Strategies to develop an LGBTQIA+-inclusive adolescent sexual health program evaluation

Introduction

Adolescent sexual health interventions are increasingly incorporating content that is inclusive of LGBTQIA+ youth (lesbian, gay, bisexual, transgender, queer/questioning, intersex, asexual, and other marginalized sexualities and genders). Evaluations of such programs must also be inclusive to enhance the validity of evaluation results and avoid further marginalization. We present strategies for increasing LGBTQIA+-inclusivity based on our evaluation of SafeSpace, a sexual health curriculum.

Methods

To design an LGBTQIA+-inclusive program evaluation, we leveraged LGBTQIA+ research staff's insights, pursued a parental consent waiver, developed an inclusive recruitment plan, and crafted demographic and sexual behavior survey measures with input from youth and equity experts. We conducted a pilot study with 42 youth ages 14-17 to assess the feasibility and efficacy of our strategies.

Results

We obtained a parental consent waiver and recruited a majority LGBTQIA+ pilot study sample (62%). Using themes from cognitive interviews with youth and experts regarding inclusive framing and use of plain language, we refined demographic measures and expanded sexual behavior measures.

Conclusion

Findings suggest that the strategies used to enhance LGBTQIA+-inclusivity in our evaluation of SafeSpace were effective in respectfully and more accurately capturing a fuller range of experiences and identities of LGBTQIA+ and cis-straight youth. The strategies and survey measures developed for this study can be applied to increase LGBTQIA+-inclusivity in other adolescent sexual health program evaluations.

Comparing Virtual and In-Person Implementation of a School-Based Sexual Health Promotion Program in High Schools with Large Latino Populations

Many sexual health programs transitioned to virtual implementation during the COVID-19 pandemic. Despite its devastation, the pandemic provided an opportunity to learn about virtual compared to in-person implementation of a sexual health promotion program-El Camino. This study assessed differences in program attendance, engagement, quality, and student ratings for virtual versus in-person implementation of El Camino as part of a rigorous evaluation in high schools with high Latino populations in Maryland. Drawing on positive youth development practices, El Camino helps participants identify personal goals and learn about sexual reproductive health and healthy relationships. This mixed-methods study incorporates data from performance measures, baseline and post-intervention participant surveys, observations, monthly implementation reports, and debriefs with facilitators to describe and compare virtual and in-person program implementation. At baseline, participants were an average of 16.2 years old; between 8 and 12th grade; 61% female; 79% Hispanic, Latino, or of Spanish origin; and 54% spoke mostly Spanish at home. Recruitment and retention of students outside of school classes were challenging for both forms of implementation. However, attendance was higher during in-person implementation and in schools where the organization implementing El Camino had a strong presence before the pandemic. Findings indicate high fidelity, excellent quality ratings, and positive student perceptions of the program and facilitators in both the virtual and in-person cohorts, which suggest that both forms of implementation were comparable and furthermore highlight the strength of the virtual adaptation of the El Camino program.

Adapting Family Planning Service Delivery in Title X and School-Based Settings during COVID-19: Provider and Staff Experiences

The COVID-19 pandemic introduced urgent and unique challenges to family planning providers and staff in ensuring continued access to high-quality services, particularly for groups who experience greater barriers to accessing services, such as women with systemically marginalized identities and adolescents and young adults (AYA). While research has documented key adaptations made to service delivery during the early phase of the pandemic, limited studies have used qualitative methods. This paper draws on qualitative interview data from family planning providers and staff in Title-X-funded clinics and school-based clinics-two settings that serve populations that experience greater barriers to accessing care-to (a) describe the adaptations made to service delivery during the first year of the pandemic and (b) explore provider and staff experiences and impressions implementing these adaptations. In-depth interviews were conducted with 75 providers and staff between February 2020 and February 2021. Verbatim transcripts were analyzed via inductive content analysis followed by thematic analysis. Four key themes were identified: (1) Title-X- and school-based staff made multiple, concurrent adaptations to continue family planning services; (2) providers embraced flexibility for patient-centered care; (3) school-based staff faced unique challenges to reaching and serving youth; and (4) COVID-19 created key opportunities for innovation. The findings suggest several lasting changes to family planning service delivery and provider mindsets at clinics serving populations hardest hit by the pandemic. Future studies should evaluate promising practices in family planning service delivery-including telehealth and streamlined administrative procedures-and explore how these are experienced by diverse patient populations, particularly AYA and those in areas where privacy or internet access are limited.

A Mixed-Methods Pilot Evaluation of Manhood 2.0, a Program to Reduce Unintended Pregnancy Among Young Men

One promising though understudied approach to addressing race/ethnic disparities in teen pregnancy rates is through sexual and reproductive health (SRH) programming for young men. This pilot study assessed the feasibility, quality, and preliminary efficacy of Manhood 2.0-a group-based, after-school SRH program for young Black and Latino men, which examines gender norms. This mixed-methods study describes program attendance and quality; participant experiences and engagement in the program; and changes in participant gender norms, knowledge, attitudes, self-efficacy, and social support. Quantitative data from baseline and post-intervention surveys (n = 51) were analyzed using paired t-tests and McNemar's tests. Qualitative data from five post-intervention focus groups (n = 27) were transcribed, coded, and analyzed for themes. At baseline, participants were ages 15 to18 years (M = 16.4 years), 30% were Latino, 66% were Black, 34% ever had sex, and 44% of sexually active participants had sex without any contraceptive method or condom. Quality ratings by program observers were high. The majority of participants (61%) attended at least 75% of sessions, and 96% rated Manhood 2.0 as "very good" or "excellent." Pre-post comparisons showed increases in receipt of SRH information; contraception knowledge; positive attitudes about supporting partners in pregnancy prevention; self-efficacy in partner communication about sex; discussing program content with friends and family; and social competence and support. Focus group participants described benefits from the Manhood 2.0 content (i.e., full range of contraceptive methods, sexual consent, gender norms) and delivery (i.e., reflective discussion, nonjudgmental facilitators). Findings suggest that Manhood 2.0 is a promising SRH program for young men.

