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1.  Psychosocial Correlates of Adolescent Males’ Pregnancy Intention 
Pediatrics  2005;116(3):e414-e419.
To identify psychosocial differences between sexually experienced male adolescents who indicate intentions to get someone pregnant and those who do not.
Cross-sectional study of 101 sexually experienced adolescent males recruited from an STD clinic in northern California. Student’s t-tests and regressions examined psychosocial differences between males who reported any intention versus no intention to get someone pregnant in the next six months. ANOVAs examined differences among different combinations of pregnancy plans/likelihood.
Adolescents’ reports of their plans for getting someone pregnant differed from their assessments of the likelihood that they would do so (χ2 = 24.33, df = 1, p < .0001). Attitudes toward pregnancy and participants’ mothers’ educational attainment differentiated those with clear pregnancy intentions (Planning, and Likely) from those with clear intentions to avoid pregnancy (Not Planning & Not Likely)
To reduce the rates of adolescent childbearing, males’ pregnancy intentions must be assessed and asked about in multiple ways.
PMCID: PMC1351209  PMID: 16140687
Adolescent Males; Pregnancy Intentions; Psychosocial Variables
2.  The Association between Sequences of Sexual Initiation and the Likelihood of Teenage Pregnancy 
Few studies have examined the health and developmental consequences, including unintended pregnancy, of different sexual behavior initiation sequences. Some work suggests that engaging in oral-genital sex first may slow the transition to coital activity and lead to more consistent contraception among adolescents.
Using logistic regression analysis, we investigated the association between sequences of sexual initiation (i.e., initiating oral-genital or vaginal sex first based on reported ages of first experience) and the likelihood of subsequent teenage pregnancy among 6,069 females who reported vaginal sex before age 20 and participated in Waves I and IV of the National Longitudinal Study of Adolescent Health (Add Health).
Among females initiating vaginal sex first, 31.4% reported a teen pregnancy. Among females initiating two behaviors at the same age, 20.5% reported a teen pregnancy. Among females initiating oral-genital sex first, 7.9% reported a teen pregnancy. In multivariate models, initiating oral-genital sex first, with a delay of at least one year to vaginal sex, and initiating two behaviors within the same year were each associated with a lower likelihood of adolescent pregnancy, relative to teens who initiated vaginal sex first (OR=0.23, 95% CI (0.15, 0.37) and OR=0.78, 95% CI (0.60, 0.92), respectively).
How adolescents begin their sexual lives may be differentially related to positive and negative health outcomes. To develop effective pregnancy prevention efforts for teens and ensure programs are relevant to youths’ needs, it is important to consider multiple facets of sexual initiation and their implications for adolescent sexual health and fertility.
PMCID: PMC3551538  PMID: 23332489
3.  Pregnancy Intentions and Teenage Pregnancy Among Latinas: A Mediation Analysis 
The extent to which pregnancy intentions mediate the relationship between individual, familial and cultural characteristics and adolescent pregnancy is not well understood. The role of intentions may be particularly important among Latina teenagers, whose attitudes toward pregnancy are more favorable than those of other groups and whose pregnancy rates are high.
Prospective, time-varying data from 2001–2004 were used to investigate whether two measures of pregnancy intentions, wantedness and happiness, mediated associations between risk factors and pregnancy among 213 Latina adolescents in San Francisco. Participants were tested for pregnancy and interviewed about pregnancy intentions, partnerships, family characteristics and activities every six months for two years. Associations and mediation were examined using logistic regression.
Neither pregnancy intention variable mediated relationships between participant characteristics and pregnancy. After adjustment for other measures, wantedness was strongly associated with pregnancy (odds ratio, 2.6), while happiness was not. Having a strong family orientation was associated with happiness (3.7) but unrelated to pregnancy. Low sexual relationship power with a main partner was associated with an elevated risk of pregnancy (3.3). If the pregnancy intentions of all participants were changed to definitely not wanting pregnancy, the estimated decline in pregnancy risk would be 16%.
Pregnancy intentions were important not as mediators but rather as independent risk factors for pregnancy. Differences in pregnancy rates between groups of Latinas may be less a function of intentional choice than of situational factors. Interventions and research should focus on identifying and targeting factors that hinder effective contraceptive use among teenagers who want to avoid pregnancy.
PMCID: PMC2951312  PMID: 20887287
4.  Young Women’s Perceptions of the Benefits of Childbearing: Associations with Contraceptive Use and Pregnancy 
High unintended pregnancy rates, and inconsistencies between reported pregnancy intentions and contraceptive behaviors, have been well documented among young U.S. women. Women’s beliefs about the benefits of childbearing and motherhood may be related to the apparent disconnect between pregnancy intentions and reproductive outcomes.
