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1.  Adolescent Pregnancy Intentions and Pregnancy Outcomes: A Longitudinal Examination 
Purpose
(a) To examine different methods of assessing pregnancy intention; (b) to identify psychosocial differences between those who indicate pregnancy intentions and those who do not; and (c) to examine the relationship between pregnancy intentions and subsequent pregnancy at 6-month follow-up in nonpregnant (at baseline), sexually experienced adolescent females.
Methods
Longitudinal cohort study of 354 sexually experienced female adolescents attending either a STD clinic or HMO adolescent medicine clinic in northern California. Student’s t-tests and regressions examined psychosocial differences between females who reported “any” and “no” pregnancy intentions. ANOVAs examined differences among different combinations of pregnancy plans/likelihood. Chi-square analyses assessed associations between baseline pregnancy intentions and subsequent pregnancy.
Results
Adolescents’ reports of their pregnancy plans and their assessments of pregnancy likelihood differed from one another (χ2 = 50.39, df = 1, p < .001). Pregnancy attitudes and baseline contraceptive use differentiated those with inconsistent pregnancy intentions (Not Planning, but Likely) from those with clear pregnancy intentions (Planning and Likely, and Not Planning and Not Likely) (Pregnancy Attitudes: F [2,338] = 68.96, p < .0001; Contraceptive Use: F [2,308] = 14.87, p < .0001). Suspected pregnancies and positive pregnancy test results were associated with baseline pregnancy intentions (Suspected: χ2 = 19.08, df = 2, p < .01; Positive Results: χ2 = 8.84, df = 2, p = .015).
Conclusions
To reduce adolescent childbearing we must assess pregnancy intentions in multiple ways. Information/education might benefit those female adolescents with inconsistent reports of pregnancy intentions.
doi:10.1016/j.jadohealth.2004.02.018
PMCID: PMC1602042  PMID: 15581524
Pregnancy intentions; Adolescent females; Attitudes; Intentions; Contraceptive use
2.  Reducing sexual risk taking behaviors among adolescents who engage in transactional sex in post-conflict Liberia 
Transactional sex (TS) has been correlated with HIV/STD infection, pregnancy, early marriage, and sexual violence in sub-Saharan Africa (SSA). Few Western-based HIV prevention programs adapted for SSA have examined intervention impacts for this group. This article examines whether an HIV prevention intervention, delivered to sixth-grade students in Liberia (age range 14–17) and found to increase condom use and other mediators for the larger sample, significantly impacted sexual behaviors and mediators for those who engaged in TS. Using an attention-matched, group-randomized controlled design, four matched pairs of elementary schools in Monrovia, Liberia, were randomly assigned to an adapted eight-module HIV prevention or a general health curriculum. Nine-month impacts of the intervention on sexual risk behaviors and mediators for those who engaged in TS, when compared with other study participants, are presented. Twelve percent of our sample of sixth graders (n = 714) ever engaged in TS. The majority of females reported being promised something in exchange for sex (52%), whereas the majority of males (52%) reported being both the giver and recipient of gifts in exchange for sex. Compared with other students, those who engaged in TS reported greater increases in the number of sex partners, reported greater frequency of sexual intercourse, were more likely to try to get pregnant or someone else pregnant, and reported greater reductions in protective sexual attitudes and HIV risk perception at the nine month follow-up, in both the intervention and the control groups. Our intervention, although successful for the general in-school adolescent sample, did not impact risk behaviors or mediators for adolescents who engaged in TS. Future research should explore the complex sexual economy in which TS is embedded and consider adapting HIV prevention interventions to the needs of this high-risk group.
doi:10.1080/17450128.2011.647773
PMCID: PMC3634670  PMID: 23626654
adolescents; AIDS; Liberia; prevention; transactional sex
3.  Pregnancy Intentions Among Women Who Do Not Try: Focusing On Women Who Are Okay Either Way 
Maternal and child health journal  2011;15(2):178-187.
Are women who are intentional about pregnancy (trying to or trying not to get pregnant) systematically different from women who are “okay either way” about getting pregnant? We use a currently sexually active subsample (n = 3,771) of the National Survey of Fertility Barriers, a random digit dialing telephone survey of reproductive-aged women (ages 25–45) in the United States. We compare women who are trying to, trying not to, or okay either way about getting pregnant on attitudes, social pressures, life course and status characteristics using bivariate analyses (chi-square tests for categorical and ANOVA tests for continuous variables). Multivariate multinomial logistic regression provides adjusted associations. Most women say that they are trying not to get pregnant (71%) or are okay either way (23%); few are trying to get pregnant. Among women with no prior pregnancies (n = 831), more say that they are trying to get pregnant (14%) but a similar percentage are okay either way (26%). Several characteristics distinguish those trying to from those okay: fertility intentions, importance of motherhood, age, parity, race/ethnicity and self identifying a fertility problem. Additional characteristics are associated with trying not to get pregnant compared to being okay: ideal number of children, wanting a baby, trusting conception, relationship satisfaction, race ethnicity, economic hardship, and attitudes about career success. Women who are “okay either way” about pregnancy should be assessed separately from women who are intentional (trying to, trying not to) about pregnancy.
doi:10.1007/s10995-010-0604-9
PMCID: PMC3010258  PMID: 20449643
Pregnancy intentions; Pregnancy planning; Life course; Fertility intentions
4.  Impact of Antiretroviral Therapy on Incidence of Pregnancy among HIV-Infected Women in Sub-Saharan Africa: A Cohort Study 
PLoS Medicine  2010;7(2):e1000229.
A multicountry cohort study in sub-Saharan Africa by Landon Myer and colleagues reveals higher pregnancy rates in HIV-infected women on antiretroviral therapy (ART).
Background
With the rapid expansion of antiretroviral therapy (ART) services in sub-Saharan Africa there is growing recognition of the importance of fertility and childbearing among HIV-infected women. However there are few data on whether ART initiation influences pregnancy rates.
Methods and Findings
We analyzed data from the Mother-to-Child Transmission-Plus (MTCT-Plus) Initiative, a multicountry HIV care and treatment program for women, children, and families. From 11 programs in seven African countries, women were enrolled into care regardless of HIV disease stage and followed at regular intervals; ART was initiated according to national guidelines on the basis of immunological and/or clinical criteria. Standardized forms were used to collect sociodemographic and clinical data, including incident pregnancies. Overall 589 incident pregnancies were observed among the 4,531 women included in this analysis (pregnancy incidence, 7.8/100 person-years [PY]). The rate of new pregnancies was significantly higher among women receiving ART (9.0/100 PY) compared to women not on ART (6.5/100 PY) (adjusted hazard ratio, 1.74; 95% confidence interval, 1.19–2.54). Other factors independently associated with increased risk of incident pregnancy included younger age, lower educational attainment, being married or cohabiting, having a male partner enrolled into the program, failure to use nonbarrier contraception, and higher CD4 cell counts.