Women's experiences with person-centered family planning care: Differences by sociodemographic characteristics

Objective

Person-centered contraceptive care is associated with positive reproductive health outcomes. Our objective was to analyze patients’ ratings on the newly developed Person-Centered Contraceptive Counseling scale (PCCC) to provide distributions for a nationally representative population and to assess differences by sociodemographic characteristics.

Study design

Using data from 2017 to 2019 National Survey of Family Growth (NSFG), we analyzed ratings across the four PCCC items among 2242 women who received contraceptive counseling in the past year. Items measured patients’ reports of how providers respected them, let them describe their contraceptive preferences, took their preferences seriously, and adequately informed them about their options. We studied each PCCC item individually as well as the combined scale, distinguishing between ratings of “excellent” versus lower ratings. Bivariate and multivariate logistic regression models assessed how patients’ characteristics (age, race/ethnicity and English proficiency, sexual orientation, income, and parity) and provider type were associated with the likelihood of experiencing person-centered care.

Results

The majority of women (59%–69%) reported that their family planning provider was “excellent” across the four PCCC items and just over half (51%) reported “excellent” on all items. In multivariate analyses, having a lower income, Black race, non-heterosexual identity, and Hispanic ethnicity combined with low English proficiency were associated with lower PCCC ratings.

Conclusions

In a nationally representative sample, the PCCC captured variation in women's experiences with person-centered family planning care by sociodemographic characteristics. Findings highlight the need for contraceptive counseling that centers on clients’ preferences and experiences, particularly for patients who belong to groups experiencing health inequities.

Implications

Person-centered care is a key component of high-quality family planning services. This analysis highlights sociodemographic disparities in person-centered care by analyzing PCCC ratings. Findings show the value of this new health care performance measure and affirm the need for family planning care that centers individuals' preferences and lived experiences.

Impacts of Re:MIX-A School-Based Teen Pregnancy Prevention Program Incorporating Young Parent Coeducators

BACKGROUND

Latinx adolescents are at increased risk of teen pregnancy. This study evaluates the impact of Re:MIX, a comprehensive sexuality education program cofacilitated by professional health educators paired with young parent educators implemented with primarily Latinx youth in Texas.

METHODS

A cluster randomized trial was conducted with students in grades 8-10 in 57 classrooms across three schools. Students completed baseline, post-test, and long-term follow-up surveys to determine the impact of the program on behavioral outcomes-sexual experience and unprotected sex-and on mediating factors including intentions, attitudes, knowledge, and self-efficacy related to sexual activity and contraception.

RESULTS

Re:MIX was implemented with fidelity and educators were well-received. At post-test, compared to control students, Re:MIX students were more likely to intend to use hormonal or long-acting contraceptive methods if they had sex, had greater reproductive health knowledge, had more confidence in their ability to ask for and give consent, and were more likely to know where to obtain contraception. Most findings were sustained at the long-term follow-up, but there were no impacts on behaviors.

CONCLUSIONS

The implementation and impact findings highlight the promising approach of pairing young parent educators with experienced health educators for teen pregnancy prevention among Latinx students.

Lessons Learned from Replicating a Randomized Control Trial Evaluation of an App-Based Sexual Health Program

This study presents findings from a randomized control trial replication evaluation of Pulse, an app-based pregnancy prevention program implemented with Black and Latinx women aged 18-20, a population with high rates of unplanned pregnancy. We used social media advertisements to enroll 1013 women online across the U.S. and automatically randomized participants to either the Pulse reproductive health app or a general health control app, stratifying by age and race/Latinx ethnicity. Participants received reminder text messages to view the app as well as text messages with app-related content throughout the intervention. Linear probability models were conducted on the analytic sample of 871 participants who completed the six-week survey and 798 who completed the six-month survey and adjusted for permuted block randomization and multiple hypothesis testing. Compared to the control group, intervention group participants had higher contraceptive knowledge (p = 0.000), which replicates findings from an earlier evaluation. However, these impacts were not sustained at six-month follow-up (p = 0.162). We found no other significant program impacts. This contrasts with an earlier evaluation that found intervention participants were less likely to have had sex without a hormonal or long-acting reversible contraceptive (LARC) method and had greater self-confidence to use contraception consistently than the control group. Different demographic characteristics, lower app usage, and more negative attitudes about and usage of hormonal/LARC contraception in the current sample may help to explain fewer impacts than the earlier evaluation.

Relationship Violence Typologies and Condom Use in Young Adult Dating Relationships

CONTEXT

Intimate partner violence is one dimension of relationships that may influence condom use, yet few studies have examined male- and female-initiated violence in efforts to understand variation in condom use.

METHODS

Power dynamics and relationship conflict approaches were employed to examine the association between relationship violence and condom use. In a latent class analysis of 8,599 dating relationships from Wave 3 (2001-2002) of the National Longitudinal Study of Adolescent to Adult Health, when the respondents were aged 18-25, relationship violence was characterized by the severity and frequency of violence and the perpetrator's gender. Random-effects logistic regression analyses assessed the association between violence classes and condom use.

RESULTS

One in five young adult dating relationships involved violence in the past year. Four violence classes were identified: one male-dominant class (3% of relationships), in which many relationships had reciprocal violence; two female-dominant classes, differentiated by the frequency and severity of violence (2% low-intensity, 4% medium-intensity); and one class with limited or no violence (91%). Male-perpetrated violence was reported less frequently but was more severe than female-perpetrated violence. Respondents in relationships in the male-dominant/high-intensity and the female-dominant/medium-intensity classes were less likely to report condom use than those in relationships in the no/low-violence class (odds ratios, 0.4-0.5).

CONCLUSIONS

This work expands on research focusing only on male-perpetrated violence and highlights the importance of capturing relationship violence in national data sets. Future surveys that collect information about violence from both partners can inform efforts to prevent violence and to support victims.