Perceived benefits of childbearing and feelings about a potential pregnancy were assessed among 1,377 women aged 15–24 (most of them black or Latina) participating in a longitudinal study in 2005–2008. The women, who were initiating hormonal contraception at public family planning clinics and did not want to become pregnant for one year, were followed for 12 months. Differences in perceived benefits of childbearing by participant characteristics were examined with linear regression, using a new multi-item measure. Cox proportional hazard regression was used to investigate the association of perceived benefits of childbearing with subsequent contraceptive discontinuation and pregnancy.
Perceptions of the benefits of childbearing decreased with increasing age (coefficient, −0.04), and white women perceived fewer benefits to childbearing than blacks (−0.2) and Latinas (p ≤ .01). As women’s perception of the benefits of childbearing increased, their one-year pregnancy rates increased, after demographic characteristics and feelings about a potential pregnancy were controlled for (hazard ratio, 1.2). Benefits of childbearing were not associated with contraceptive discontinuation.
To better assess pregnancy risk among young women wanting to avoid pregnancy, it may be useful to acknowledge that they hold not only explicit pregnancy desires, but also beliefs about the benefits of childbearing, which may influence sexual behavior and pregnancy.
PMCID: PMC3620026  PMID: 23489854
5.  Correlates of delayed sexual intercourse and condom use among adolescents in Uganda: a cross-sectional study 
BMC Public Health  2012;12:817.
Comprehensive sex education, including the promotion of consistent condom use, is still an important intervention strategy in tackling unplanned pregnancies, HIV/AIDS and sexually transmitted infections (STIs) among Ugandan adolescents. This study examines predictors of the intention to use a condom and the intention to delay sexual intercourse among secondary school students (aged 12–20) in Uganda.
A school-based sample was drawn from 48 secondary schools throughout Uganda. Participants (N = 1978) completed a survey in English measuring beliefs regarding pregnancy, STIs and HIV and AIDS, attitudes, social norms and self-efficacy towards condom use and abstinence/delay, intention to use a condom and intention to delay sexual intercourse. As secondary sexual abstinence is one of the recommended ways for preventing HIV, STIs and unplanned pregnancies among the sexually experienced, participants with and without previous sexual experience were compared.
For adolescents without sexual experience (virgins), self-efficacy, perceived social norms and attitude towards condom use predicted the intention to use condoms. Among those with sexual experience (non-virgins), only perceived social norm was a significant predictor. The intention to delay sexual intercourse was, however, predicted similarly for both groups, with attitudes, perceived social norm and self-efficacy being significant predictors.
This study has established relevant predictors of intentions of safe sex among young Ugandans and has shown that the intention to use condoms is motivated by different factors depending on previous sexual experience. A segmented approach to intervention development and implementation is thus recommended.
PMCID: PMC3503743  PMID: 22998762
Ugandan adolescents; Delayed sexual intercourse; Condom use; Attitudes; Social norms; Self-efficacy; Segmented approach; sub-Saharan Africa
6.  The Role of Mental Health Factors, Behavioral Factors, and Past Experiences in the Prediction of Rapid Repeat Pregnancy in Adolescence 
This study investigates the predictors of rapid repeat pregnancy (subsequent pregnancy within 24 months of previous pregnancy outcome) in a sample of urban adolescents.
Adolescents aged 12 to 19 years (N = 354) who were predominantly African American (94.1%) completed individual interviews during pregnancy and at 24 months post-partum. Logistic regression was used to determine the relationship between mental health factors, behavioral factors, and negative life experiences in the prediction of rapid repeat pregnancy.
Forty-two percent (N = 147) of adolescents reported a rapid repeat pregnancy. Baseline reports of later age at menarche (12.43 vs. 11.91; p = .003) and a greater likelihood of aggression were significantly associated with having a rapid repeat pregnancy within 24 months. Age at menarche and self reported aggression contributed independently to the prediction of a closely spaced second pregnancy (p<.05).
It is suggested that pubertal onset and individual mental health as it relates to measures of aggression should be considered when developing programs targeting adolescents at highest risk for rapid repeat pregnancy.
PMCID: PMC2677824  PMID: 19101455
Adolescents; Rapid repeat pregnancy; Pregnancy risk; Subsequent childbearing
7.  Associating Pregnancy Intent with Pregnancy: Prospective Findings from the Central Pennsylvania Women’s Health Study (CePAWHS) 
We examined whether adult women’s intention for future pregnancy predicted actual pregnancies occurring in a 2-year follow-up study.