Conclusions
ART use is associated with significantly higher pregnancy rates among HIV-infected women in sub-Saharan Africa. While the possible behavioral or biomedical mechanisms that may underlie this association require further investigation, these data highlight the importance of pregnancy planning and management as a critical but neglected component of HIV care and treatment services.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Human immunodeficiency virus (HIV) causes Acquired Immunodeficiency Syndrome (AIDS), which is a major global cause of disease and death. More than 33 million people around the world are infected with HIV, with nearly 5,500 dying daily from HIV and AIDS-related complications. HIV/AIDS is especially problematic in sub-Saharan Africa, where it is the leading cause of death. There is no cure for HIV/AIDS, but medicines known as “antiretroviral therapy” (ART) can prolong life and reduce complications in patients infected with HIV. 97% of patients with HIV/AIDS live in low- and middle-income countries. According to the World Health Organization, nearly 10 million of these patients need ART. As patients' access to treatment is often hindered by the high cost and low availability of ART, global health efforts have focused on promoting ART use in resource-limited nations. Such efforts also increase awareness of how HIV is spread (contact with blood or semen, in sexual intercourse, sharing needles, or from mother to child during childbirth). ART reduces, but does not remove, the chance of a mother's passing HIV to her child during birth.
Why Was This Study Done?
By the end of 2007, 3 million HIV-infected patients in poor countries were receiving ART. Many of those treated with ART are young women of child-bearing age. Childbirth is an important means of spreading HIV in sub-Saharan Africa, where 60% of all HIV patients are women. This study questions whether the improved health and life expectancy that results from treatment with ART affects pregnancy rates of HIV-infected patients. The study explores this question in seven African countries, by examining the rates of pregnancy in HIV-infected women before and after they started ART.
What Did the Researchers Do and Find?
The authors looked at the records of 4,531 HIV-infected women enrolled in the Mother-to-Child-Transmission-Plus (MTCT-Plus) Initiative in seven African countries. MTCT -Plus, begun in 2002, is a family-centered treatment program that offers regular checkups, blood tests, counseling, and ART treatment (if appropriate) to women and their families. At each checkup, women's CD4+ cell counts and World Health Organization guidelines were used to determine their eligibility for starting ART. Over a 4-year period, nearly a third of the women starting ART experienced a pregnancy: 244 pregnancies occurred in the “pre-ART” group (women not receiving ART) compared to 345 pregnancies in the “on-ART” group (women receiving ART). The chance of pregnancy increased over time in the on-ART group to almost 80% greater than the pre-ART group, while remaining relatively low and constant in the pre-ART group. The authors noted that, as expected, other factors also increased the chances of pregnancy, including younger age, lower educational status, and use of nonbarrier contraception such as injectable hormones.
What Do These Findings Mean?
This study suggests that starting ART is associated with higher pregnancy rates in sub-Saharan Africa, nearly doubling the chances of a woman becoming pregnant. The reasons for this link are unclear. One possible explanation is behavioral: women receiving ART may feel more motivated to have children as their health and quality of life improve. However, the study did not examine how pregnancy desires and sexual activity of women changed while on ART, and cannot discern why ART is linked to increased pregnancy. By using pregnancy data gathered from patient questionnaires rather than laboratory tests, the study is limited by the possibility of inaccurate patient reporting. Understanding how pregnancy rates vary in HIV-infected women receiving ART helps support the formation of responsive, effective HIV programs. Female HIV patients of child-bearing age, who form the majority of patients receiving ART in sub-Saharan Africa, would benefit from programs that combine starting HIV treatment with ART with education and contraception counseling and pregnancy-related care.
Additional Information
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1000229.
Information is available from the US National Institute of Allergy and Infectious Diseases on HIV infection and AIDS
HIV InSite has comprehensive information on all aspects of HIV/AIDS, including a list of articles and other sources of information about the primary care of adolescents with HIV
A UNAIDS 2008 report is available on the global AIDS epidemic
The International Planned Parenthood Foundation provides information on sexual and reproductive health and HIV
The International Center for AIDS Care and Treatment Programs at the Columbia University Mailman School of Public health provides information to assist HIV care and treatment programs in resource-limited settings
doi:10.1371/journal.pmed.1000229
PMCID: PMC2817715  PMID: 20161723
5.  An Evaluation of California’s Adolescent Sibling Pregnancy Prevention Program 
CONTEXT
The siblings of adolescents who have been pregnant or are parents have disproportionately high rates of teenage pregnancies and births. California’s Adolescent Sibling Pregnancy Prevention Program is targeted at these high-risk youths.
METHODS
An evaluation of the program was conducted in 1997–1999 with 1,176 predominantly Hispanic 11–17-year-olds who had at least one sibling who was an adolescent parent or had been pregnant—731 youths who were program clients and 445 youths who received no systematic services. All evaluation participants completed an interview and questionnaire at enrollment and again nine months later.
RESULTS
Female program clients had a significantly lower pregnancy rate than comparison females over the evaluation period (4% vs. 7%), as well as a lower rate of sexual initiation (7% vs. 16%). They also significantly decreased their frequency of school truancy, whereas this outcome increased among comparison females; program females had significantly more definite intentions of remaining abstinent at posttest than comparison females. Consistency of contraceptive use increased over time among males in the program and decreased among comparison males. Delivery of group services was correlated with delayed onset of intercourse among males, and the receipt of services related to psychosocial skills was correlated with greater contraceptive use at last sex among all sexually experienced youth.
CONCLUSIONS
This new program, which serves a population known to be at very high risk for early pregnancy, appears to be effective at reducing rates of pregnancy and improving several pregnancy-related risk behaviors.
PMCID: PMC3791863  PMID: 12729135
6.  Long-Term Biological and Behavioural Impact of an Adolescent Sexual Health Intervention in Tanzania: Follow-up Survey of the Community-Based MEMA kwa Vijana Trial 
PLoS Medicine  2010;7(6):e1000287.
David Ross and colleagues conduct a follow-up survey of the community-based MEMA kwa Vijana (“Good things for young people”) trial in rural Tanzania to assess the long-term behavioral and biological impact of an adolescent sexual health intervention.
Background
The ability of specific behaviour-change interventions to reduce HIV infection in young people remains questionable. Since January 1999, an adolescent sexual and reproductive health (SRH) intervention has been implemented in ten randomly chosen intervention communities in rural Tanzania, within a community randomised trial (see below; NCT00248469). The intervention consisted of teacher-led, peer-assisted in-school education, youth-friendly health services, community activities, and youth condom promotion and distribution. Process evaluation in 1999–2002 showed high intervention quality and coverage. A 2001/2 intervention impact evaluation showed no impact on the primary outcomes of HIV seroincidence and herpes simplex virus type 2 (HSV-2) seroprevalence but found substantial improvements in SRH knowledge, reported attitudes, and some reported sexual behaviours. It was postulated that the impact on “upstream” knowledge, attitude, and reported behaviour outcomes seen at the 3-year follow-up would, in the longer term, lead to a reduction in HIV and HSV-2 infection rates and other biological outcomes. A further impact evaluation survey in 2007/8 (∼9 years post-intervention) tested this hypothesis.
Methods and Findings
This is a cross-sectional survey (June 2007 through July 2008) of 13,814 young people aged 15–30 y who had attended trial schools during the first phase of the MEMA kwa Vijana intervention trial (1999–2002). Prevalences of the primary outcomes HIV and HSV-2 were 1.8% and 25.9% in males and 4.0% and 41.4% in females, respectively. The intervention did not significantly reduce risk of HIV (males adjusted prevalence ratio [aPR] 0.91, 95%CI 0.50–1.65; females aPR 1.07, 95%CI 0.68–1.67) or HSV-2 (males aPR 0.94, 95%CI 0.77–1.15; females aPR 0.96, 95%CI 0.87–1.06). The intervention was associated with a reduction in the proportion of males reporting more than four sexual partners in their lifetime (aPR 0.87, 95%CI 0.78–0.97) and an increase in reported condom use at last sex with a non-regular partner among females (aPR 1.34, 95%CI 1.07–1.69). There was a clear and consistent beneficial impact on knowledge, but no significant impact on reported attitudes to sexual risk, reported pregnancies, or other reported sexual behaviours. The study population was likely to have been, on average, at lower risk of HIV and other sexually transmitted infections compared to other rural populations, as only youth who had reached year five of primary school were eligible.