Parent-Teen Communication about Sexual and Reproductive Health: Cohort Differences by Race/Ethnicity and Nativity

Parent-teen discussions about sexual and reproductive health (SRH) are associated with delayed sex and higher contraceptive use among teens. Using the National Survey of Family Growth, we conducted bivariate and multivariate analyses of different types of parent-teen SRH discussions among two cohorts of teens. We describe differences in patterns for males and females by race/ethnicity and nativity, and test for racial/ethnic interactions within each cohort. Analyses found that the prevalence of parent-teen discussions about SRH increased across cohorts. For males and females, there were increases in parent-teen discussions about condoms, and for males only, there were increases in any SRH discussions and discussions about contraception and STIs. Based on interactions, parent-teen discussions and STI discussions increased most for Hispanic females, and among Hispanics, increased most for the foreign-born. These data indicate increases in different types of parent-teen SRH discussions, particularly for males and foreign-born teens overall, and for Hispanic teen females regarding condom use. Future research should examine what factors are driving these changes, including changes in the structure of U.S. Hispanic communities and expansion of evidence-based teen pregnancy prevention programs.

Do young men's reports of hormonal and long-acting contraceptive method use match their female partner's reports?

Objective

To assess whether young men's reports of hormonal and long-acting contraceptive methods match their female partner's reports.

Study design

We analyzed a sample of 1096 heterosexual couples (aged 18–26) from the National Longitudinal Study of Adolescent to Adult Health Romantic Pair subsample. We compared male and female partner reports of hormonal/long-acting method use using class of method (hormonal/long-acting) rather than type (e.g., intrauterine device). Regression analyses linked men's reports of individual and relationship characteristics with alignment of reporting.

Results

Sixteen percent of young men reported hormonal/long-acting method use at last sex differently than their female partner, that is, had a mismatched report. Men who had fewer lifetime sexual partners, had greater relationship satisfaction, believed their partner was monogamous and had a matched report of condom use at last sex were more likely to match their partner's report of hormonal/long-acting contraceptive use. Men living with children (from either partner) were less likely to have a matched report. Hispanic men were more likely to have a matched report than black men.

Conclusions

Men are an increasingly important part of pregnancy prevention efforts. Pregnancy prevention and healthy relationship programs that incorporate communication skills may also indirectly improve young men's knowledge of their partner's contraceptive use and engagement in contraceptive decision making.

Implications

Analyses showed that nearly two thirds of the 16% of young men that did not accurately report their partner's hormonal/long-acting method use at last sex underreport method use. Men at increased risk of misreporting may benefit the most from targeted pregnancy prevention programs.

Impacts of a School-Wide, Peer-Led Approach to Sexuality Education: A Matched Comparison Group Design

BACKGROUND

Teen Prevention Education Program (PEP) is a school-wide, peer-led comprehensive sexuality education program currently implemented in more than 50 schools across 2 states. Many teen pregnancy prevention researchers and practitioners view peer-led programs as a promising approach for reducing teen pregnancy and associated sexual risk behaviors. However, prior research on the effectiveness of these programs indicates mixed results.

METHODS

We randomly assigned schools to implement Teen PEP immediately (intervention group) or on a delayed schedule (comparison group) and used propensity score matching to improve the comparability of the study groups. We surveyed students at baseline and about 6 months after the program ended.

RESULTS

Teen PEP did not significantly impact rates of sexual activity or unprotected sex; however, the program led to improvements in exposure to information about sexual health topics and knowledge of preventing pregnancy and transmission of sexually transmitted infections.

CONCLUSIONS

Teen PEP succeeded in accomplishing some of its most proximal goals, increasing students' access to information and knowledge. However, we found little evidence that the program affects sexual risk-taking within 6 months of its conclusion. Future research will examine the program's longer-term impacts on sexual risk behaviors.

Nonmarital School-Age Motherhood

Despite a voluminous literature on the determinants of adokscent parenthood, little research exists on school-kvel influences on nonmartal, school-age motherhood. To address this gap, analyses of nationally representative data were conducted to examine individual, family, and school-level predictors of nonmarital motherhood between 8th grade and 12th grade. All independent variables were measured in 8th grade, and the analyses were repeated separately for Black adolescents and White adolescents. The analyses indicated that school safety was an important predictor of nonmarital motherhood. However, school context did not overridefamily and individual-level effects. Low individual educational perfonnance measures, such as lower test scores and self-reported grades, predicted a higher risk of early motherhood, as did being held back in school and repeatedly changing schools. A substantial level of involvement in school clubs and religious organizations was associated with a lower risk of school-age motherhood.

Programs to improve adolescent sexual and reproductive health in the US: a review of the evidence

BACKGROUND

US adolescents have high rates of teen pregnancy, childbearing, and sexually transmitted infections (STIs), highlighting the need to identify and implement effective programs that will help improve teen sexual and reproductive health.

MATERIALS AND METHODS

This review identified 103 random-assignment evaluations of 85 programs that incorporated intent-to-treat analyses and assessed impacts on pregnancy, childbearing, STIs, and their key determinants - sexual activity, number of sexual partners, condom use, and other contraceptive use - among teens. This review describes the evidence base for five broad program approaches, including abstinence education, comprehensive sex education, clinic-based programs, youth development programs, and parent-youth relationship programs. We also describe programs with impacts on key outcomes, including pregnancy/childbearing, STIs, and those that found impacts on both sexual activity and contraceptive use.

RESULTS

Our review identified 52 effective programs: 38 with consistent impacts on reproductive health outcomes, and 14 with mixed findings (across subpopulations, follow-ups, or multiple measures of a single outcome). We found that a variety of program approaches produced impacts on sexual and reproductive health outcomes. Parent-youth relationship programs and clinic-based program evaluations more frequently showed impacts than other program approaches, although we also identified a number of abstinence-education, comprehensive sex education, and youth-development programs with impacts on sexual and reproductive health outcomes. Overall, we identified nine program evaluations with impacts on teen pregnancies or births, five with impacts on reducing STIs, and 15 with impacts on both delaying/reducing sexual activity and increasing contraceptive use (including condom use).

