural, reservation-based community. We used multivariate logistic regression models to estimate associations between independent variables and lifetime sexual experience (vaginal and/or anal sex) across the following categories: sociodemographic, knowledge, attitudes/perceptions, beliefs, intentions, skills, behaviors, and theoretical constructs. The sample was 56.2% female, mean age 15.1 years (SD = 1.7), and 22.5% were sexually experienced. In our final model, condom use self-efficacy (attitude/perception factor) and intentions to remain abstinent until marriage (intention factor) were associated with lower odds of lifetime sexual experience. Age (sociodemographic factor), intention to have sex (intention factor), use of any contraception (behavior factor), and higher response efficacy (theoretical construct) were associated with lifetime sexual experience. Of these, intention to have sex was the strongest indicator. These results both corroborate and contrast with other research conducted among rural, reservation-based AI/AN youth. Our findings show programs targeting intentions may have the greatest impact among reservation-based AI youth, and justify program delivery stratified by age group in this setting.

Developmental Assets and Risky Sexual Behaviors among American Indian Youth

This study examined the relationship between developmental assets during early and mid-adolescence and early adult sexual behaviors among American Indians using a subsample from the National Longitudinal Study of Adolescent Health (N = 465). Grounded in an assets framework, the authors explored the protective role of personal, family, school, and community assets as well as cumulative assets for sexual behaviors including early sexual debut, number of sexual partners, and frequency of condom use. The results indicated that certain assets during early and mid-adolescence, such as self-control, family support, and school attachment were protective for various risky sexual behaviors in early adulthood. Furthermore, cumulative assets emerged as an important predictor of sexual behaviors. These findings highlight the utility of applying a developmental asset framework to understand protective factors among American Indian youth.

Applying the Theory of Reasoned Action to Understanding Teen Pregnancy with American Indian Communities

Objectives American Indian girls have higher teen pregnancy rates than the national rate. Intervention studies that utilize the Theory of Reasoned Action have found that changing attitudes and subjective norms often leads to subsequent change in a variety of health behaviors in young adults. The current study goal is to better understand sexual decision-making among American Indian youth using the Theory of Reasoned Action model and to introduce ways to utilize attitudes and subjective norms to modify risky behaviors. Methods The project collected qualitative data at a reservation site and an urban site through 16 focus groups with American Indian young people aged 16-24. Results Attitudes towards, perceived impact of, and perception of how others felt about teen pregnancy vary between American Indian parents and non-parents. Particularly, young American Indian parents felt more negatively about teen pregnancy. Participants also perceived a larger impact on female than male teen parents. Conclusions There are differences between American Indian parents and non-parents regarding attitudes towards, the perceived impact of, and how they perceived others felt about teen pregnancy. Teen pregnancy prevention programs for American Indian youth should include youth parents in curriculum creation and curriculum that addresses normative beliefs about teen pregnancy and provides education on the ramifications of teen pregnancy to change attitudes.

NATIVE-It's Your Game: Adapting a Technology-Based Sexual Health Curriculum for American Indian and Alaska Native youth

Sexually transmitted infection (STI) and birth rates among American Indian/Alaska Native (AI/AN) youth indicate a need for effective middle school HIV/STI and pregnancy prevention curricula to delay, or mitigate, the consequences of early sexual activity. While effective curricula exist, there is a dearth of curricula with content salient to AI/AN youth. Further, there is a lack of sexual health curricula that take advantage of the motivational appeal, reach, and fidelity of communication technology for this population, who are sophisticated technology users. We describe the adaptation process used to develop Native It's Your Game, a stand-alone 13-lesson Internet-based sexual health life-skills curriculum adapted from an existing promising sexual health curriculum, It's Your Game-Tech (IYG-Tech). The adaptation included three phases: (1) pre-adaptation needs assessment and IYG-Tech usability testing; (2) adaptation, including design document development, prototype programming, and alpha testing; and (3) post-adaption usability testing. Laboratory- and school-based tests with AI/AN middle school youth demonstrated high ratings on usability parameters. Youth rated the Native IYG lessons favorably in meeting the needs of AI/AN youth (54-86 % agreement across lessons) and in comparison to other learning channels (57-100 %) and rated the lessons as helpful in making better health choices (73-100 %). Tribal stakeholders rated Native IYG favorably, and suggested it was culturally appropriate for AI/AN youth and suitable for implementation in tribal settings. Further efficacy testing is indicated for Native IYG, as a potential strategy to deliver HIV/STI and pregnancy prevention to traditionally underserved AI/AN middle school youth.