Data are from the Central Pennsylvania Women’s Health Study population-based longitudinal survey of women ages 18–45 (n=1,420). The analytic sample consists of 889 non-pregnant women who had reproductive capacity. Intention for future pregnancy was ascertained at baseline, and women were re-interviewed 2 years later to document interval pregnancies. The impact of pregnancy intention on subsequent pregnancy was analyzed using multiple logistic regression adjusting for relevant covariates.
At baseline, 46% of women were considering a future pregnancy. One hundred thirty-seven women became pregnant during the 2-year study; of these pregnancies, 83% were intended (occurring in women considering a future pregnancy at baseline) and 17% were unintended (occurring in women not considering a future pregnancy at baseline). Pregnancies occurred in 28% of women who at baseline were considering future pregnancy and 5% of women not considering pregnancy. In adjusted analysis, baseline pregnancy intention was associated with pregnancy occurrence in women ages 25–34 (adjusted OR 4.19, 95% CI 2.20–7.97) and ages 35–45 (adjusted OR 26.89, 95% CI 9.05–79.93), but not in women ages 18–24.
In this prospective study, pregnancy intention was strongly associated with pregnancy incidence over a 2-year follow-up period among women ages 25 and older, suggesting that pregnancy intentions could be used to identify women at higher risk of pregnancy. Future investigation is needed to confirm these findings and to explore the reasons why pregnancy intentions were not predictive for women ages 18–24.
PMCID: PMC2758401  PMID: 19447320
pregnancy intention; unintended pregnancy; preconception health
8.  Pregnancy Intentions, Long-Acting Contraceptive Use, and Rapid Subsequent Pregnancies among Adolescent and Adult First-Time Mothers 
Greater understanding is needed related to qualitatively-assessed pregnancy intentions and rapid subsequent pregnancies among adolescent and adult mothers.
4-site prospective study of 227 adolescent and adult mothers. Data analyzed to understand the relationship between pregnancy intentions, adolescent status, and use of long-acting contraceptives and rapid subsequent pregnancy.
The findings from this study provide evidence of the importance of goal-oriented pregnancy intentions, long-acting contraceptive use, and older age in delaying a second pregnancy.
Findings reveal the need for clinician awareness of the qualitative pregnancy intentions of young women and potential desired use of long-acting contraceptives.
PMCID: PMC3346287  PMID: 22512527
adolescent pregnancy; rapid subsequent pregnancy; pregnancy intention
9.  An Expanded Model of the Temporal Stability of Condom Use Intentions: Gender-Specific Predictors among High-Risk Adolescents 
Adolescents involved with the criminal justice system are at particularly high-risk for the Human Immunodeficiency Virus and sexually transmitted infections.
The purpose of this study was to longitudinally examine gender-specific models of condom use, incorporating temporal stability of intentions.
Adolescents on probation (N=728) were recruited to complete longitudinal surveys including measures of Theory of Planned Behavior and gender-specific constructs, relationship length, and condom use.
Gender-specific models of condom use behavior suggested by previous research were mostly replicated. For young women, the effect of baseline intentions on subsequent condom use behavior was stronger when intentions were either stable or increasing. For young men, more stable, increasing intentions were directly associated with more condom use. There was preliminary evidence to suggest an association between temporal stability of intentions and decreasing condom use in stable relationships.
Intervention efforts should be tailored by gender and aim to forestall decreasing intentions and condom use over time by addressing difficulties in maintaining condom use.
PMCID: PMC3140620  PMID: 21347619
Juvenile justice system; Risky sexual behavior; STIs/HIV; Temporal stability of intentions; Theory of planned behavior
10.  Prospective Assessment of Pregnancy Intentions Using a Single- Versus a Multi-Item Measure 
Traditional measures of pregnancy intentions that are dichotomous and retrospective do not fully capture the complexity surrounding women’s plans to become pregnant.
During January–June 2008, 249 women aged 15–44 awaiting pregnancy test results at family planning clinics in Pittsburgh completed a survey containing both single- and multi-item measures of pregnancy intentions. Chi-square analyses were used to assess differences between subgroups of women.
Few women were trying to become or planning for pregnancy (11% on the single-item measure; 20% on the multi-item measure), while approximately one-third of the sample were not trying to become or planning for pregnancy (31% on the single-item and 36% on the multi-item measure). The single-item measure categorized more women as ambivalent about pregnancy (58%) than did the multi-item measure (44%). Of women categorized as ambivalent by the single-item measure, 62% were also categorized as ambivalent by the multi-item measure. Overall, 68% of responses to the two measures were concordant. With both measures, women who were not planning or trying for pregnancy were more likely than those who were planning for pregnancy or who were ambivalent to indicate that they planned to have an abortion if their test was positive (27–29% vs. 0–2%).