CONCLUSION

Future efforts should conduct replications of existing program evaluations, identify implementation components linked to impacts, rigorously evaluate programs that appear promising, and expand the evidence base on programs that impact hormonal and long-acting contraceptive method use.

Relationship characteristics and contraceptive use among dating and cohabiting young adult couples

CONTEXT

Contraceptive decision making occurs in the context of relationships. Although many individual-level characteristics have been linked to youths' contraceptive use, less is known about associations between contraceptive use and relationship-level characteristics.

METHODS

Data from the 2001-2002 romantic pair subsample of the National Longitudinal Study of Adolescent Health were used to describe characteristics of 322 dating relationships and 406 cohabiting relationships among young adults aged at least 18 years. Logistic regression was employed to assess associations between these characteristics and hormonal or long-acting contraceptive use and condom use. Data from both partners allowed discordance in reports between partners in some measures to be examined.

RESULTS

Cohabiting couples were less likely than dating couples to have used condoms (19% vs. 37%) and hormonal or long-acting methods (40% vs. 57%) at last sex. In dating relationships, couples reporting discordant levels of intimacy and couples in which neither partner reported a high level of intimacy had greater odds of condom use than couples in which both partners reported high intimacy (odds ratios, 4.5 and 3.3, respectively); mistrust and male problem drinking were negatively associated with condom use (0.3 for each). For cohabiting couples, frequency of sex was negatively associated with condom use and hormonal method use (0.8 for each).

CONCLUSIONS

At least for dating couples, contraceptive use is linked to multiple dimensions of relationships, particularly measures reflecting relationship quality-both positive and negative.

Relationship types and contraceptive use within young adult dating relationships

CONTEXT

Although expanding research has found that relationship characteristics can shape contraceptive use among young adults, limited research has examined how relationship characteristics intersect to form distinct types of relationships and how relationship types are linked to contraceptive use.

METHODS

Data from the 2002-2005 rounds of the National Longitudinal Survey of Youth 1997 cohort were used to examine contraceptive use in 3,485 young adult dating relationships. Latent class analysis was employed to develop a typology of relationships using measures of relationship structure (duration) and quality (intimacy, commitment and conflict). Multinomial logistic regression analyses were used to estimate associations between relationship type and contraceptive use and method choice at last sex.

RESULTS

Four types of relationships were identified, two shorter term and two longer term, differentiated by levels of intimacy, commitment and conflict. Young adults in longer term relationships with greater conflict and lower intimacy and commitment were less likely than those in other long-term relationships to use hormonal and dual methods versus no method (relative risk ratios, 0.6-0.7). Hormonal method use, versus no method use or condom use, was more prevalent in short-term relationships with greater intimacy and commitment and lower conflict than in other short-term relationships (1.7 and 1.9, respectively).

CONCLUSIONS

Classifying short-term relationships as "casual" or long-term ones as "serious" may ignore heterogeneity within these categories that may have implications for contraceptive use. Future qualitative research could provide a better understanding of relationship types and couples' fertility intentions and access to and use of contraceptives.

Racial and ethnic differences in the transition to a teenage birth in the United States

CONTEXT

Rates of teenage childbearing are high in the United States, and they differ substantially by race and ethnicity and nativity status.

METHODS

Data from the National Longitudinal Survey of Youth 1997 cohort were used to link characteristics of white, black, U.S.-born Hispanic and foreign-born Hispanic adolescents to teenage childbearing. Following a sample of 3,294 females aged 12-16 through age 19, discrete-time logistic regression analyses were used to examine which domains of teenagers' lives were associated with the transition to a teenage birth for each racial and ethnic group, and whether these associations help explain racial and ethnic and nativity differences in this transition.

RESULTS

In a baseline multivariate analysis controlling for age, compared with whites, foreign-born Hispanics had more than three times the odds of a teenage birth (odds ratio, 3.5), while blacks and native-born Hispanics had about twice the odds (2.1 and 1.9, respectively). Additional controls (for family environments; individual, peer and dating characteristics; characteristics of first sexual relationships; and subsequent sexual experience) reduced the difference between blacks and whites, and between foreign-born Hispanics and whites, and eliminated the difference between U.S.-born Hispanics and whites. Further, if racial or ethnic minority adolescents had the same distribution as did white teenagers across all characteristics, the predicted probability of a teenage birth would be reduced by 40% for blacks and 35% for U.S.-born Hispanics.

CONCLUSIONS

Differences in the context of adolescence may account for a substantial portion of racial, ethnic and nativity differences in teenage childbearing.

Family environments and the relationship context of first adolescent sex: Correlates of first sex in a casual versus steady relationship

Limited research has examined how family environments are associated with the relationship context of first sex, an important indicator of reproductive health risk. We use data from the 1997 National Longitudinal Survey of Youth to assess the association between the family environment - parent-parent relationships, parent-adolescent relationships, and family structure - and relationship context of first heterosexual sexual intercourse, distinguishing between the transition to first sex in serious and casual relationships. Twenty-five percent of females and 43% of males who had sex by age 18 did so in a casual relationship. All dimensions of the family environment were linked to the relationship context of first sex. Notably, higher parental monitoring was associated with a reduced risk of transitioning to first sex in a casual relationship versus no sex, and greater family routines were associated with a reduced risk of transitioning to sex in a steady relationship versus having no sex, for males and females. A strong maternal-adolescent relationship was associated with a reduced risk of first sex in a casual relationship but only for males. Additionally, in two-parent families, a strong father-adolescent relationship was associated with reduced risk of transitioning to casual sex, but only for females. Pregnancy and STI prevention programs should work with parents to foster positive parent-adolescent relationships, to become aware of their adolescents' activities and to recognize that parents are important models for adolescent relationship behaviors.