Family and Friend Influence on Urban-Dwelling American Indian Adolescent Girl's Sexual Risk Behavior

Previous research with American Indian (AI) adolescent sexual risk behavior primarily focused on reservation-dwelling youth despite 70% of AIs living off Native lands. Using grounded theory methodology, I sampled 20 adolescent AI girls via talking circles and interviews to explore the perceptions of AI adolescent girls living in an urban, Midwest area about the influence of family and friends on their sexual behavior. Similar to research with other racial groups, participants cited their family and friends as a major influence. Five unique themes emerged related to family and friend influence. Urban-dwelling AI girls rely on their female family members and peers for information related to sex and receive varying messages from their networks of family and friends, which often overlap. AI youth have unique family groups yet have some similarities to other ethnic groups with regard to family and friend relationships that may allow for enhanced intervention development.

HIV, Chlamydia, Gonorrhea, and Primary and Secondary Syphilis among American Indians and Alaska Natives Within Indian Health Service Areas in the United States, 2007-2010

National rates from human immunodeficiency virus (HIV) and sexually transmitted disease (STD) surveillance may not effectively convey the impact of HIV and STDs on American Indian/Alaska Native (AI/AN) communities. Instead, we compared average annual diagnosis rates per 100,000 population of HIV, chlamydia (CT), gonorrhea (GC), and primary and secondary (P&S) syphilis, from 2007 to 2010, among AI/AN aged ≥ 13 years residing in 625 counties in the 12 Indian Health Service Areas, all AI/AN, and all races/ethnicities to address this gap. AI/AN comprised persons reported as AI/AN only, with or without Hispanic ethnicity. Out of 12 IHS Areas, 10 had higher case rates for CT, 3 for GC, and 4 for P&S syphilis compared to rates for all races/ethnicities. Eight Areas had higher HIV diagnosis rates than for all AI/AN, but HIV rates for all IHS Areas were lower than national rates for all races/ethnicities. Two IHS Areas ranking highest in rates of CT and GC and four Areas with highest P&S syphilis also had high HIV rates. STD and HIV rates among AI/AN were greater in certain IHS Areas than expected from observing national rates for AI/AN. Integrated surveillance of overlapping trends in STDs and HIV may be useful in guiding prevention efforts for AI/AN populations.

The Relationship Between Pregnancy Prevention and STI/HIV Prevention and Sexual Risk Behavior Among American Indian Men

OBJECTIVE

We examined the relationship between American Indian men's attitudes toward pregnancy prevention, STI/HIV prevention, and sexual risk behavior. Attention was given to: (1) attitudes and intentions to use condoms and sexual risk behavior; (2) STI/HIV prevention characteristics and sexual risk behavior; (3) attitudes toward abstinence and monogamy and sexual risk behavior; and (4) decision-making in relationships and sexual risk behavior.

STUDY DESIGN

Our sample included 120 heterosexual American Indian men aged 18 to 24 living on a reservation. Data were collected during in-depth interviews. A community-based participatory research framework was used to ensure the relevancy and acceptability of the study given the sensitivity of the topic.

PRINCIPAL FINDINGS

Results demonstrated that attitudinal factors were associated with sexual risk behavior, particularly inconsistent condom use. Attitudes associated with consistent condom use suggested greater levels of positive dispositions toward prevention and intention to use condoms. Consistent condom use was associated with more cautious attitudes toward sex with multiple sex partners. Study results suggested that American Indian men who reported sex with multiple partners exhibited a set of attitudes and beliefs toward pregnancy prevention and STI/HIV prevention that corresponded with a disposition resulting from their behaviors, in that engaging in sexual risk behavior elevated their levels of risk perception.

CONCLUSIONS

Our findings suggest that heterosexual American Indian men living in rural environments need sexual and reproductive health programs and clinical services that address differing attitudes toward condom use within the context of multiple sex partners and sexual risk behavior.

Factors Associated With Early Sexual Experience Among American Indian and Alaska Native Youth

PURPOSE

American Indian and Alaska Native (AI/AN) youth experience disparities associated with sexual and reproductive health, including early age of sexual initiation. Identifying factors that are most proximally related to early sexual intercourse and that are modifiable through health promotion interventions may help to reduce these disparities. Using a multisystem approach, we assessed individual (biological, psychological, and behavioral), familial, and extrafamilial (peer behavioral) factors associated with lifetime sexual experience among AI/AN early adolescents living in three geographically dispersed U.S. regions.

METHODS

We analyzed cross-sectional data from 537 AI/AN youth aged 12-14 years, recruited from 27 study sites in Alaska, Arizona, and the Pacific Northwest. We used multilevel logistic regression models to estimate associations between independent variables and lifetime sexual intercourse (oral and/or vaginal sex) individually, within discrete systems, and across systems.

RESULTS

The analytical sample was 55.1% female, with a mean age of 13.2 years (standard deviation = 1.06 years); 6.5% were sexually experienced. In the final model, we found that lower next-year intentions to have oral or vaginal sex (psychological factors), avoidance of risky situations, and nonuse of alcohol (behavioral factors) were associated with lower odds of lifetime sexual intercourse (all p ≤ .01). No other variables were significantly associated with lifetime sexual intercourse.