Prospective assessment of pregnancy intention with either a single- or a multi-item measure may allow for a more nuanced assessment of pregnancy intention than current measures. The multi-item measure may reduce the number of women categorized as ambivalent and aid the development of targeted contraceptive and preconception counseling interventions.
PMCID: PMC2939374  PMID: 20444179
11.  Prevalence of Obesity in Adolescents with History of Pregnancy and Associated Factors in Korea 
The pregnancy was a risk factor for excessive weight gain for women. However, there is no information about the prevalence of obesity and its relationship with a history of pregnancy in girls. Therefore, the purpose of this study was to investigate differences in the prevalence of obesity in adolescent females with a history of pregnancy and factors associated with it, in Korea.
In 2009, 69 of 34,247 female students revealed that they had experienced pregnancy in response to the 5th Korea Youth Risk Behavior Web-based Survey (KYRBWS-V) project by the Korea Centers for Disease Control and Prevention (KCDCP). The body mass index (BMI) and experienced pregnancy categories of the KYRBWS-V were assessed, and, for data analysis, the independent t-test, chi-square test, and multivariate logistic regression were used.
The risk of pregnancy was increased by approximately 47% per unit increase in age, and 331% per unit increase in depression, respectively. Conversely, the risk decreased by 19% per unit increase in BMI and 33% per unit increase (ranged from 1: very rich to 5: very poor) in the family economic state.
Obesity in adolescent females is minimally affected by a history of pregnancy, if at all, despite the fact that pregnancy was a risk factor for excessive weight gain in women. However, adolescent females with a history of pregnancy have higher levels of depression than do normal peers in Korea.
PMCID: PMC3481640  PMID: 23113083
Youth risk behavior; Obesity; Pregnancy; Adolescent; Korea
12.  Adolescent pregnancy desire and pregnancy incidence 
Research has suggested the importance of pregnancy desire in explaining pregnancy risk behavior among adolescent females. Much of the literature, however, uses cross-sectional study designs to examine this relationship. Because bias may strongly influence these results, more prospective studies are needed to confirm the relationship between pregnancy desire and pregnancy incidence over time.
Non-pregnant adolescents aged 14-19 years (N=208) completed baseline interviews and interviews every 6 months thereafter for 18 months. Logistic regression was used to examine demographic and psychosocial correlates of pregnancy desire. Cox regression analysis was used to determine if pregnancy desire predicted pregnancy incidence over time after controlling for potential confounders.
Twenty-four percent of participants either desired pregnancy or were ambivalent towards pregnancy in the next year. Pregnancy desire was associated with older age, relationship duration of less than 6 months, and higher perceived stress. After accounting for potential confounders, pregnancy desire doubled the risk of becoming pregnant over the 18 month follow-up period (RR=2.00, 95% CI=0.99-4.02). Additionally, a heightened risk for pregnancy was found among those who expressed some desire for pregnancy and who were not in school compared to those who expressed no desire for pregnancy and who were in school (RR=4.84, 95% CI=1.21-19.31).
Our analysis reinforces the importance of evaluating pregnancy desire among sexually active adolescent females. Interventions should target young women in new romantic relationships and who are not in school to improve pregnancy prevention efforts. Additionally, improving coping abilities may help reduce feelings of pregnancy desire among adolescent females.
PMCID: PMC3052996  PMID: 21177123
13.  Predictive Ability and Stability of Adolescents’ Pregnancy Intentions in a Predominantly Latino Community 
Studies in Family Planning  2010;41(3):179-192.
Using data from a prospective cohort of 555 adolescent girls and boys from a predominantly Latino neighborhood of San Francisco, we examined how well four survey questionnaire items measuring pregnancy intentions predicted the incidence of pregnancy. We also compared consistency of responses among items and assessed how intentions fluctuated over time. Girls experienced 72 pregnancies over two years (six-month cumulative incidence = 8 percent), and boys reported being responsible for 50 pregnancies (six-month cumulative incidence = 10 percent). Although the probability of becoming pregnant generally increased with higher intention to do so, the risk of becoming pregnant was elevated only at the highest response categories for each item. Most pregnancies occurred among teenagers reporting the lowest levels of intention: for instance, 73 percent of pregnancies occurred among girls who reported that they definitely did not want to become pregnant. Considerable change in respondents’ intentions were found over short periods of time: 18 percent and 41 percent of responses to the wantedness and happiness items, respectively, changed between six-month survey visits. The development of appropriate strategies to reduce pregnancy among adolescents would benefit from a more nuanced understanding of how teenagers view the prospect of pregnancy and what determines whether they actively protect themselves from unintended pregnancy.