Teenage Childbearing Among Youth Born to Teenage Mothers

Using data from the National Longitudinal Survey of Youth, this article examined how early maternal characteristics, an adolescent's family environment, and the adolescent's own attitudes and behaviors were associated with the odds of a nonmarital teenage birth among youth born to teenage mothers. Multivariate analyses indicated that these domains were closely linked. Early maternal characteristics shaped the later family environment of adolescents (parenting quality and home environment), which, in turn, was associated with the attitudes and behaviors of teens that put them at risk of a nonmarital birth. Notably, there was variation in some of the associations by gender. Increased mother's cognitive ability lowered the risk of a nonmarital birth for boys, but not for girls, whereas fertility expectations were significant for girls, but not for boys. There were no race-ethnic differences in the risk of a teenage birth among girls, although Black boys had a higher risk than White boys.

Relationship Characteristics and the Relationship Context of Nonmarital First Births Among Young Adult Women

OBJECTIVES: The objectives of this study were to examine whether and how characteristics of the relationship dyad are linked to nonmarital childbearing among young adult women, additionally distinguishing between cohabiting and nonunion births. METHODS: We used the National Longitudinal Survey of Youth, 1997 Cohort and discrete-time event history methods to examine these objectives. RESULTS: Our analyses found that similarities and differences between women and their most recent sexual partner in educational attainment, disengagement from work or school, race/ethnicity, and age were linked to the risk and context of nonmarital childbearing. For example, partner disengagement (from school and work) was associated with increased odds of a nonmarital birth regardless of whether the woman herself was disengaged. Additionally, having a partner of a different race/ethnicity was associated with nonmarital childbearing for whites, but not for blacks and Hispanics. CONCLUSIONS: We conclude that relationship characteristics are an important dimension of the lives of young adults that influence their odds of having a birth outside of marriage.

Union Transitions Following the Birth of a Child to Cohabiting Parents

Despite a growing interest in the family trajectories of unmarried women, there has been limited research on union transitions among cohabiting parents. Using data from the 2002 National Survey of Family Growth, we examined how family complexity (including relationship and fertility histories), as well as characteristics of the union and birth, were associated with transitions to marriage or to separation among 1,105 women who had a birth in a cohabiting relationship. Cohabiting parents had complex relationship and fertility histories, which were tied to union transitions. Having a previous nonmarital birth was associated with a lower relative risk of marriage and a greater risk of separation. In contrast, a prior marriage or marital birth was linked to union stability (getting married or remaining cohabiting). Characteristics of the union and birth were also important. Important racial/ethnic differences emerged in the analyses. Black parents had the most complex family histories and the lowest relative risk of transitioning to marriage. Stable cohabitations were more common among Hispanic mothers, and measures of family complexity were particularly important to their relative risk of marriage. White mothers who began cohabiting after conception were the most likely to marry, suggesting that ''shot-gun cohabitations'' serve as a stepping-stone to marriage.

Relationship characteristics and contraceptive use among young adults

CONTEXT

Young adults have high rates of unintended childbearing and STDs, yet little research has examined the role of relationship characteristics in their contraceptive use.

METHODS

Data collected from the 2002-2005 rounds of the National Longitudinal Survey of Youth yielded a sample of 4,014 dating relationships among sexually active 18-26-year-olds. Bivariate analysis and multivariate logistic and multinomial logistic regressions assessed associations between relationship characteristics and contraceptive use at last sex.

RESULTS

In three-quarters of the relationships, respondents had used some method at last intercourse; respondents in 26% of the relationships had used a condom only, in 26% a hormonal method only and in 23% dual methods. Compared with respondents in relationships in which first sex occurred within two months of starting to date, those who first had sex before dating were more likely to have used any method at last sex (odds ratio, 1.4), particularly condoms or dual methods (relative risk ratio, 1.5 for each). The relative risk of using a hormonal method only, rather than no method or condoms only, increased with relationship duration (1.01) and level of intimacy (1.1-1.2). Discussing marriage or cohabitation was associated with reduced odds of having used any method (0.7) and a reduced relative risk of having used condoms alone or dual methods (0.6 for each). Increasing levels of partner conflict and asymmetry were also linked to reduced odds of any method use (0.97 and 0.90, respectively).

CONCLUSIONS

Prevention programs should address relationship context in contraceptive decision making, perhaps by combining relationship and sex education curricula to foster communication and negotiation skills.

Unintended births: patterns by race and ethnicity and relationship type

CONTEXT

Childbearing intentions vary by race and ethnicity and by relationship type. However, few studies have examined whether they differ by race and ethnicity within relationship type.

METHODS

Data from the Early Childhood Longitudinal Study were used to examine the childbearing intentions of 9,100 mothers of a cohort of children born in 2001. Multivariate and multinomial regression analyses were conducted to examine whether relationship type (married, cohabiting or neither) helps explain racial and ethnic differences in childbearing intentions and whether associations between race and ethnicity and childbearing intentions vary by relationship type.

RESULTS

Blacks were more likely than whites to have had an unintended birth (odds ratio, 2.5); the relationship held among married (2.6), but not unmarried, mothers. For most relationship types, black mothers had higher relative risks than whites of having had an unwanted birth, rather than an intended or a mistimed one. Asian married mothers were more likely than their white counterparts to have had an unwanted, rather than intended, birth (1.9). The odds of an unintended birth were lower among foreign-born Hispanic cohabiting women than among white cohabiting women (0.6), a finding driven by the lower risk of unwanted than of other births among foreign-born Hispanics (0.3–0.5). Few differences were apparent between native-born Hispanics and white mothers.

CONCLUSIONS

Racial and ethnic differences in childbearing intentions are frequently contingent on relationship context. Differences between whites and blacks are largely attributable to married women. Assessment of childbearing intendedness among Hispanics should take nativity into account.