Conclusions
SRH knowledge can be improved and retained long-term, but this intervention had only a limited effect on reported behaviour and no significant effect on HIV/STI prevalence. Youth interventions integrated within intensive, community-wide risk reduction programmes may be more successful and should be evaluated.
Trial Registration
ClinicalTrials.gov NCT00248469
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Every year, about 2.5 million people become infected with the human immunodeficiency virus (HIV), the virus that causes AIDS. HIV is most often spread through unprotected sex with an infected partner, so individuals can reduce their risk of HIV infection by abstaining from sex, by delaying first sex, by having few partners, and by always using a condom. And, because nearly half of new HIV infections occur among youths (15- to 24-year-olds), programs targeted at adolescents that encourage these protective behaviors could have a substantial impact on the HIV epidemic. One such program is the MEMA kwa Vijana (“Good things for young people”) program in rural Tanzania. This program includes in-school sexual and reproductive health (SRH) education for pupils in their last three years of primary education (12- to 15-year-olds) that provides them with the knowledge and skills needed to delay sexual debut and to reduce sexual risk taking. Between 1999 and 2002, the program was trialed in ten randomly chosen rural communities in the Mwanza Region of Tanzania; ten similar communities that did not receive the intervention acted as controls. Since 2004, the program has been scaled up to cover more communities.
Why Was This Study Done?
Although the quality and coverage of the MEMA kwa Vijana program was good, a 2001/2002 evaluation found no evidence that the intervention had reduced the incidence of HIV (the proportion of the young people in the trial who became HIV positive during the follow-up period) or the prevalence (the proportion of the young people in the trial who were HIV positive at the end of the follow-up period) of herpes simplex virus 2 (HSV-2, another sexually transmitted virus). However, the evaluation found improvements in SRH knowledge, in reported sexual attitudes, and in some reported sexual behaviors. Evaluations of other HIV prevention programs in other developing countries have also failed to provide strong evidence that such programs decrease the risk of HIV infection or other biological outcomes such as the frequency of other sexually transmitted infections or pregnancies, even when SRH knowledge improves. One possibility is that it takes some time for improved SRH knowledge to be reflected in true changes in sexual behavior and in HIV prevalence. In this follow-up study, therefore, researchers investigate the long-term impact of the MEMA kwa Vijana program on HIV and HSV-2 prevalence and ask whether the improvement in knowledge, reported attitudes and sexual risk behaviours seen at the 3-year follow up has persisted.
What Did the Researchers Do and Find?
In 2007/8, the researchers surveyed nearly 14,000 young people who had attended the trial schools between 1999 and 2002. Each participant had their HIV and HSV-2 status determined and answered questions (for example, “can HIV be caught by sexual intercourse (making love) with someone,” and “if a girl accepts a gift from a boy, must she agree to have sexual intercourse (make love) with him?”) to provide three composite sexual knowledge scores and one composite attitude score. 1.8% of the male and 4.0% of the female participants were HIV positive; 25.9% and 41.4% of the male and female participants, respectively, were HSV-2 positive. The prevalences were similar among the young people whose trial communities had been randomly allocated to receive the MEMA kwa Vijana Program and those whose communities had not received it, indicating that the MEMA kwa Vijana intervention program had not reduced the risk of HIV or HSV-2. The intervention program was associated, however, with a reduction in the proportion of men reporting more than four sexual partners in their lifetime and with an increase in reported condom use at last sex with a non-regular partner among women. Finally, although the intervention had still increased SRH knowledge, it now had had no impact on reported attitudes to sexual risk, reported pregnancies, or other reported risky sexual behaviors beyond what might have happened due to chance.
What Do These Findings Mean?
These findings indicate that, in the MEMA kwa Vijana trial, SRH knowledge improved and that this improved knowledge was retained for many years. Disappointingly, however, this intervention program had only a limited effect on reported sexual behaviors and no effect on HIV and HSV-2 prevalence at the 9-year follow-up. Although these findings may not be generalizable to other adolescent populations, they suggest that intervention programs that target only adolescents might not be particularly effective. Young people might find it hard to put their improved skills and knowledge into action when challenged, for example, by widespread community attitudes such as acceptance of older male–younger female relationships. Thus, the researchers suggest that the integration of youth HIV prevention programs within risk reduction programs that tackle sexual norms and expectations in all age groups might be a more successful approach and should be evaluated.
Additional Information
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1000287.
This study is further discussed in a PLoS Medicine Perspective by Rachel Jewkes
More information about the MEMA kwa Vijana program is available at their Web site
Information is available from the Programme for Research and Capacity Building in Sexual and Reproductive Health and HIV in Developing Countries on recent and ongoing research on HIV infection and other STIs
Information is available from the World Health Organization on HIV and on the health of young people
Information on HIV is available from UNAIDS
Information on HIV in children and adolescents is available from UNICEF
Information on HIV prevention interventions in the education sector is available from UNESCO
Information on HIV infection and AIDS is available from the US National Institute of Allergy and Infectious Diseases
The US Centers for Disease Control and Prevention provide information on HIV/AIDS and on HIV/AIDS among youth (in English and Spanish)
HIV InSitehas comprehensive information on all aspects of HIV/AIDS, including links to information on the prevention of HIV/AIDS
Information is available from Avert, an international AIDS charity, on many aspects of HIV/AIDS, including information on HIV and AIDS prevention and AIDS and sex education (in English and Spanish)
doi:10.1371/journal.pmed.1000287
PMCID: PMC2882431  PMID: 20543994
7.  Correlates of delayed sexual intercourse and condom use among adolescents in Uganda: a cross-sectional study 
BMC Public Health  2012;12:817.
Background
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.
Methods
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.
Results
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.
Conclusions
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.
doi:10.1186/1471-2458-12-817
PMCID: PMC3503743  PMID: 22998762
Ugandan adolescents; Delayed sexual intercourse; Condom use; Attitudes; Social norms; Self-efficacy; Segmented approach; sub-Saharan Africa
8.  Pregnancy Intentions and Teenage Pregnancy Among Latinas: A Mediation Analysis 
CONTEXT
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.
METHODS
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.
RESULTS
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%.
CONCLUSIONS
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.
doi:10.1363/4218610
PMCID: PMC2951312  PMID: 20887287
9.  Which outcome expectancies are important in determining young adults’ intentions to use condoms with casual sexual partners?: a cross-sectional study 
BMC Public Health  2013;13:133.
Background
The prevalence of unwanted pregnancy and sexually transmitted infection amongst young adults represents an important public health problem in the UK. Individuals’ attitude towards the use of condoms has been identified as an important determinant of behavioural intentions and action. The Theory of Planned Behaviour has been widely used to explain and predict health behaviour. This posits that the degree to which an individual positively or negatively values a behaviour (termed ‘direct attitude’) is based upon consideration of the likelihood of a number of outcomes occurring (outcome expectancy) weighted by the perceived desirability of those outcomes (outcome evaluation). Outcome expectancy and outcome evaluation when multiplied form ‘indirect attitude’. The study aimed to assess whether positive outcome expectancies of unprotected sex were more important for young adults with lower safe sex intentions, than those with safer sex intentions, and to isolate optimal outcomes for targeting through health promotion campaigns.