PMCID: PMC3265987  PMID: 21469271
14.  Associations between Multiple Pregnancies and Health Risk Behaviors among US Adolescents 
This study examined the associations between health risk behaviors (i.e., substance use behaviors, physical violence, or carried a weapon) and multiple adolescent pregnancies (i.e., experiencing or causing more than one pregnancy).
We analyzed 1999-2003 data (three years: 1999, 2001, and 2003) from the National Youth Risk Behavior Survey (YRBS), a nationally representative survey of high school students (N = 14,211 participants). Multinomial logistic regression was used to compare one and multiple pregnancies versus no pregnancies. Logistic regression was used to compare multiple pregnancies versus one pregnancy.
A dose-response relationship was observed between multiple adolescent pregnancies and health risk behaviors; the more risk behaviors endorsed the greater likelihood of experiencing/causing multiple adolescent pregnancies. Participants who engaged in a “high” degree of risk behaviors were significantly more likely to have experienced/caused multiple adolescent pregnancies than no pregnancies (or only one pregnancy) versus youth who endorsed no risk behaviors. Earlier sexual debut and more lifetime sexual partners were also associated with increased risk of endorsing multiple adolescent pregnancies.
The health risk behaviors examined in our study can provide warning signs to influential persons who can potentially deliver important prevention messages to at-risk adolescents.
PMCID: PMC2992968  PMID: 21094438
15.  The Relationship between Pregnancy Intention and Preconception Health Behaviors 
Preventive medicine  2011;53(1-2):85-88.
To describe smoking, heavy drinking, and folic acid supplementation in preconception women and determine if the likelihood of healthy preconception behaviors differs by whether and when women intend future pregnancy.
Analysis was based on 35,351 nonpregnant women who participated in the 2004 Behavioral Risk Factor Surveillance System (BRFSS) who were of reproductive age (18–44 years), sexually active, and capable of future pregnancy. The association between future pregnancy intention and preconception behaviors was determined adjusting for diabetes, weight category, age group, race/ethnicity, marital status, education, income, and children living in household.
Eighty-percent of women were non-smokers, 94.3% non-heavy drinkers, and 42.6% daily folic acid users. In adjusted analysis, only the odds of folic acid supplementation remained higher in women intending pregnancy in the next 12 months (adjusted odds ratio 1.57, 95% confidence interval 1.21–2.04) compared with women not intending future pregnancy. Women intending pregnancy later or ambivalent about future pregnancy were no more likely to be engaging in healthy preconception behaviors than women not intending future pregnancy.
Women intending pregnancy within 12 months were more likely to use folic acid, but pregnancy intention was not associated with preconception smoking or heavy drinking.
PMCID: PMC3143280  PMID: 21539855
16.  Pregnancy Desire Among a Sample of Young Couples Who Are Expecting a Baby 
Adolescents’ desire for a pregnancy has been explored more among females than among males. A more comprehensive understanding of teenagers’ pregnancy desires is needed to inform pregnancy prevention efforts and to support couples as they undergo the transition to parenthood.
In an observational cohort study conducted in 2007–2011 at clinics in Connecticut, data were collected from 296 couples (females aged 14–21 and their partners) who were expecting a baby. The degree to which each partner had wanted the pregnancy and partners’ perceptions of each other’s pregnancy desires were assessed. Multilevel regression models examined associations between pregnancy desire and individual, partner, family and community characteristics, and between desire and life and relationship satisfaction.
Forty-nine percent of females and 53% of males reported having wanted the pregnancy. Pregnancy desire scores were positively associated with being male, expecting a first baby, perceived partner desire and parental response to the pregnancy; scores were negatively associated with being in school, being employed and parental support. Females’ perceptions of their partners’ pregnancy desires were slightly more accurate than males’ (kappas, 0.36 and 0.28, respectively). Pregnancy desire was positively associated with both life and relationship satisfaction, particularly among males.
Adolescents’ pregnancy desires require further attention as a possible focus of pregnancy prevention efforts, and health care providers may want to ensure that young couples with unwanted pregnancies are offered additional psychological and social services as they transition to parenthood.
PMCID: PMC3834585  PMID: 23231332
17.  Associations between religiosity and sexual and contraceptive behaviors 
Study Objective
To determine associations between religiosity and female adolescents' sexual and contraceptive behaviors.
We conducted a secondary analysis on data from a randomized controlled trial comparing interventions designed to prevent pregnancy and STDs. Multivariable modeling assessed the association between a religiosity index consisting of items related to religious behaviors and impact of religious beliefs on decisions and sexual outcomes.
572 female adolescents aged 13 to 21, recruited via a hospital-based adolescent clinic and community-wide advertisements.