The relationship context of nonmarital childbearing in the U.S

Using Early Childhood Longitudinal Study-Birth Cohort data, we present estimates of nonmarital births in the United States in 2001, both within and outside of cohabiting unions. We additionally examine how mother and father characteristics are associated with the relationship context at birth, and assess racial/ethnic differences in these relationships. We find that 52% of nonmarital births (and 19% of all births) occur within cohabitating unions-a substantial increase in cohabiting births since the early 1990s. The increase in cohabiting births among white and Hispanic women largely reflects a shift from marital to cohabiting births, while the increase in cohabiting births among black women largely reflects a shift from single to cohabiting births. Mother and father characteristics, including marital and fertility histories, are associated with relationship status at birth. However, with the exception of mother's education, only the association between father characteristics and relationship status at birth vary by race and ethnicity.

Family Structure History: Links to Relationship Formation Behaviors in Young Adulthood

Using data from three waves of the National Longitudinal Study of Adolescent Health (N=4,538), we examine the intergenerational link between parental family structure history and relationship formation in young adulthood. We investigate: (a) first, whether parental family structure history is associated with young adults' own relationship formation behaviors; (b) second, which dimensions of family structure history are most predictive of children's later relationship formation behaviors; and (c) third, if the association between family structure history and young adulthood relationship formation differs by gender. Our findings provide evidence of an intergenerational link between parent relationship histories and their offspring's own relationship formation behaviors in young adulthood, over and above confounding factors.

Trends in sexual experience, contraceptive use, and teenage childbearing: 1992-2002

PURPOSE

To examine how cohort trends in family, individual, and relationship characteristics are linked to trends in adolescent reproductive health outcomes to provide a better understanding of factors behind recent declines in teenage birth rates.

METHODS

We examine a sample of three cohorts of females and males aged 15-19 in 1992, 1997, and 2002, based on retrospective information from the 2002 National Survey of Family Growth. We identify how family, individual, and relationship characteristics are associated with the transition to sexual intercourse, contraceptive use at first sex, and the transition to a teen birth.

RESULTS

Cohort trends and multivariate analyses indicate changes in family and relationship characteristics among American teens have been associated with positive trends in reproductive health since the early 1990s. Factors associated with improvement in adolescent reproductive health include positive changes in family environments (including increases in parental education and a reduced likelihood of being born to a teen mother) and positive trends in sexual relationships (including an increasing age at first sex and reductions in older partners). These positive trends may be offset, in part, by negative changes in family environments (including an increased likelihood of being born to unmarried parents) and the changing racial/ethnic composition of the teen population.

CONCLUSIONS

Recent increases in the U.S. teen birth rate highlight the continued importance of improving reproductive health outcomes. Our research suggests that it is important for programs to take into consideration how family, individual, and relationship environments influence decision-making about sex, contraception, and childbearing.

Immigration measures and reproductive health among Hispanic youth: findings from the national longitudinal survey of youth, 1997-2003

PURPOSE

To explore relationships between immigration measures and risk of reproductive and sexual events among U.S. Hispanic adolescents.

METHODS

We examined generation status, language in the home and country of origin in relation to sexual activity, contraception, and childbearing among 1614 Hispanic adolescents, using nationally representative 1997-2003 longitudinal data. Multivariable analyses controlled for potentially confounding variables. Tests for effect modification by gender and Mexican origin were conducted.

RESULTS

Fewer first generation adolescents transitioned to sexual intercourse before age 18 (odds ratio [OR]=.80, 95% confidence interval [CI]=.66-.98) and fewer first and second generation sexually active teens used contraceptives consistently at age 17 (OR=.32, 95% CI=.17-.60 and OR=.50, 95% CI=.31-.80, respectively) than third-generation teens. Language was similarly associated with the transition to sexual intercourse and contraceptive practices. Versus teens of Mexican origin, teens of Puerto Rican origin and origins other than Cuba and Central/South America had greater odds of becoming sexually active; youth of all origins except Central/South America had fewer multiple live births (OR=.14-.31). Gender modified the effects of generation on consistent use of contraceptives and condoms at age 17. Gender also modified the effect of country of origin on transitioning to sexual intercourse before age 18 years.

CONCLUSIONS

Results expand on previous observations that generation, language, and country of origin are predictors of reproductive and sexual risks for Hispanic adolescents. These immigration measures may therefore be useful in targeting community and clinical preventive services.

High-Risk Subsequent Births Among Co-Residential Couples: The Role of Fathers, Mothers, and Couples

This study examines predictors of a cumulative measure of high-risk births, rather than single risks separately, as in prior research. Using the Early Childhood Longitudinal Study-Birth Cohort survey, we incorporate data from fathers and mothers to assess characteristics associated with births subsequent to a focal child's birth within high-risk circumstances. Components of a high-risk birth include: high-parity, very closely-spaced, or births to unmarried couples, unhappy couples, or couples in high-conflict relationships. Both fathers' and mothers' pregnancy intentions affect whether couples have a subsequent high-risk birth. The odds of a high-risk subsequent birth, relative to no birth and to a low-risk birth, are more than twice as high if only the father intended the birth of the previous child rather than if the child was intended by both the mother and father. High-risk subsequent births are much more likely among couples where the prior child was high risk and where family income was low, and lower where both father and mother had lived with both biological parents. Findings highlight the importance of father data in fertility research.

Condom use and consistency among male adolescents in the United States

PURPOSE

To incorporate a behavioral model of health services utilization to examine whether male adolescents' family, individual, sex education, and partner factors are associated with several measures of condom use and consistency in heterosexual relationships.

METHODS

We examine a sample of sexually experienced male adolescents 15-19 years of age in the 2002 National Survey of Family Growth (NSFG) to identify factors associated with condom use at first sex and last sex, condom consistency with their most recent sexual partner, and condom consistency in the past 4 weeks.

RESULTS

Male adolescents who were Hispanic and those who did not receive formal sex education had lower odds of condom use and/or consistency, whereas African-American male adolescents and those with more positive attitudes about condoms had greater odds. Males who were older at most recent sex, who had an older sexual partner or a casual first sexual partner, who had a partner who used a method of contraception, who were in longer relationships, or who engaged in more frequent sex had reduced odds of contraceptive use.