CONCLUSIONS

Interventions that reduce sexual intentions, exposure to risky situations, and alcohol use may help to delay sexual initiation among AI/AN early adolescents.

Understanding gender roles in teen pregnancy prevention among American Indian youth

OBJECTIVES

To examine the impact of gender norms on American Indian (AI) adolescents' sexual health behavior.

METHODS

The project collected qualitative data at a reservation site and an urban site through 24 focus groups and 20 key informant interviews.

RESULTS

The reasons that AI youth choose to abstain or engage in sexual intercourse and utilize contraception vary based on gender ideologies defined by the adolescent's environment. These include social expectations from family and peers, defined roles within relationships, and gender empowerment gaps.

CONCLUSIONS

Gender ideology plays a large role in decisions about contraception and sexual activity for AI adolescents, and it is vital to include redefinitions of gender norms within AI teen pregnancy prevention program.

Sex differences in associations of school connectedness with adolescent sexual risk-taking in Nova Scotia, Canada

BACKGROUND

Associations of lower school connectedness have been seen with adolescent sexual risk behaviors, but little is known about gender differences with respect to these relationships. Understanding any such differences could contribute to better supporting the school environment to promote youth sexual health.

METHODS

We used provincially representative cross-sectional data from 1415 sexually active students in grades 10 to 12 in Nova Scotia, Canada, to determine whether lower school connectedness was associated with students' sexual risk behaviors using multivariate logistic regression, stratifying by sex.

RESULTS

In boys, lower connectedness was associated with three risk behaviors, having  ≥ 2 partners in the previous year (odds ratio [OR] 1.07; 95% confidence interval [CI] 1.01-1.13), no condom use at last intercourse (OR 1.06; 95% CI 1.01-1.12), and having unplanned intercourse due to substance use (OR 1.09; 95% CI 1.03-1.15). No such associations were seen in girls.

CONCLUSIONS

These results demonstrate that gender differences may exist for associations of school connectedness and sexual risk behaviors; connectedness may be more important for boys than for girls in this area of adolescent health. Educators should consider gender differences when designing interventions to maximize youth sexual health through school-based interventions. Further research on school connectedness and risk-taking should examine genders separately.

Urban American Indian Adolescent Girls: Framing Sexual Risk Behavior

PURPOSE

The purpose of this study was to explore factors that influence urban adolescent American Indian (AI) girls' sexual risk behavior.

DESIGN

A qualitative study was conducted with grounded theory methodology to reveal factors and processes that influence sexual risk behavior.

METHOD

Talking circles, individual interviews, and event history calendars were used with 20 urban AI 15- to 19-year-old girls to explore influences on sexual risk behavior.

RESULTS

The generated theory-framing sexual risk behavior-describes social and structural factors and processes that influenced the girls' sexual risk behavior. The theory extends Bronfenbrenner's ecological model by identifying microsystem, mesosystem, and macrosystem influences on sexual risk behavior.

DISCUSSION

Urban AI girls reported similar social and structural influences on sexual risk behavior as urban adolescents from other racial and ethnic groups. However, differences were noted in the family structure, cultural heritage, and unique history of AIs.

IMPLICATIONS

This theory can be used in culturally responsive practice with urban AI girls.

Expanding urban American Indian youths' repertoire of drug resistance skills: pilot results from a culturally adapted prevention program

This article examines changes in the drug resistance strategies used by urban American Indian (UAI) middle school students during a pilot test of a substance use prevention curriculum designed specifically for UAI youth, Living in 2 Worlds (L2W). L2W teaches four drug resistance strategies (refuse, explain, avoid, leave [R-E-A-L]) in culturally appropriate ways. Data come from 57 UAI students (53% female; mean age = 12.5 years) who participated in L2W during an academic enrichment class for Native youth at two Phoenix schools. Students completed a pre-test questionnaire before the L2W lessons and a post-test 7 months later. Questions assessed the use of R-E-A-L and alternative strategies commonly reported by UAI youth (change the subject, use humor). Tests of mean differences from pre-test to post-test showed significant increases in use of refuse, explain, and leave, and an expanding R-E-A-L repertoire. Use of more passive strategies (avoid, use humor) did not change significantly, except for change the subject, which increased. Changes in the use of strategies did not differ significantly by gender, age, school grades, parental education, or length of urban residence. The L2W curriculum appears effective in teaching culturally relevant communication strategies that expand UAI youths' repertoire of drug resistance skills.

Substance use and sexual risk behaviors among american Indian and alaska native high school students

BACKGROUND

We describe the prevalence of behaviors that put American Indian and Alaska Native (AI/AN) high school students at risk for teen pregnancy and sexually transmitted infections (STIs) and the relationships among race/ethnicity and these behaviors.