Methods
A cross-sectional survey design was used. Data was collected from 1051 school and university students aged 16–24 years. Measures of intention, direct attitude and indirect attitude were taken. Participants were asked to select outcome expectancies which were most important in determining whether they would use condoms with casual sexual partners.
Results
People with lower safe sex intentions were more likely than those with safer sex intentions to select all positive outcome expectancies for unprotected sex as salient, and less likely to select all negative outcome expectancies as salient. Outcome expectancies for which the greatest proportion of participants in the less safe sex group held an unfavourable position were: showing that I am a caring person, making sexual experiences less enjoyable, and protecting against pregnancy.
Conclusions
The findings point to ways in which the attitudes of those with less safe sex intentions could be altered in order to motivate positive behavioural change. They suggest that it would be advantageous to highlight the potential for condom use to demonstrate a caring attitude, to challenge the potential for protected sex to reduce sexual pleasure, and to target young adults’ risk appraisals for pregnancy as a consequence of unprotected sex with casual sexual partners.
doi:10.1186/1471-2458-13-133
PMCID: PMC3599836  PMID: 23406327
Outcome expectancies; Condom use; Theory of planned behaviour; Attitude; Expectancy-value muddle; Dimensional salience
10.  Predictors of early sexual initiation among a nationally representative sample of Nigerian adolescents 
BMC Public Health  2008;8:136.
Background
Early sexual debut among adolescents is associated with considerable negative heath and development outcomes. An understanding of the determinants or predictors of the timing of sexual debut is important for effective intervention, but very few studies to date have addressed this issue in the Nigerian context. The aim of the present study is to examine predictors of adolescent sexual initiation among a nationally representative sample of adolescents in Nigeria.
Methods
Interviewer-collected data of 2,070 never-married adolescents aged 15–19 years were analysed to determine association between age of sexual debut and demographic, psychosocial and community factors. Using Cox proportional hazards regression multivariate analysis was carried out with two different models – one with and the other without psychosocial factors. Hazard ratio (HR) and 95% confidence interval (CI) were calculated separately for males and females.
Results
A fifth of respondents (18% males; 22% females) were sexually experienced. In the South 24.3% males and 28.7% females had initiated sex compared to 12.1% of males and 13.1% females in the North (p < 0.001). In the first model, only region was significantly associated with adolescent sexual initiation among both males and females; however, educational attainment and age were also significant among males. In the second (psychosocial) model factors associated with adolescent sexual debut for both genders included more positive attitudes regarding condom efficacy (males: HR = 1.28, 95% CI = 1.07–1.53; females: HR = 1.24, 95% CI = 1.05–1.46) and more positive attitudes to family planning use (males: HR = 1.19, 95% CI = 1.09–1.31; females: HR = 1.18, 95% CI = 1.07–1.30). A greater perception of condom access (HR = 1.42, 95% CI = 1.14–1.76) and alcohol use (HR = 1.90, 95% CI = 1.38–2.62) among males and positive gender-related attitudes (HR = 1.13, 95% CI = 1.04–1.23) among females were also associated with increased likelihood of adolescent sexual initiation. Conversely, personal attitudes in favour of delayed sexual debut were associated with lower sexual debut among both males (males: HR = 0.36, 95% CI = 0.25–0.52) and females (HR = 0.38, 95% CI = 0.25–0.57). Higher level of religiosity was associated with lower sexual debut rates only among females (HR = 0.59, 95% CI = 0.37–0.94).
Conclusion
Given the increased risk for a number of sexually transmitted health problems, understanding the factors that are associated with premarital sexual debut will assist programmes in developing more effective risk prevention interventions.
doi:10.1186/1471-2458-8-136
PMCID: PMC2390536  PMID: 18439236
11.  Associations between Intimate Partner Violence and Termination of Pregnancy: A Systematic Review and Meta-Analysis 
PLoS Medicine  2014;11(1):e1001581.
Lucy Chappell and colleagues conduct a systematic review and meta analysis to investigate a possible association between intimate partner violence and termination of pregnancy.
Please see later in the article for the Editors' Summary
Background
Intimate partner violence (IPV) and termination of pregnancy (TOP) are global health concerns, but their interaction is undetermined. The aim of this study was to determine whether there is an association between IPV and TOP.
Methods and Findings
A systematic review based on a search of Medline, Embase, PsycINFO, and Ovid Maternity and Infant Care from each database's inception to 21 September 2013 for peer-reviewed articles of any design and language found 74 studies regarding women who had undergone TOP and had experienced at least one domain (physical, sexual, or emotional) of IPV. Prevalence of IPV and association between IPV and TOP were meta-analysed. Sample sizes ranged from eight to 33,385 participants. Worldwide, rates of IPV in the preceding year in women undergoing TOP ranged from 2.5% to 30%. Lifetime prevalence by meta-analysis was shown to be 24.9% (95% CI 19.9% to 30.6%); heterogeneity was high (I2>90%), and variation was not explained by study design, quality, or size, or country gross national income per capita. IPV, including history of rape, sexual assault, contraceptive sabotage, and coerced decision-making, was associated with TOP, and with repeat TOPs. By meta-analysis, partner not knowing about the TOP was shown to be significantly associated with IPV (pooled odds ratio 2.97, 95% CI 2.39 to 3.69). Women in violent relationships were more likely to have concealed the TOP from their partner than those who were not. Demographic factors including age, ethnicity, education, marital status, income, employment, and drug and alcohol use showed no strong or consistent mediating effect. Few long-term outcomes were studied. Women welcomed the opportunity to disclose IPV and be offered help. Limitations include study heterogeneity, potential underreporting of both IPV and TOP in primary data sources, and inherent difficulties in validation.
Conclusions
IPV is associated with TOP. Novel public health approaches are required to prevent IPV. TOP services provide an opportune health-based setting to design and test interventions.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Intimate partner violence (sometimes referred to as domestic violence) is one of the commonest forms of violence against women and is a global health problem. The World Health Organization defines intimate partner violence as any act of physical, psychological, or sexual aggression or any controlling behavior (for example, restriction of access to assistance) perpetrated by the woman's current or past intimate partner. Although men also experience it, intimate partner violence is overwhelmingly experienced by women, particularly when repeated or severe. Studies indicate that the prevalence (the percentage of a population affected by a condition) of intimate partner violence varies widely within and between countries: the prevalence of intimate partner violence among women ranges from 15% in Japan to 71% in Ethiopia, and the lifetime prevalence of rape (forced sex) within intimate relationships ranges from 5.9% to 42% across the world, for example. Overall, a third of women experience intimate partner violence at some time during their lifetimes. The health consequences of such violence include physical injury, depression, suicidal behavior, and gastrointestinal disorders.
Why Was This Study Done?