CONCLUSIONS

Findings highlight multiple domains of influence on condom use behaviors among male adolescents. Programs that provide targeted services, address condom use attitudes, and help teens to negotiate condom use decision making with sexual partners may help to reduce high rates of sexually transmitted infections among male adolescents in the United States.

Pathways from family religiosity to adolescent sexual activity and contraceptive use

CONTEXT

Few studies with nationally representative longitudinal data have examined whether and how family religiosity is associated with adolescent sexual and contraceptive behavior.

METHODS

Data from the 1997 National Longitudinal Survey of Youth were used to examine associations between a multidimensional measure of family religiosity assessed during early adolescence and reproductive health outcomes (sexual activity, number of partners and consistent contraceptive use) at age 17. Pathways through which family religiosity is associated with these outcomes were identified using structural equation models.

RESULTS

Family religiosity was negatively associated with adolescent sexual activity, both directly (beta, -0.14) and indirectly (-0.02). The indirect association was mediated by family cohesion (as reflected in parental monitoring among the entire sample and among males, and in parent-teenager relationship quality and family routine activities among females) and negative peer behaviors. Greater family religiosity was indirectly associated with having fewer sexual partners (-0.03) and with using contraceptives consistently (0.02); these relationships were mediated through later age at first sex, more positive peer environments and higher levels of parental monitoring and awareness. However, among sexually active males (but not females), family religiosity was directly and negatively associated with contraceptive consistency (-0.11).

CONCLUSION

Cohesive family environments and positive peer networks contribute to reduced levels of risky sexual behavior among adolescents from religious families. Parents who monitor their children's activities and peer environments, engage their families in regular activities and foster strong parent-child relationships can help reduce risky sexual behavior, regardless of family religiosity. Parental involvement in prevention programs may help reduce rates of teenage pregnancy and STDs.

Factors Associated With Multiple-Partner Fertility Among Fathers

This article uses a sample of 1,731 fathers aged 16 - 45 from the 2002 National Survey of Family Growth to identify factors associated with multiple-partner fertility. Almost one third of fathers who reported multiple-partner fertility did so across a series of nonmarital relationships, and nonmarital-only multiple-partner fertility has been increasing across recent cohorts of men. Being older, having a first sexual experience or a first child at a young age, and fathering a child outside of marriage or cohabitation are associated with greater odds of multiple-partner fertility, whereas having additional children with the first birth mother is associated with reduced odds. Black, Hispanic, and young fathers have especially high odds of experiencing multiple-partner fertility across a series of nonmarital relationships.

Adolescents' discussions about contraception or STDs with partners before first sex

CONTEXT

Limited research has examined the individual, family and relationship factors that determine whether teenagers discuss contraception or STDs with their sexual partners before having sex for the first time.

METHODS

Logistic regression analyses of data from 1,426 teenagers who participated in Waves 1 (1995) and 2 (1996) of the National Longitudinal Study of Adolescent Health and who had first sex between waves examined factors influencing whether respondents discussed contraception or STDs with their partner before first sex, and whether these factors differ by gender.

RESULTS

Fifty-three percent of females and 45% of males discussed contraception or STDs before having first sex. The greater respondents' perceived condom knowledge and the greater their communication with their parents about everyday life, the higher their odds of discussing contraception or STDs before first sex (odds ratio, 1.2 for each). Being black was positively associated with sexual communication before first sex (1.9); as the number of dating activities and score on a test of verbal ability increased, so did the odds of such communication (1.6 and 1.02, respectively). The predictors of discussions about contraception or STDs did not differ by gender.

CONCLUSIONS

By increasing teenagers' knowledge about condoms and other methods of contraception, pregnancy and STD prevention programs can help to encourage communication among teenage partners before the initiation of sexual intercourse. Programs should also encourage conversations between parents and teenagers, even when not about sex.

Contraceptive use patterns across teens' sexual relationships: the role of relationships, partners, and sexual histories

By using data from the National Longitudinal Study of Adolescent Health, we examine how adolescent relationship characteristics, partner attributes, and sexual relationship histories are associated with contraceptive use and consistency, incorporating random effects to control for respondent-level unobserved heterogeneity. Analyses show that teens' contraceptive use patterns vary across relationships. Teens with more-homogamous partners, with more-intimate relationships, and who communicate about contraception before sex have greater odds of contraceptive use and/or consistency. Teens in romantic relationships, and who are older when engaging in sex for the first time, have greater odds of ever using contraceptives but reduced odds of always using contraceptives. Teens continue habits from previous relationships: teens with experience practicing contraceptive consistency and females who previously have used hormonal contraceptive methods are better able to maintain consistency in subsequent relationships. Also, relationship and partner characteristics are less important for females who previously used hormonal methods.

Contraceptive use patterns within females' first sexual relationships: the role of relationships, partners, and methods

This study used the 1995 National Survey of Family Growth (NSFG) to assess whether characteristics of females' sexual partners, relationships, and choice of contraceptive methods were associated with contraceptive use patterns within their first sexual relationship. White, black, and Hispanic females under age 25 (N=915) provided retrospective information on sexual activity and contraceptive use for first sexual relationships that occurred between 1991 and 1995. Females with older sexual partners and with same race/ethnicity partners (among Hispanics) had reduced odds of ever using contraception and/or uninterrupted use. Longer sexual relationships were associated with higher odds of ever using contraception but lower odds of uninterrupted use. Females who were older at first sex, who used hormonal methods (among whites), or who switched to more effective methods during their first sexual relationships had higher odds of ever using contraception and/or uninterrupted use. In contrast, switching to less effective methods during a first sexual relationship was associated with reduced odds of uninterrupted use.

Young teenagers and older sexual partners: correlates and consequences for males and females

CONTEXT

Limited nationally representative information exists on the characteristics of teenagers who had first sex at an early age with an older partner.