METHODS

We analyzed merged 2007 and 2009 data from the national Youth Risk Behavior Survey, a biennial, self-administered, school-based survey of US students in grades 9-12 (N = 27,912). Prevalence estimates and logistic regression, controlling for sex and grade, were used to examine the associations between race/ethnicity, and substance use, and sexual risk behaviors.

RESULTS

Of the 26 variables studied, the adjusted odds ratios (AOR) were higher among AI/AN than White students for 18 variables (ranging from 1.4 to 2.3), higher among AI/AN than Black students for 13 variables (ranging from 1.4 to 4.2), and higher among AI/AN than Hispanic students for 5 variables (ranging from 1.4 to 1.5). Odds were lower among AI/AN than Black students for many of the sexual risk-related behaviors.

CONCLUSIONS

The data suggest it is necessary to develop targeted, adolescent-specific interventions aimed at reducing behaviors that put AI/AN high school students at risk for teen pregnancy, STI/HIV, and other health conditions.

The association between family and community social capital and health risk behaviours in young people: an integrative review

Background

Health risk behaviours known to result in poorer outcomes in adulthood are generally established in late childhood and adolescence. These ‘risky’ behaviours include smoking, alcohol and illicit drug use and sexual risk taking. While the role of social capital in the establishment of health risk behaviours in young people has been explored, to date, no attempt has been made to consolidate the evidence in the form of a review. Thus, this integrative review was undertaken to identify and synthesise research findings on the role and impact of family and community social capital on health risk behaviours in young people and provide a consolidated evidence base to inform multi-sectorial policy and practice.

Methods

Key electronic databases were searched (i.e. ASSIA, CINAHL, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Database of Abstracts of Reviews of Effects, Embase, Medline, PsycINFO, Sociological Abstracts) for relevant studies and this was complemented by hand searching. Inclusion/exclusion criteria were applied and data was extracted from the included studies. Heterogeneity in study design and the outcomes assessed precluded meta-analysis/meta-synthesis; the results are therefore presented in narrative form.

Results

Thirty-four papers satisfied the review inclusion criteria; most were cross-sectional surveys. The majority of the studies were conducted in North America (n=25), with three being conducted in the UK. Sample sizes ranged from 61 to 98,340. The synthesised evidence demonstrates that social capital is an important construct for understanding the establishment of health risk behaviours in young people. The different elements of family and community social capital varied in terms of their saliency within each behavioural domain, with positive parent–child relations, parental monitoring, religiosity and school quality being particularly important in reducing risk.

Conclusions

This review is the first to systematically synthesise research findings about the association between social capital and health risk behaviours in young people. While providing evidence that may inform the development of interventions framed around social capital, the review also highlights key areas where further research is required to provide a fuller account of the nature and role of social capital in influencing the uptake of health risk behaviours.

Geographic variation in trends and characteristics of teen childbearing among American Indians and Alaska Natives, 1990-2007

To study teen birth rates, trends, and socio-demographic and pregnancy characteristics of AI/AN across geographic regions in the US. The birth rate for US teenagers 15-19 years reached a historic low in 2009 (39.1 per 1,000) and yet remains one of the highest teen birth rates among industrialized nations. In the US, teen birth rates among Hispanic, non-Hispanic black, and American Indian/Alaska Native (AI/AN) youth are consistently two to three times the rate among non-Hispanic white teens. Birth certificate data for females younger than age 20 were used to calculate birth rates (live births per 1,000 women) and joinpoint regression to describe trends in teen birth rates by age (<15, 15-17, 18-19) and region (Aberdeen, Alaska, Bemidji, Billings, California, Nashville, Oklahoma, Portland, Southwest). Birth rates for AI/AN teens varied across geographic regions. Among 15-19-year-old AI/AN, rates ranged from 24.35 (California) to 123.24 (Aberdeen). AI/AN teen birth rates declined from the early 1990s into the 2000s for all three age groups. Among 15-17-year-olds, trends were approximately level during the early 2000s-2007 in six regions and declined in the others. Among 18-19-year-olds, trends were significantly increasing during the early 2000s-2007 in three regions, significantly decreasing in one, and were level in the remaining regions. Among AI/AN, cesarean section rates were lower in Alaska (4.1%) than in other regions (16.4-26.6%). This is the first national study to describe regional variation in AI/AN teen birth rates. These data may be used to target limited resources for teen pregnancy intervention programs and guide research.