Main Outcome Measures
Sexual experience, pregnancy, STDs, number of lifetime partners, frequency of sexual activity, previous contraceptive use, and planned contraceptive use.
Mean participant age was 17.4±2.2 years and 68% had been sexually active. Most (74.1%) had a religious affiliation and over half (52.8%) reported that their religious beliefs impact their decision to have sex at least “somewhat.” Multivariate analyses showed that, compared with those with low religiosity, those with high religiosity were less likely to have had sexual intercourse (OR=0.23, 95% CI=0.14, 0.39). Among sexually active participants, those with high religiosity were less likely to have been pregnant (OR=0.46, 95% CI=0.22, 0.97), to have had an STD (OR=0.42, 95% CI=0.22, 0.81), or to have had multiple (≥4) lifetime partners (OR=0.38, 95% CI=0.21, 0.68) compared to those with low religiosity. Levels of religiosity were not significantly associated with frequency of intercourse, contraception use at last intercourse, or planned contraceptive use.
In this cohort, religiosity appeared to be a protective factor rather than a risk factor with regard to sexual behavior and was not associated with contraception use.
PMCID: PMC2933332  PMID: 20493738
adolescent; religion; religiosity; sexual behavior; contraception; abstinence; virginal; sexual decision making; pregnancy; sexually transmitted disease
18.  Better learning in schools to improve attitudes toward abstinence and intentions for safer sex among adolescents in urban Nepal 
BMC Public Health  2013;13:244.
School-based sex education is an effective medium to convey health information and skills about preventing sexually transmitted infections (STIs) and unwanted pregnancies among adolescents. However, research on school-based sex education is limited in many developing countries, including Nepal. This study thus had two main objectives: (1) to assess students’ evaluation of school-based sex education, and (2) to examine the associations between students’ evaluations of school-based sex education and their (a) attitudes toward abstinence and (b) intentions for safer sex.
This cross-sectional study was conducted among 634 students from six schools in the Kathmandu Valley during May–June 2010. We used a self-administered questionnaire to assess students’ evaluations of school-based sex education, attitudes toward abstinence, and intentions for safer sex. The data were then analyzed using multiple linear regression models.
Regarding “information on HIV and sexual health”, many students perceived that they received the least amount of information on HIV counseling and testing centers (mean 2.29, SD 1.00) through their schools. In terms of “support and involvement of teachers and parents” in sex education, parents’ participation ranked as the lowest (mean 1.81, SD 1.01). Audiotapes were reported as the least used among the listed “teaching aids for sexual health education” (mean 1.54, SD 0.82). In multivariate analysis, receiving more “information on HIV and sexual health” was positively associated with more positive “attitudes toward abstinence” (β = 0.11, p = <0.018) and greater “intentions for safer sex” (β = 0.17, p = <0.001) among students. Similarly, increased “support and involvement from teachers and parents” was also positively associated with more positive “attitudes toward abstinence” (β = 0.16, p = <0.001) and greater “intentions for safer sex” (β = 0.15, p = <0.002).
Our results suggest that students’ needs and expectations regarding HIV and sexual health education are not being met through their schools. Moreover, comprehensive information on HIV and sexual health along with increased support and involvement of teachers and parents in sex education might help to improve adolescents’ attitudes toward abstinence and intentions for safer sex. Adapting future school-based interventions to incorporate such elements may thus be an effective strategy to promote adolescent sexual health.
PMCID: PMC3608152  PMID: 23509909
Students; School health services; Sex education; Attitudes; Intentions; Abstinence; Safer sex; Nepal
19.  HIV/STD Risk Behaviors Among In-School Adolescents in Post-Conflict Liberia 
We conducted a randomized trial to address the health needs of in-school adolescents in Liberia, where we analyzed data from a behavioral survey administered to 820 students from 8 urban schools. Our findings suggest that adolescents are at significant risk for HIV and other sexually transmitted diseases (STDs): 36% of respondents were sexually experienced, 34% of those had first sex at ages 14 or younger, and 66% of first sexual encounters were unprotected while 16% were described as “forced.” Also, females were more likely to have older boyfriends (Pearson chi square = 19.2, p = 0.0001) and sex resulting into pregnancies (Pearson chi square = 11.5, p = 0.01), while males were more likely to have a greater number of sexual partners (Pearson chi square = 5.6, p = 0.05) in the previous 3 months. We recommend further research to explore challenges associated with implementing behavioral-driven studies in post-conflict environments.
PMCID: PMC3244556  PMID: 21924644
adolescents; HIV/STDs; Liberia; post-conflict setting; school; sub-Saharan Africa
20.  In Their Own Words: Romantic Relationships and the Sexual Health of Young African American Women 
Public Health Reports  2013;128(Suppl 1):33-42.