Intimate partner violence can also lead to gynecological disorders (conditions affecting the female reproductive organs), unwanted pregnancy, premature labour and birth, and sexually transmitted infections. Because violence may begin or intensify during pregnancy, some countries recommend routine questioning about intimate partner violence during antenatal care. However, women seeking termination of pregnancy (induced abortion) are not routinely asked about intimate partner violence. Every year, many women worldwide terminate a pregnancy. Nearly half of these terminations are unsafe, and complications arising from unsafe abortions are responsible for more than 10% of maternal deaths (deaths from pregnancy or childbirth-related complications). It is important to know whether intimate partner violence and termination of pregnancy are associated in order to develop effective strategies to deal with both these global health concerns. Here, the researchers conducted a systematic review and meta-analysis to investigate the associations between intimate partner violence and termination or pregnancy. A systematic review identifies all the research on a given topic using predefined criteria; meta-analysis combines the results of several studies.
What Did the Researchers Do and Find?
The researchers identified 74 studies that provided information about experiences of intimate partner violence among women who had had a termination of pregnancy. Data in these studies indicated that, worldwide, intimate partner violence rates among women undergoing termination ranged from 2.5% to 30% in the preceding year and from 14% to 40% over their lifetime. In the meta-analysis, the lifetime prevalence of intimate partner violence was 24.9% among termination-seeking populations. The identified studies provided evidence that intimate partner violence was associated with termination and with repeat termination. In one study, for example, women presenting for a third termination were more than two and a half times more likely to have a history of physical or sexual violence than women presenting for their first termination. Moreover, according to the meta-analysis, women in violent relationships were three times as likely to conceal a termination from their partner as women in non-violent relationships. Finally, the studies indicated that women undergoing terminations of pregnancy welcomed the opportunity to disclose their experiences of intimate partner violence and to be offered help.
What Do These Findings Mean?
These findings indicate that intimate partner violence is associated with termination of pregnancy and that a woman's partner not knowing about the termination is a risk factor for intimate partner violence among women seeking termination. Overall, the researchers' findings support the concept that violence can lead to pregnancy and to subsequent termination of pregnancy, and that there may be a repetitive cycle of abuse and pregnancy. The accuracy of these findings is limited by heterogeneity (variability) among the included studies, by the likelihood of underreporting of both intimate partner violence and termination in the included studies, and by lack of validation of reports of violence through, for example, police reports. Nevertheless, health-care professionals should consider the possibility that women seeking termination of pregnancy may be experiencing intimate partner violence. In trying to prevent repeat terminations, health-care professionals should be aware that while focusing on preventing conception may reduce the chances of a woman becoming pregnant, she may still be vulnerable to abuse. Finally, given the clear associations between intimate partner violence and termination of pregnancy, the researchers suggest that termination services represent an appropriate setting in which to test interventions designed to reduce intimate partner violence.
Additional Information
Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001581.
The World Health organization provides detailed information about intimate partner violence and about termination of pregnancy (some information available in several languages)
MedlinePlus provides links to other resources about intimate partner violence and about termination of pregnancy (in English and Spanish)
The World Bank has a webpage that discusses the role of the health sector in preventing gender-based violence and a webpage with links to other resources about gender-based violence
The Gender and Health Research Unit of the South African Medical Research Council provides links to further resources about intimate partner violence (research briefs/policy briefs/fact sheets/research reports)
DIVERHSE (Domestic & Interpersonal Violence: Effecting Responses in the Health Sector in Europe) is a European forum for health professionals, nongovernmental organizations, policy-makers, and academics to share their expertise and good practice in developing and evaluating interventions to address violence against women and children in a variety of health-care settings
London School of Hygiene & Tropical Medicine's Gender Violence and Health Centre also has a number of research resources
The UK National Health Service Choices website provides personal stories of intimate partner violence during pregnancy
The March of Dimes provides information on identifying intimate partner violence during pregnancy and making a safety plan
doi:10.1371/journal.pmed.1001581
PMCID: PMC3883805  PMID: 24409101
12.  Theoretically Motivated Interventions for Reducing Sexual Risk Taking in Adolescence: A Randomized Controlled Experiment Applying Fuzzy-trace Theory 
Fuzzy-trace theory is a theory of memory, judgment, and decision-making, and their development. We applied advances in this theory to increase the efficacy and durability of a multicomponent intervention to promote risk reduction and avoidance of premature pregnancy and STIs. 734 adolescents from high schools and youth programs in three states (Arizona, Texas, and New York) were randomly assigned to one of three curriculum groups: RTR (Reducing the Risk), RTR+ (a modified version of RTR using fuzzy-trace theory), and a control group.
We report effects of curriculum on self-reported behaviors and behavioral intentions plus psychosocial mediators of those effects, namely, attitudes and norms, motives to have sex or get pregnant, self-efficacy and behavioral control, and gist/verbatim constructs.
Among 26 outcomes, 19 showed an effect of at least one curriculum relative to the control group: RTR+ produced improvements for 17 outcomes and RTR produced improvements for 12 outcomes. For RTR+, two differences (for perceived parental norms and global benefit perception) were confined to age, gender, or racial/ethnic subgroups. Effects of RTR+ on sexual initiation emerged six months after the intervention, when many adolescents became sexually active. Effects of RTR+ were greater than RTR for nine outcomes, and remained significantly greater than controls at one-year follow-up for 12 outcomes. Consistent with fuzzy-trace theory, results suggest that, by emphasizing gist representations, which are preserved over long time periods and are key memories used in decision-making, the enhanced intervention produced larger and more sustained effects on behavioral outcomes and psychosocial mediators of adolescent risk-taking.
doi:10.1037/a0036717
PMCID: PMC4115050  PMID: 24773191
risk taking; risky decision making; adolescent health; STI prevention
13.  Pregnancy attitudes, contraceptive service utilization, and other factors associated with Los Angeles homeless youths’ use of effective contraception and withdrawal 
Journal of pediatric and adolescent gynecology  2013;26(6):10.1016/j.jpag.2013.06.007.
Study Objective
This study aims to understand the associations of contraceptive service utilization (i.e., accessing condoms or birth control), pregnancy attitudes, and lifetime pregnancy history among male and female homeless youth in relation to use of effective contraception and withdrawal.
Design, Setting, and Participants
Between October 2011 and February 2012, homeless youth (14–27 years old) from two drop-in centers in Los Angeles (N=380) were recruited and completed a questionnaire. The data in this paper are restricted to those who reported vaginal sex at last sex (N=283).
Main Outcome Measures
Analyses examined history of foster care, sexual abuse, exchange sex, pregnancy, lifetime homelessness duration, current living situation, contraceptive service utilization, and pregnancy attitudes in predicting use of effective contraception and withdrawal at last sex.
Results
Over 62% of females and 43% of males report having ever been pregnant or impregnating someone. There are no gender-based differences in pregnancy attitudes; 21% agree they would like to become pregnant within the year. Additionally, there are no gender-based differences in reported contraceptive use at last vaginal sex. In the multivariable model, high school education, contraceptive service utilization (RRR: 4.0), and anti-pregnancy attitudes (RRR: 1.3) are significant positive predictors of using effective contraception; anti-pregnancy attitudes (RRR:1.2) and gender (RRR: 0.3) are significantly associated with using withdrawal.
Conclusions
Health professionals should acknowledge that some homeless youth desire pregnancy; for those that do not, access to effective contraception is important. Programs must continue to promote pregnancy prevention, and include discussions of healthy pregnancy habits for pregnancy-desiring youth.
doi:10.1016/j.jpag.2013.06.007
PMCID: PMC3834348  PMID: 24238265
homeless youth; pregnancy; attitudes toward pregnancy; contraception; condoms; sexual health
14.  Factors associated with unintended pregnancy, poor birth outcomes and post-partum contraceptive use among HIV-positive female adolescents in Kenya 
BMC Women's Health  2012;12:34.