Two approaches to tailoring treatment for cultural minority adolescents

At this time, compared with mainstream (Caucasian) youth, cultural minority adolescents experience more severe substance-related consequences and are less likely to receive treatment. Although several empirically supported interventions (ESIs), such as motivational interviewing (MI), have been evaluated with mainstream adolescents, fewer published studies have investigated the fit and efficacy of these interventions with cultural minority adolescents. In addition, many empirical evaluations of ESIs have not explicitly attended to issues of culture, race, and socioeconomic background in their analyses. As a result, there is some question about the external validity of ESIs, particularly in disadvantaged cultural minority populations. This review seeks to take a step toward filling this gap, by addressing how to improve the fit and efficacy of ESIs like MI with cultural minority youth. Specifically, this review presents the existing literature on MI with cultural minority groups (adult and adolescent), proposes two approaches for evaluating and adapting this (or other) behavioral interventions, and elucidates the rationale, strengths, and potential liabilities of each tailoring approach.

Evaluation of a substance abuse, HIV and hepatitis prevention initiative for urban Native Americans: the Native Voices program

Although many community-based prevention interventions are conducted in American Indian and Alaska Native (AI/AN) communities, few studies report the outcomes. This article is a mixed methods outcome evaluation of an HIV/AIDS, hepatitis, and substance abuse prevention intervention for an urban AI/AN community, Native Voices. The study group wascomposed of 100youth (ages 13 to 18) who lived in the San Francisco Bay Area. The outcome measures of interest were knowledge, perception of risk, sexual self-efficacy, ethnic identity, and sexual risk behavior. The findings indicate that knowledge, perception of risk, and sexual self-efficacy increased, while no change was shown in measures of ethnic identity and behavior. Findings extended prior research by evaluating the Gathering of Native Americans (GONA) curriculum, a promising intervention designed for AI/AN people.

Young Native American Men and Their Intention to Use Family Planning Services

This study examines the extent to which age, fatherhood, relationship status, self-control of birth control method, and the use of birth control influence young Native American men’s intention to use family planning services. Data were collected for this study during in-depth interviews with 112 Native American men between the ages of 18 and 24 years. The mean age reported was 21. Thirty-eight percent of the young men reported having children. Almost 70% of the young men reported being in a steady relationship. Eighty-eight percent reported that it was very important that they have self-control of the type of birth control that they use. In addition, 88% of the young men reported that they would use some type of birth control within the next year to prevent a pregnancy with their partner. Logistic regression analysis indicated that as age increased, young men were less likely to seek family planning services for birth control. The young men who reported being fathers were more likely than the young men who did not report being fathers to seek family planning services for birth control. Findings from this study suggest that public health efforts to educate Native American men about family planning services are most effective in their adolescence, before they transition into young adulthood. Fatherhood may also be considered a protective factor that may increase the likelihood that young Native American men will seek family planning services for birth control. Public health efforts that address reproductive health among young Native American men may be effective with Native American men in adolescence, prior to their transition to young adulthood. Family planning services that provide outreach education and care to Native American fathers may also be effective.

School-related assets and youth risk behaviors: alcohol consumption and sexual activity

BACKGROUND

Two risk behaviors, alcohol consumption and early initiation of sexual intercourse (ISI), can have devastating consequences for youth. The purpose of this study was to determine the association of school connectedness and school-related behaviors (eg, academic performance, skipping school, getting into trouble at school) with these 2 risk behaviors.

METHODS

The Youth Asset Survey (YAS) was administered to 1117 youth/parent pairs in their homes using Computer-Assisted Personal/Self-Interviewing (CAPI/CASI). The YAS measures 17 youth assets and risk behaviors including alcohol consumption and sexual activity.

RESULTS

The mean age of the sample was 14.3 years; 53% were female; and 70% were from 2-parent homes. Five school-related behaviors were positively associated with no ISI. Four school-related behaviors were positively associated with reporting no alcohol consumption in the past 30 days, including the School Connectedness asset (only among 12- to 13-year-olds), not skipping school (only among non-Hispanic Caucasians), staying out of trouble, and paying attention.

CONCLUSIONS

School is very much a part of the lives of youth and therefore the relationship they have with their school experience is important and may influence their involvement in risk behaviors. Feeling connected to school is a positive asset that can protect youth from such risky behaviors as sexual initiation and alcohol consumption.

Exploring racial/ethnic differences in substance use: a preliminary theory-based investigation with juvenile justice-involved youth

Background

Racial/ethnic differences in representation, substance use, and its correlates may be linked to differential long-term health outcomes for justice-involved youth. Determining the nature of these differences is critical to informing more efficacious health prevention and intervention efforts. In this study, we employed a theory-based approach to evaluate the nature of these potential differences. Specifically, we hypothesized that (1) racial/ethnic minority youth would be comparatively overrepresented in the juvenile justice system, (2) the rates of substance use would be different across racial/ethnic groups, and (3) individual-level risk factors would be better predictors of substance use for Caucasian youth than for youth of other racial/ethnic groups.