We assessed young African American women's understanding of “dual protection” (DP) (i.e., strategies that simultaneously protect against unintended pregnancies and sexually transmitted diseases [STDs]) and how relationship factors influence their use of DP methods.
We conducted 10 focus groups with African American women (n=51) aged 15–24 years in Atlanta, Georgia, to identify barriers to and facilitators of their DP use. Focus group participants also completed a brief self-administered questionnaire that assessed demographics and sexual behaviors. We analyzed focus group data by theme: relationships, planning for sex, pregnancy intentions, STD worries, the trade-off between pregnancy and STDs, attitudes toward condoms and contraceptives, and understanding of DP.
From the questionnaire, 51% of participants reported that an STD would be the “worst thing that could happen,” and 26% reported that being pregnant would be “terrible.” Focus group data suggested that most participants understood what DP was but thought it was not always feasible. Relationship factors (e.g., trust, intimacy, length of relationship, and centrality) affected pregnancy intentions, STD concerns, and use of DP. Social influences (e.g., parents) and pregnancy and STD history also affected attitudes about pregnancy, STDs, and relationships.
Although participants identified risks associated with sex, a complex web of social and relationship factors influenced the extent to which they engaged in protective behavior. The extent to which relationship factors influence DP may reflect developmental tasks of adolescence and should be considered in any program promoting sexual health among young African American women.
PMCID: PMC3562744  PMID: 23450883
21.  The association of unwanted pregnancy and social support with depressive symptoms in pregnancy: evidence from rural Southwestern Ethiopia 
Depression in pregnancy has adverse health outcomes for mothers and children. The magnitude and risk factors of maternal depression during pregnancy is less known in developing countries. This study examines the association between pregnancy intention, social support and depressive symptoms in pregnancy in Ethiopia.
Data for this study comes from a baseline survey conducted as part of a community- based cohort study that involved 627 pregnant women from a Demographic Surveillance Site (DSS) in Southwestern Ethiopia. The Edinburgh Postnatal Depression Scale (EPDS) was used to measure depressive symptoms during pregnancy. Data on depressive symptoms, pregnancy intention, social support and other explanatory variables were gathered using an interviewer-administered structured questionnaire. The association between independent variables and depressive symptom during pregnancy was assessed using multivariable logistic regression.
The prevalence of depressive symptoms during pregnancy was 19.9% (95% CI, 16.8-23.1), using EPDS cut off point of 13 and above. The mean score on the EPDS was 8, ranging from 0 to 25 (SD ±5.4). Women reporting that the pregnancy was unwanted were almost twice as likely to experience depressive symptoms compared with women with a wanted pregnancy. (Adjusted Odds Ratio (AOR) = 1.96, 95% Confidence Interval (CI) 1.04-3.69) Women who reported moderate (AOR = 0.27; 95% CI 0.14-0.53) and high (AOR = 0.23, 95% CI 0.11-0.47) social support during pregnancy were significantly less likely to report depressive symptoms. Women who experienced household food insecurity and intimate partner physical violence during pregnancy were also more likely to report depressive symptoms.
About one in five pregnant women in the study area reported symptoms of depression. While unwanted pregnancy increases women’s risk of depression, increased social support plays a buffering role from depression. Thus, identifying women’s pregnancy intention and the extent of social support they receive during antenatal care visits is needed to provide appropriate counseling and improve women’s mental health during pregnancy.
PMCID: PMC3716614  PMID: 23800160
Depressive symptoms; Social support; Pregnancy; Violence; Food insecurity; Ethiopia
22.  Safer Choices 2: Rationale, Design Issues, and Baseline Results in Evaluating School-Based Health Promotion for Alternative School Students 
Contemporary clinical trials  2007;29(1):70-82.
Students attending ‘alternative’ high schools form relatively small, highly mobile high-risk populations, presenting challenges for the design and implementation of HIV-, other STI-, and pregnancy-prevention interventions. This paper describes the rationale, study design, and baseline results for the Safer Choices 2 program.
Study Design
Modified group-randomized intervention trial with crossover of schools but not of students. The study cohort was defined a priori as those who completed the baseline measures and were still enrolled at the time of first follow-up.
Design Results
Of 940 students initially enrolled in the study, 711 (76%) formed the study cohort. There were significant demographic differences between those included and those excluded from the study cohort in sex, age, sexual experience, experience with pregnancy, drug use, and some psychosocial measures. There were no significant differences between the intervention and control groups within the study cohort. The only significant difference between those students excluded from the intervention group and those excluded from the control group was reported age at first intercourse.