Background
Although the experiences of unintended pregnancies and poor birth outcomes among adolescents aged 15–19 years in the general population are well documented, there is limited understanding of the same among those who are living with HIV. This paper examines the factors associated with experiencing unintended pregnancies, poor birth outcomes, and post-partum contraceptive use among HIV-positive female adolescents in Kenya.
Methods
Data are from a cross-sectional study that captured information on pregnancy histories of HIV-positive female adolescents in four regions of Kenya: Coast, Nairobi, Nyanza and Rift Valley provinces. Study participants were identified through HIV and AIDS programs in the four regions. Out of a total of 797 female participants, 394 had ever been pregnant with 24% of them experiencing multiple pregnancies. Analysis entails the estimation of random-effects logit models.
Results
Higher order pregnancies were just as likely to be unintended as lower order ones (odds ratios [OR]: 1.2; 95% confidence interval [CI]: 0.8–2.0) while pregnancies occurring within marital unions were significantly less likely to be unintended compared to those occurring outside such unions (OR: 0.1; 95% CI: 0.1–0.2). Higher order pregnancies were significantly more likely to result in poor outcomes compared to lower order ones (OR: 2.5; 95% CI: 1.6–4.0). In addition, pregnancies occurring within marital unions were significantly less likely to result in poor outcomes compared to those occurring outside such unions (OR: 0.3; 95% CI: 0.1–0.9). However, experiencing unintended pregnancy was not significantly associated with adverse birth outcomes (OR: 1.3; 95% CI: 0.5–3.3). There was also no significant difference in the likelihood of post-partum contraceptive use by whether the pregnancy was unintended (OR: 0.9; 95% CI: 0.5–1.5).
Conclusions
The experience of repeat unintended pregnancies among HIV-positive female adolescents in the sample is partly due to inconsistent use of contraception to prevent recurrence while poor birth outcomes among higher order pregnancies are partly due to abortion. This underscores the need for HIV and AIDS programs to provide appropriate sexual and reproductive health information and services to HIV-positive adolescent clients in order to reduce the risk of undesired reproductive health outcomes.
doi:10.1186/1472-6874-12-34
PMCID: PMC3492047  PMID: 23039966
HIV-positive female adolescents; Unintended pregnancy; Poor birth outcomes; Post-partum contraceptive use; Kenya
15.  In Their Own Words: Romantic Relationships and the Sexual Health of Young African American Women 
Public Health Reports  2013;128(Suppl 1):33-42.
Objective
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.
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.
Results
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.
Conclusions
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
16.  Young Women’s Perceptions of the Benefits of Childbearing: Associations with Contraceptive Use and Pregnancy 
CONTEXT
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.
METHODS
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.
RESULTS
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.
CONCLUSIONS
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.
doi:10.1363/4502313
PMCID: PMC3620026  PMID: 23489854
17.  Are Latina Women Ambivalent About Pregnancies They Are Trying to Prevent? Evidence from the Border Contraceptive Access Study 
CONTEXT
Women’s retrospective reports of their feelings about a pregnancy and of its intendedness are often inconsistent, particularly among Latinas. Interpretation of this incongruence as ambivalence overlooks the possibility that happiness about the prospect of pregnancy and desire to prevent pregnancy need not be mutually exclusive.
METHODS
Data from the 2006–2008 Border Contraceptive Access Study—a prospective study of 956 Latina oral contraceptive users aged 18–44 in El Paso, Texas—were used to compare women’s planned pill use and childbearing intentions with their feelings about a possible pregnancy. Associations between women’s feelings and their perceptions of their partner’s feelings were examined using logistic regression. Prospective and retrospective intentions and feelings were compared among women who became pregnant during the study.
RESULTS
Forty-one percent of women who planned to use the pill for at least another year and 34% of those who wanted no more children said they would feel very or somewhat happy about becoming pregnant in the next three months. Perceiving that a male partner would feel very upset about a pregnancy was negatively associated with the woman’s own happiness about the pregnancy, among women who planned to continue pill use and those who wanted no more children (coefficients, −4.4 and −3.9, respectively). Of the 36 women who became pregnant during the study, 24 reported feeling very happy about the pregnancy in retrospect, while only 14 had prospectively reported feeling happy about a possible pregnancy.
CONCLUSIONS
Intentions and happiness appear to be distinct concepts for this sample of Latina women.
doi:10.1363/4519613
PMCID: PMC3891865  PMID: 24192284
18.  Prospective Assessment of Pregnancy Intentions Using a Single- Versus a Multi-Item Measure 
CONTEXT
Traditional measures of pregnancy intentions that are dichotomous and retrospective do not fully capture the complexity surrounding women’s plans to become pregnant.
METHODS
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.
RESULTS
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%).
CONCLUSIONS
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.
doi:10.1363/4123809
PMCID: PMC2939374  PMID: 20444179
19.  Pregnancy Risk Among Older Youth Transitioning Out Of Foster Care 
Children and youth services review  2013;35(10):1760-1765.
Youth served in the foster care system have higher rates of pregnancy than general population youth; yet we have little information about risk and protective factors to target in order to prevent early pregnancy in this population. We assessed early pregnancy risk and protective factors known for general population adolescents for their relevance to youth in the foster care system. Using data from a longitudinal study of 325 older youth from the foster care system, we examined bivariate and multivariate relationships between these factors and pregnancy between age 17 and 19 using logistic regression. Models examined risk for early parenting separately by gender. The pregnancy rate increased by 300% between ages 17 and 19. At 19, 55% of females had been pregnant, while 23% of males had fathered a child. Although this study assessed multiple known factors, few were significant for this high risk group. Females who were not sexually active at age 17 were less likely to become pregnant, but those who reported using birth control were as likely to become pregnant as those who did not. Also, females with a history of arrest were more likely to have a pregnancy between 17 and 19. Males who left the foster care system before their 19th birthday were more likely to make someone pregnant. Youth from the foster care system are at exceptional risk of early pregnancy, no matter their maltreatment history, religiosity, school connectedness, or academic achievement, particularly in the years between 17 and 19. This high risk group needs pregnancy prevention interventions and access to effective birth control.
doi:10.1016/j.childyouth.2013.08.001
PMCID: PMC3902972  PMID: 24489422
adolescent; pregnancy; foster care; risk/protective factors; males
20.  Let’s stay together: relationship dissolution and sexually transmitted diseases among parenting and non-parenting adolescents 
Journal of behavioral medicine  2010;33(6):454-465.
Relationships influence sexual risk and maternal-child health. Few studies have assessed relationship dissolution and its association with sexually transmitted diseases (STD) among adolescent parents. Our study aimed to describe relationship dissolution among 295 parenting and non-parenting adolescents over an 18-month period and how it related to STD incidence. Results showed that nonparenting adolescents in a relationship with someone other than their baby’s father were more likely to have a relationship dissolution over an 18-month period compared to those in a relationship with the baby’s father (OR = 1.69, P < .05). Parenting adolescents who ended their relationship with their baby’s father were 3 times more likely to get an STD over the course of the study compared to parenting adolescents who remained with their baby’s father (39% vs. 13%). Comparatively, non-parenting adolescents who ended their relationship were only 1.4 times more likely to get an STD compared to non-parenting adolescents who remained with their partner (44% vs. 32%). Our results suggest that prevention programs that incorporate male partners and components that strengthen relationship skills may reduce HIV/STD risk and help adolescents adapt during times of transition such as parenthood.
doi:10.1007/s10865-010-9276-6
PMCID: PMC3085168  PMID: 20607596
Relationship dissolution; STDs; Pregnancy; Adolescent relationships
21.  Adolescents’ Pregnancy Intentions 
Purpose
This study explores if and how adolescents’ pregnancy intentions relate to life situations and health-related behaviors prenatally and up to 2 years postpartum.