Methods

To evaluate these hypotheses, we recruited a large, diverse sample of justice-involved youth in the southwest (N = 651; M age = 15.7, SD = 1.05, range = 14-18 years); 66% male; 41% Hispanic, 24% African American, 15% Caucasian, 11% American Indian/Alaska Native). All youth were queried about their substance use behavior (alcohol, marijuana, tobacco, illicit hard drug use) and individual-level risk factors (school involvement, employment, self-esteem, level of externalizing behaviors).

Results

As predicted, racial/ethnic minority youth were significantly overrepresented in the juvenile justice system. Additionally, Caucasian youth reported the greatest rates of substance use and substance-related individual-level risk factors. In contrast, African American youth showed the lowest rates for substance use and individual risk factors. Contrary to predictions, a racial/ethnic group by risk factor finding emerged for only one risk factor and one substance use category.

Conclusions

This research highlights the importance of more closely examining racial/ethnic differences in justice populations, as there are likely to be differing health needs, and subsequent treatment approaches, by racial/ethnic group for justice-involved youth. Additionally, this study highlights the need for timely, empirically supported (developmentally and cross-culturally) substance abuse interventions for all justice-involved youth.

Sexually transmitted disease core theory: roles of person, place, and time

The authors' purpose was to expand sexually transmitted disease core theory by examining the roles of person, place, and time in differentiating geographic core areas from outbreak areas. The authors mapped yearly census-tract-level syphilis rates for San Francisco, California, based on new primary and secondary syphilis cases reported to the San Francisco City sexually transmitted disease surveillance program between January 1, 1985, and December 31, 2007. SaTScan software (Information Management Services, Inc., Silver Spring, Maryland) was used to identify geographic clusters of significantly elevated syphilis rates over space and time. The authors graphed epidemic curves for 1) core areas, 2) outbreak areas, 3) neither core nor outbreak areas, and 4) noncore areas, where noncore areas included outbreaks, and stratified these curves according to demographic characteristics. Five clusters of significantly elevated primary and secondary syphilis rates were identified. A 5-year threshold was useful for differentiating core clusters from outbreak clusters. Epidemic curves for core areas, outbreak areas, neither core nor outbreak areas, and noncore areas were perfectly synchronized in phase trends and wavelength over time, even when broken down by demographic characteristics. Between epidemics, the occurrence of syphilis affected all demographic groups equally. During an epidemic, a temporary disparity in syphilis occurrence arose and a homogeneous core group of cases could be defined.

The relationship between selected developmental assets and health-promoting behaviours of adolescents in Southern Taiwan

AIMS AND OBJECTIVES

To examine the relationship between selected developmental assets and health-promoting behaviours of adolescents.

BACKGROUND

Developmental assets can be considered as potential health assets for adolescents. Understanding the relationship between developmental assets and health-promoting behaviours among adolescents could provide nurses with a new approach to design intervention programmes for adolescent health-promoting behaviours.

DESIGN

A cross-sectional study design.

METHODS

Anonymous questionnaires were administered to 453 adolescents aged between 13-16 years. Canonical correlation analysis was used to examine the relationship between selected developmental assets and health-promoting behaviours.

RESULTS

Canonical correlation analysis indicated two significantly meaningful variate pairs between selected developmental assets and health-promoting behaviour sets. The first pair variate accounted for 51.3% of the total variance, which showed that adolescents who had better self-esteem, future aspirations, responsible choices, family communication, non-parental adult role models, peer role models and community involvement had better behaviours of life appreciation, health responsibility, social support, stress management, nutrition and exercise. The second pair variate accounted for 9.6% of the total variance, which showed that adolescents who had better responsible choices had better stress management behaviours.

CONCLUSION

Developmental assets are important to adolescents' health-promoting behaviours. Interventions focusing on strengthening developmental assets can potentially provide an innovative approach for nurses to improve health-promoting behaviours of adolescents.

RELEVANCE TO CLINICAL PRACTICE

Strengthening developmental assets can potentially improve the health-promoting behaviours of adolescents. Individual and sociopolitical domains should be incorporated into programmes for enhancement of developmental assets. School nurses can cooperate with family and community and provide environments improving adolescents' developmental assets. Nurses should actively engage in developmental asset programmes for adolescents. The tools for measuring developmental assets modified and developed in this study were valid and reliable. They can be used for further examination of the developmental assets for adolescents in various subset populations.

Dealing with the long-term social implications of research

Biomedical and behavioral research may affect strongly held social values and thereby create significant controversy over whether such research should be permitted in the first place. Institutional review boards (IRBs) responsible for protecting the rights and welfare of participants in research are sometimes faced with review of protocols that have significant implications for social policy and the potential for negative social consequences. Although IRB members often raise concerns about potential long-term social implications in protocol review, federal regulations strongly discourage IRBs from considering them in their decisions. Yet IRBs often do consider the social implications of research protocols and sometimes create significant delays in initiating or even prevent such research. The social implications of research are important topics for public scrutiny and professional discussion. This article examines the reasons that the federal regulations preclude IRBs from assessing the social risks of research, and examines alternative approaches that have been used with varying success by national advisory groups to provide such guidance. The article concludes with recommendations for characteristics of a national advisory group that could successfully fulfill this need, including sustainability, independence, diverse and relevant expertise, and public transparency.