Baseline Data Results
Students (n = 940) enrolled were predominately African-American (29.7%) and Hispanic (61.3%); 57.3% were female; 66% had ever had sex; and reported drug use in the previous 30 days ran from 4.3% (cocaine) to 26.9% (marijuana). Of the 627 sexually experienced, 41.8% reported their age at first intercourse as 13 years or younger; 28.5% reported ever being or having gotten someone pregnant; 74% reported sex in the past 3 months. Of the 464 sexually active in the last 3 months, 55.4% reported unprotected intercourse and 31.3% reported using drugs beforehand.
The cross-over design will provide a rigorous test of the intervention; however, loss to follow-up of this population can result in some selection bias. Students attending dropout prevention and recovery schools are at high risk for HIV, STIs, and pregnancy, and are in need of interventions.
PMCID: PMC2706129  PMID: 17611167
Randomized Controlled Trial; Group Randomized Trial; Adolescent; Sexual Behavior; HIV Infections/prevention and control; Sexually Transmitted Diseases/prevention and control; Pregnancy in Adolescence/prevention and control; Sex Education; African-Americans; Hispanic-Americans; Unsafe Sex
23.  Adolescents’ Pregnancy Intentions 
This study explores if and how adolescents’ pregnancy intentions relate to life situations and health-related behaviors prenatally and up to 2 years postpartum.
Adolescent girls who reported that they had “wanted a baby” (n = 75) as their reason for pregnancy were compared with those who reported that the pregnancy “just happened” (n = 79) at four separate time periods: prenatally, at 6 and 24 months postpartum, and at 18 months postpartum for teens who became pregnant again subsequent to the study pregnancy.
Those who stated that they wanted a baby were more likely to be Hispanic, married, and out of school before becoming pregnant. They were less likely to receive welfare as their primary means of support and to have run away from home in the past than teens who stated that their pregnancy just happened. Self-reported reason for pregnancy was unrelated to repeat pregnancy by 18 months postpartum, but those who had wanted the study baby were less likely to undergo elective termination of a subsequent pregnancy and less likely to become pregnant by a different partner. The groups diverged at 24 months postpartum when those who wanted a baby were more likely to be married to the father of the baby, be financially supported by him, receive child care assistance from him, and have attempted or succeeded at breastfeeding the study child.
Self-reported reason for pregnancy reveals many important characteristics of pregnant adolescents both at the time of presentation and up to 2 years postpartum. Young women in this study who reported intentional pregnancy seem to fare better with regard to their financial status and their relationship with the father of the baby.
PMCID: PMC3864670  PMID: 10331837
Adolescent pregnancy; Unintended pregnancies; Childbearing intentions; Child abuse/neglect
24.  Childhood Maltreatment, Psychological Dysregulation, and Risky Sexual Behaviors in Female Adolescents 
Journal of Pediatric Psychology  2011;36(7):743-752.
Objective Maltreated female adolescents are at risk for engaging in sexual behaviors consistent with HIV infection and teen pregnancy. The current study applied a model positing the key role of psychological dysregulation in the development of adolescent females’ sexual behavior. Methods The sample consisted of adolescent females aged 14–17 years who had experienced substantiated childhood maltreatment (n = 275) and a demographically matched, non-maltreated comparison group (n = 210). Results Multiple mediator analysis revealed that, when in company with a host of plausible mechanisms, sexual preoccupation mediated the relationship between psychological dysregulation and risky sexual behaviors. Conclusion Maltreated females may have difficulty regulating emotions, cognitions, and behaviors, which, when coupled with a propensity to entertain sexual thoughts and consume sexually explicit materials, may increase the likelihood that they act on sexual impulses and engage in high-risk sexual behaviors.
PMCID: PMC3146756  PMID: 21335615
adolescent sexual behavior; maltreatment; psychological dysregulation; structural modeling
25.  The Importance of Autonomous Regulation for Students' Successful Translation of Intentions into Behavior Change via Planning 
Physical activity has a high prevention potential in adolescents. This study investigated the relations between physical activity and intention, autonomous regulation, and planning. We hypothesized that planning mediates the relationship between intention and behavior and that this mediation should depend on the level of autonomous regulation. Stratified randomization sampling method was administered to assemble a sample of N = 534 students among two schools in China. To test the hypothesis, autonomous regulation, intention, and physical activity were assessed at baseline as well as planning and follow-up physical activity four weeks after the pretest. A moderated mediation model confirmed that planning mediated the intention-behavior relation with the effect of planning being moderated by autonomous regulation. Study results demonstrated that autonomous regulation facilitated the translation of intention into behavior change via planning. To promote physical activity among adolescents, interventions targeting planning and autonomous regulation might facilitate successful translation of intentions into behavior change.
PMCID: PMC3170742  PMID: 21991441

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