Methods
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.
Results
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.
Conclusion
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
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.
Background
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.
Conclusion
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.
doi:10.1016/j.cct.2007.05.003
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.  Internet Use among Ugandan Adolescents: Implications for HIV Intervention 
PLoS Medicine  2006;3(11):e433.
Background
The Internet is fast gaining recognition as a powerful, low-cost method to deliver health intervention and prevention programs to large numbers of young people across diverse geographic regions. The feasibility and accessibility of Internet-based health interventions in resource-limited settings, where cost-effective interventions are most needed, is unknown. To determine the utility of developing technology-based interventions in resource-limited settings, availability and patterns of usage of the Internet first need to be assessed.
Methods and Findings
The Uganda Media and You Survey was a cross-sectional survey of Internet use among adolescents (ages 12–18 years) in Mbarara, Uganda, a municipality mainly serving a rural population in sub-Saharan Africa. Participants were randomly selected among eligible students attending one of five participating secondary day and boarding schools in Mbarara, Uganda. Of a total of 538 students selected, 93% (500) participated.
Of the total respondents, 45% (223) reported ever having used the Internet, 78% (175) of whom reported going online in the previous week. As maternal education increased, so too did the odds of adolescent Internet use. Almost two in five respondents (38% [189]) reported already having used a computer or the Internet to search for health information. Over one-third (35% [173]) had used the computer or Internet to find information about HIV/AIDS, and 20% (102) had looked for sexual health information. Among Internet users, searching for HIV/AIDS information on a computer or online was significantly related to using the Internet weekly, emailing, visiting chat rooms, and playing online games. In contrast, going online at school was inversely related to looking for HIV/AIDS information via technology. If Internet access were free, 66% (330) reported that they would search for information about HIV/AIDS prevention online.
Conclusions
Both the desire to use, and the actual use of, the Internet to seek sexual health and HIV/AIDS information is high among secondary school students in Mbarara. The Internet may be a promising strategy to deliver low-cost HIV/AIDS risk reduction interventions in resource-limited settings with expanding Internet access.
A survey among 500 adolescent pupils in rural Uganda suggests widespread interest in online information about sexual health and HIV/AIDS. Over one-third of Internet users had already searched for relevant information online, and many of the others said they would like to educate themselves about HIV/AIDS online.
Editors' Summary
Background.
HIV/AIDS is a major health burden in sub-Saharan Africa, including Uganda. Despite a recent reduction of the number of HIV-infected individuals, HIV transmission remains a problem among Ugandan adolescents. Recent surveys suggest that about half of sexually active adolescents do not consistently use condoms, and that young people are less knowledgeable about HIV than they were 15 years ago.
Why Was This Study Done?
The Internet has a number of characteristics that make it an attractive tool in health education and HIV prevention, especially for adolescents—including interactivity, privacy, the overlap between education and play, and the ability to individualize information based on an initial assessment of background conditions, interest, and knowledge. It is also thought that despite these advantages, the Internet's potential in resource-poor settings with higher HIV infection rates and limited access to other health care resources has not been explored much. This study was done to gain some initial insights on the desired and actual use of the Internet to seek sexual health and HIV/AIDS information among adolescents in Uganda.
What Did the Researchers Do and Find?
They did a survey of 500 adolescent pupils randomly selected from five participating boarding schools in Mbarara, a small town in a rural part of Uganda. They asked three questions: To what extent are the adolescents exposed to computers and the Internet? Are they interested in accessing health information online? Who uses the Internet and how? Almost half of the participants said they had used the Internet at least once, and the majority said they had been online during the previous week. Most Internet users (82%) reported going online at school; 57% said they use Internet cafes, 17% access the Internet at home; and 11% at someone else's house. More than a third of all participants reported having used the Internet or computer to look up health information, and many had been looking for information on sexual health and HIV/AIDS. About two-thirds of the participants said that if Internet use were free, they would search for information on sexual health and HIV/AIDS prevention. The researchers analyzed the responses further to identify the most influential factors in whether one of the Internet users would go online to educate themselves about HIV/AIDS. They found that those participants who used the Internet more often and those who engaged in online activities like chat rooms, games, and e-mail, were more likely to search for HIV/AIDS information. On the other hand, those who went online only at school were less likely to do so.
What Do These Findings Mean?
Approximately the same proportion—roughly one-third—of adolescents in a rural setting in Uganda reported having used the Internet to look up health-related information as of young people in the United States. Together with the result that an additional third said that they would go online to educate themselves about HIV/AIDS if Internet use was free, this study suggests that initiatives in Africa to improve online access for adolescents as well as to develop content tailored for young people in specific settings would make a difference.
Additional Information.
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.0030433
Links page for adolescents and youth from HIV InSite at UCSF
Africa Initiative
HIV/AIDS education module from the US Public Broadcasting System
Lesson plan for “Using the Internet to Access Sexual Health Information” from the Information Institute of Syracuse
doi:10.1371/journal.pmed.0030433
PMCID: PMC1630714  PMID: 17090211
24.  The Impact of Contraceptive Counseling in Primary Care on Contraceptive Use 
ABSTRACT
BACKGROUND
Whether contraceptive counseling improves contraceptive use is unknown.
OBJECTIVE
To evaluate the association between contraceptive counseling provided by primary care physicians and patients’ contraceptive use.
DESIGN/PARTICIPANTS
All women aged 18–50 who visited one of four primary care clinics between October 2008 and April 2010 were invited to complete surveys about their visit. Seven to 30 days post visit, participants completed a survey assessing pregnancy intentions, receipt of contraceptive counseling, and use of contraception at last sexual intercourse. Survey data were linked to medical record data regarding contraceptive prescriptions prior to and during the clinic visit. Women were classified as in need of contraceptive counseling if they were sexually active, were not pregnant or trying to get pregnant, and had no evidence of contraceptive use prior to their index clinic visit.
KEY RESULTS
Fifty percent (n = 386) of women were in need of contraceptive counseling at the time of their visit. Those who received contraceptive counseling from a primary care provider were more likely to report use of hormonal contraception when they last had sex (unadjusted OR: 3.83, CI: 2.25–6.52), even after adjusting for age, race, education, income, marital status, pregnancy intentions, and prior pregnancy (adjusted OR: 2.68, CI: 1.48–4.87). Counseling regarding specific types of contraception was associated with an increased use of those methods. For example, counseling regarding hormonal contraceptives was associated with a greater likelihood of use of hormonal methods (adjusted OR: 4.78, CI: 2.51–9.12) and counseling regarding highly effective reversible methods was highly associated with use of those methods (adjusted OR: 18.45, CI: 4.88–69.84). These same relationships were observed for women with prior evidence of contraceptive use.