Adolescent sexuality and positive well-being: a group-norms approach

The link between adolescent sexual activity and psychological well-being is a controversial issue in developmental psychology. This cross-sectional study investigated the association between three aspects of teenage sexuality (genital sexual experience, age of sexual onset, and number of sex partners) and positive well-being (hedonic, eudaimonic, and overall) in a sample of 475 high school seniors (48% female; 89% White) from a single school district in a rural upstate New York community. Based on a group-norms perspective, we expected higher well-being in adolescents whose sexual behaviors followed group-normative patterns. As expected, sexually experienced and on-time (at age 16) students reported higher well-being than sexually inexperienced or late-onset (17 or older) students. Contrary to expectations, a high number of sex partners and an early sexual onset (15 or younger) were not related to lower well-being. Early-onset girls reported higher levels of well-being than normative-onset peers. Findings are discussed in relationship to theoretical perspectives and past empirical findings of teenage sexuality as a developmental asset versus risk.

Preferred drug resistance strategies of urban American Indian youth of the southwest

This study explored the drug resistance strategies that urban American Indian adolescents consider the best and worst ways to respond to offers of alcohol, cigarettes, and marijuana. Focus group data were collected from 11 female and 9 male American Indian adolescents attending urban middle schools in the southwest. The youth were presented with hypothetical substance offer scenarios and alternative ways of responding, based on real-life narratives of similar youth. They were asked to choose a preferred strategy, one that would work every time, and a rejected strategy, one they would never use. Using eco-developmental theory, patterns in the preferred and rejected strategies were analyzed to identify culturally specific and socially competent ways of resisting substance offers. The youth preferred strategies that included passive, non-verbal strategies like pretending to use the substance, as well as assertive strategies like destroying the substance. The strategies they rejected were mostly socially non-competent ones like accepting the substance or responding angrily. Patterns of preferred and rejected strategies varied depending on whether the offer came from a family member or non-relative. These patterns have suggestive implications for designing more effective prevention programs for the growing yet underserved urban American Indian youth population.

Influence of family structure on sexual behavior of Turkish female adolescents

BACKGROUND

The aim of this study was to evaluate the link between romantic relationship and/or sexual activity of adolescents, and family structure.

METHODS

Medical records of 1087 adolescent girls were evaluated for age, statute (student, working, out-of-school), incidence of romantic relationship and sexual activity, and family structures.

RESULTS

Teenager students had significantly less romantic relationships and experience of sexual intercourse than other groups. Parent-adolescent communication was negatively correlated with absence of romantic relationship and sexual intercourse.

CONCLUSION

Adolescents who have left school and are working constitute a population having higher romantic relationships and sexual intercourse experiences compared with the student adolescents. Good relationships with parents were associated with less risky sexual behavior. Close relationships with school delay the onset of sexual activity.

A multi-level analysis of risk perception, poverty and sexual risk-taking among young people in Cape Town, South Africa

Various studies have underscored the relevance of community-level factors to sexual behavior and HIV/AIDS prevention efforts in Africa. However, there is a paucity of research and theorizing in this area compared to the preponderance of prevention models that focus solely on individual-level factors. Using data from the Cape Area Panel Survey and hierarchical linear models, this study examines the effects of a combination of individual-level factors and community-level poverty on sexual behaviors. Male and female respondents who perceived themselves to be at great risk of HIV infection were less likely to indulge in risky sexual behaviors. For females, race and community-level poverty were confounded such that race mediated the effects of community-level poverty. Results from this study indicate that multiple rationalities affect sexual behaviors in Cape Town, South Africa and that there is a need to consider both the social embeddedness of sexual behaviors and the rational components of decision making when designing HIV/AIDS prevention programs.

Sexually transmitted diseases among American Indians in Arizona: an important public health disparity

OBJECTIVE

We conducted an analysis of rates, geographic distribution, and time to treatment of chlamydia, gonorrhea, and early syphilis (ES) among Arizona American Indians (AIs) to address racial disparities affecting this group.

METHODS

We used the Arizona Department of Health Services' sexually transmitted disease (STD) surveillance database to identify STD cases and calculate rates among AIs in Arizona from 2003 to 2007. We mapped AI ES cases reported during that time frame by reported resident ZIP code, calculated days elapsed from specimen collection to initial treatment, and compared rates and time to treatment for AIs with those of non-Hispanic white (NHW) individuals.