METHODS

Gender-specific analyses were conducted of 2002 National Survey of Family Growth data from 1,838 females and 1,426 males aged 18-24. Multivariate analyses examined the associations between family and individual characteristics and having a first sexual experience before age 16 with an older partner, and between age and partners' age difference at first sex and contraceptive use and having or fathering a child as a teenager.

RESULTS

Sex at a young age with an older partner was associated with not living with a biological parent at age 14 and Hispanic ethnicity for females and males, early menarche and religious attendance for females, and black race for males. Among females and males, first sex by age 16 was negatively associated with contraceptive use at first sex (odds ratios, 0.7 for each) and positively associated with a teenage birth (1.6 and 2.9, respectively); having an older first partner was associated with poor reproductive health outcomes among females. Among females, the combination of young age and an older partner at first sex was positively associated with having a teenage birth. Among males, sex before age 16 with an older partner was associated with more than twice the odds of fathering a child as a teenager compared with the odds among those who had first sex at age 16-17.

CONCLUSIONS

Interventions should target specific teenage populations, including males, to dissuade them from having sex at a young age and with older partners. Also, prevention efforts should target potential older teenage partners and adult partners of young teenagers.

Contraceptive use and consistency in U.S. teenagers' most recent sexual relationships

CONTEXT

Most U.S. teenage pregnancies are unintended, partly because of inconsistent or no use of contraceptives. Understanding the factors associated with contraceptive use in teenagers' most recent relationships can help identify strategies to prevent unintended pregnancy.

METHODS

Data on 1,468 participants in Waves 1 and 2 of the National Longitudinal Study of Adolescent Health who had had two or more sexual relationships were analyzed to assess factors associated with contraceptive use patterns in teenagers' most recent sexual relationship. Odds ratios were generated through logistic regression.

RESULTS

Many relationship and partner characteristics were significant for females but nonsignificant for males. For example, females' odds of ever, rather than never, having used contraception in their most recent relationship increased with the duration of the relationship (odds ratio, 1.1); their odds were reduced if they had not known their partner before dating him (0.2). The odds of consistent use (vs. inconsistent or no use) were higher for females in a "liked" relationship than for those in a romantic relationship (2.6), and for females using a hormonal method instead of condoms (4.5). Females' odds of consistent use decreased if the relationship involved physical violence (0.5). Among teenagers in romantic or "liked" relationships, the odds of ever-use and of consistent use were elevated among females who had discussed contraception with the partner before their first sex together (2.9 and 2.1, respectively), and the odds increased among males as the number of presexual couple-like activities increased (1.2 for each).

CONCLUSIONS

Teenagers must use contraception consistently over time and across relationships despite pressure not to. Therefore, they must learn to negotiate sexual and contraceptive decisions in each relationship.

Patterns of contraceptive use within teenagers' first sexual relationships

CONTEXT

Teenagers have a high unintended pregnancy rate, in part because of inconsistent use or nonuse of contraceptives. It is important to determine how partner and relationship characteristics are related to contraceptive use and consistency within adolescents' first sexual relationships.

METHODS

Logistic and multinomial logistic regression analyses of data from 1,027 participants in the first two waves of the National Longitudinal Study of Adolescent Health examined the influence of relationship and partner characteristics on ever-use and consistent use of contraceptive methods during teenagers' first sexual relationships.

RESULTS

Teenagers who had waited a longer time between the start of a relationship and first sex with that partner, discussed contraception before first having sex or used dual contraceptive methods had significantly increased odds of ever or always using contraceptives. Adolescents who had taken a virginity pledge, had an older partner, had a greater number of close friends who knew their first partner, or reported having a relationship that was not romantic but that involved holding hands, kissing and telling their partners they liked or loved them had decreased odds of contraceptive use or consistency. As relationship length increased, teenagers were more likely to ever have used a method, but less likely to always have used a method.

CONCLUSIONS

Parents and programs should encourage teenagers to delay sexual intercourse, discuss contraception with partners before initiating sex and be vigilant about contraceptive use, particularly in long-term sexual relationships and in relationships with older partners.

Explaining demographic trends in teenage fertility, 1980-1995

CONTEXT

The teenage birthrate rose sharply in the late 1980s and early 1990s, and then declined in the 1990s. Attempts to explain these changes have failed to account for the changing environment in which adolescents live.

METHODS

Data from the 1995 cycle of the National Survey of Family Growth are used to compare the experiences of three cohorts of teenage females in the 1980s and 1990s. A life-course framework is used to examine trends in characteristics of adolescents and adolescent mothers over time, and event-history analyses are conducted to determine which characteristics are associated with the risk of a teenage birth in each cohort. A comparison of the predicted probabilities from hazard analyses shows how changes in the context of adolescence across the cohorts help explain changes in the probability of a teenage birth over time.

RESULTS

Factors associated with the increase in the teenage birthrate in the 1980s include negative changes in family environments (such as increases in family disruption) and an increase in the proportion of teenagers having sex at an early age. Factors associated with the recent decline in the teenage birthrate include positive changes in family environments (such as improvements in maternal education), formal sex education programs and discussions with parents about sex, stabilization in the proportion of teenagers having sex at an early age and improved contraceptive use at first sex. Sexually experienced teenagers in the mid- 1990s were younger, on average, at first sex than were their counterparts in the 1980s, and thus are at an increased risk of a teenage birth. Partner factors, including nonvoluntary first sexual experiences, were not associated with the risk of a adolescent birth in any cohort.

CONCLUSIONS

Programs to further reduce the teenage birthrate should take into account the role of family stability, parent-child communication, sex education programs and engagement in school, as well as attempt to reduce the proportion of adolescents having sex at an early age and to improve contraceptive use. The increasing risk levels among sexually experienced teenagers suggest that current programs may be reducing sexual activity among adolescents already at a low risk of a teenage birth, without addressing the needs of those at highest risk.