RESULTS

Annual Arizona AI STD rates for chlamydia, gonorrhea, and ES from 2003 to 2007 ranged from 2.7 to 7.8 times those of NHW people. During the same time period, the annual rates for all three STDs among adolescents aged 15 to 19 years were also higher among AIs and ranged from 2.0 to 14.8 times those of NHW individuals. The majority of cases for ES reported ZIP codes located in the northeastern and southern central portions of the state. The median time to treatment in AI populations was significantly longer than in NHW populations for chlamydia and gonorrhea, but not for ES.

CONCLUSIONS

High rates of STDs have been identified among AIs in certain regions of Arizona. Additionally, there are significant delays in treatment for gonorrhea and chlamydia. STD prevention and education programs that prioritize this health disparity and promote expeditious screening, diagnosis, and treatment are needed.

Circle of life: rationale, design, and baseline results of an HIV prevention intervention among young American Indian adolescents of the Northern Plains

In spite of significant disparities in sexual health outcomes for American Indian youth, no studies exist examining the effectiveness of HIV-prevention interventions. Circle of Life is an HIV-prevention intervention specifically developed for American Indian middle-school youth. We describe the rationale, methodology, and baseline results of a longitudinal randomized trial of Circle of Life conducted among American Indian youth aged 11-15 in a reservation community. The innovative design includes two pre-intervention waves to determine patterns of behavior prior to the intervention that might be associated with a differential impact of the intervention on sexual risk. We used one-way analysis of variance and chi-square tests to test for significant differences between randomized group assignment at each baseline wave and generalized estimating equations (GEE) to test significant differences in the rate of change in outcomes by group longitudinally. We present the collaborative and adaptive strategies for consenting, assenting, and data collection methodology in this community. Achieved response rates are comparable to other similar studies. Results from the two baseline waves indicate that few outcomes significantly varied by randomized intervention assignment. Ten percent of youth reported having had sex at Wave 1, rising to 15% at Wave 2. Among those who had had sex, the majority (>70%) reported using a condom at last sex. The project is well positioned to carry out the longitudinal assessments of the intervention to determine the overall impact of the Circle of Life and the differential impact by pre-intervention patterns of behavior across youth.

Confidence as a predictor of sexual and reproductive health outcomes for youth

PURPOSE

To assess the association between four positive youth development (PYD) constructs of confidence and adolescent sexual and reproductive health (ASRH) outcomes.

METHODS

We searched nine online databases to locate behavioral research that examined the association between four constructs of confidence (belief in the future, self-determination, clear and positive identity, and self-efficacy) and ASRH outcomes (e.g., ever had sex, condom use, contraception use, number of partners, pregnancy/birth, and sexually transmitted infection). Findings were coded as "protective," "risk," or "no association." The presence of at least two longitudinal studies reporting consistent significant associations for at least one ASRH outcome indicated evidence for a protective or risk association.

RESULTS

We found evidence to support two of the four PYD constructs of confidence (belief in the future and self-determination) as protective factors for ASRH outcomes. Evidence was insufficient to draw conclusions about clear and positive identity as a protective factor, and was mixed for self-efficacy. Measures of confidence varied considerably across the studies reviewed, reflecting varying definitions; often, the measures used had limited information on reliability. Few longitudinal investigations were identified, and available studies were inconsistent in how they examined the association between the PYD constructs and ASRH outcomes. Evidence for most constructs was insufficient to identify their influence on specific sub-groups of youth.

CONCLUSIONS

Despite the need for additional research, this review suggests that belief in the future and self-determination are promising protective factors. Further research is needed to better understand the potential for self-efficacy and clear and positive identity as protective factors.

Character as a predictor of reproductive health outcomes for youth: a systematic review

To review research examining the influence of character on adolescent sexual and reproductive health (ASRH). We defined character as comprising two positive youth development constructs: prosocial norms and spirituality. We conducted a systematic review of behavioral research published from 1985 through 2007 that examined the association between two character constructs (prosocial norms and spirituality) and ASRH outcomes. We coded results as showing a protective association, risk association, or no association, and as longitudinal, or cross-sectional. We considered consistent associations from at least two longitudinal studies for a given outcome to be sufficient evidence for a protective or risk association. There is sufficient evidence to indicate that prosocial norms and spirituality can be protective factors for some ASRH outcomes including intention to have sex, early sex or ever having sex, contraceptive and condom use, frequency of sex, and pregnancy. The generalizability of findings by age, race/ethnicity, and gender was unclear. Findings suggest that some character sub-constructs are associated with a reduced likelihood of several adverse ASRH outcomes and with an increased likelihood of using contraceptives and intending to use condoms. Further research is needed to better understand mixed results and results showing some character sub-constructs, such as religious affiliation, to be associated with adverse ASRH outcomes.