CONCLUSIONS
Contraceptive counseling in primary care settings is associated with increased hormonal contraceptive use at last intercourse. Increasing provision of contraceptive counseling in primary care may reduce unintended pregnancy.
doi:10.1007/s11606-011-1647-3
PMCID: PMC3138576  PMID: 21301983
contraceptive counseling; contraception; primary care; women’s health
25.  Intermittent Preventive Treatment of Malaria in Pregnancy with Mefloquine in HIV-Infected Women Receiving Cotrimoxazole Prophylaxis: A Multicenter Randomized Placebo-Controlled Trial 
PLoS Medicine  2014;11(9):e1001735.
Clara Menéndez and colleagues conducted a randomized controlled trial among HIV-positive pregnant women in Kenya, Mozambique, and Tanzania to investigate the safety and efficacy of mefloquine as intermittent preventative therapy for malaria in women receiving cotrimoxazole prophylaxis and long-lasting insecticide treated nets.
Please see later in the article for the Editors' Summary
Background
Intermittent preventive treatment in pregnancy (IPTp) with sulfadoxine-pyrimethamine (SP) is recommended for malaria prevention in HIV-negative pregnant women, but it is contraindicated in HIV-infected women taking daily cotrimoxazole prophylaxis (CTXp) because of potential added risk of adverse effects associated with taking two antifolate drugs simultaneously. We studied the safety and efficacy of mefloquine (MQ) in women receiving CTXp and long-lasting insecticide treated nets (LLITNs).
Methods and Findings
A total of 1,071 HIV-infected women from Kenya, Mozambique, and Tanzania were randomized to receive either three doses of IPTp-MQ (15 mg/kg) or placebo given at least one month apart; all received CTXp and a LLITN. IPTp-MQ was associated with reduced rates of maternal parasitemia (risk ratio [RR], 0.47 [95% CI 0.27–0.82]; p = 0.008), placental malaria (RR, 0.52 [95% CI 0.29–0.90]; p = 0.021), and reduced incidence of non-obstetric hospital admissions (RR, 0.59 [95% CI 0.37–0.95]; p = 0.031) in the intention to treat (ITT) analysis. There were no differences in the prevalence of adverse pregnancy outcomes between groups. Drug tolerability was poorer in the MQ group compared to the control group (29.6% referred dizziness and 23.9% vomiting after the first IPTp-MQ administration). HIV viral load at delivery was higher in the MQ group compared to the control group (p = 0.048) in the ATP analysis. The frequency of perinatal mother to child transmission of HIV was increased in women who received MQ (RR, 1.95 [95% CI 1.14–3.33]; p = 0.015). The main limitation of the latter finding relates to the exploratory nature of this part of the analysis.
Conclusions
An effective antimalarial added to CTXp and LLITNs in HIV-infected pregnant women can improve malaria prevention, as well as maternal health through reduction in hospital admissions. However, MQ was not well tolerated, limiting its potential for IPTp and indicating the need to find alternatives with better tolerability to reduce malaria in this particularly vulnerable group. MQ was associated with an increased risk of mother to child transmission of HIV, which warrants a better understanding of the pharmacological interactions between antimalarials and antiretroviral drugs.
Trial registration
ClinicalTrials.gov NCT 00811421; Pan African Clinical Trials Registry PACTR 2010020001813440
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Malaria, a mosquito-borne parasitic disease, kills about 600,000 people every year. Most of these deaths occur among young children living in sub-Saharan Africa but pregnant women living in Africa are also very vulnerable to malaria. Infection with malaria during pregnancy can cause severe maternal anemia (reduced red blood cell numbers), stillbirths, and pre-term and low-birthweight babies, and is responsible for the deaths of many African women and their babies. To reduce the loss of life from malaria in pregnancy, the World Health Organization (WHO) recommends that pregnant women living in Africa receive the antimalarial drug sulfadoxine-pyrimethamine (SP) at each scheduled antenatal care visit given at least a month apart (intermittent preventive treatment in pregnancy [IPTp]). In addition, WHO advises pregnant women to sleep under insecticide-treated bed nets to protect themselves from the bites of infected mosquitoes and recommends effective case management of pregnant women with malarial illness.
Why Was This Study Done?
Pregnant women living in Africa are often infected with HIV, the virus that causes AIDS. HIV infection increases both the risk and severity of malaria infection during pregnancy, and at least one million pregnancies are complicated by co-infection with malaria and HIV in sub-Saharan Africa every year. WHO recommends that HIV-positive pregnant women take cotrimoxazole (CTX) daily to prevent opportunistic infections (CTX prophylaxis [CTXp]). Unfortunately, both CTX and SP are antifolate drugs and taking two drugs of this type increases a woman's risk of developing a severe skin reaction. Moreover, although CTXp protects children and HIV-infected adults against malaria, it is not known whether CTXp alone protects HIV-infected pregnant women adequately against malaria. Thus, evaluations of alternative drugs for use in IPTp in HIV-positive pregnant women are needed. In this randomized placebo-controlled trial, the researchers study the safety and efficacy of the antimalarial drug mefloquine (MQ) in HIV-infected women receiving CTXp. A randomized, placebo-controlled trial compares outcomes among people chosen through the play of chance to receive either the drug under investigation or a “dummy” (placebo) drug.
What Did the Researchers Do and Find?
The researchers allocated 1,071 HIV-infected pregnant women from Kenya, Mozambique, and Tanzania to receive three doses of MQ (IPTp-MQ), given at least one month apart, or three doses of placebo. All the women received CTXp and were given an insecticide-treated bed net. In an intention-to-treat analysis (an analysis that considers the outcomes of all trial participants irrespective of whether they receive their allocated treatment), the prevalence of parasitemia (parasites in the blood) at delivery among women given IPTp-MQ was 3.5% whereas the prevalence among women given the placebo was 6.9%. In other words, compared to placebo, IPTp-MQ was associated with a reduced risk of maternal parasitemia. IPTp-MQ was also associated with a reduced rate of placental malaria (parasites in the placenta) and a reduced incidence of hospital admissions for non-pregnancy related causes. There was no difference in adverse pregnancy outcomes such as stillbirth between the intervention groups but drug tolerability was poorer in the MQ group than in the placebo group. Finally, in an exploratory (unplanned) according-to-protocol analysis (an analysis that only considers outcomes in trial participants who receive their allocated intervention), women in the MQ group had a higher HIV viral load at delivery than women in the control group and were nearly twice as likely to transmit HIV to their child around the time of birth.
What Do These Findings Mean?
These findings suggest that the addition of IPTp-MQ to CTXp and the use of insecticide-treated bed nets can improve malaria prevention and maternal health in HIV-infected pregnant women in Africa. However, the poor tolerability of MQ and the association of MQ treatment with both an increased HIV viral load at delivery and a higher frequency of mother-to-child-transmission of HIV when compared to placebo raise concerns about the use of MQ in IPTp. Because these last two findings came from an exploratory analysis, which is more likely to throw up a chance finding than a pre-planned analysis further studies are needed to confirm these unexpected but potentially important findings. Nevertheless, overall, the findings of this study suggest that MQ should not be recommended for IPTp in HIV-infected pregnant women in Africa and highlight the need to find alternative drugs for malaria prevention in this group of women who are particularly vulnerable to malaria.
Additional Information
Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001735.
This study is further discussed in a PLOS Medicine Perspective by Richard Steketee.
A related PLOS Medicine Research Article by González et al. compares the efficacy of IPTp-MQ and IPTp-SP in HIV-negative women
Information is available from the World Health Organization on malaria (in several languages) and on malaria in pregnancy; information on IPTp and the current WHO policy recommendation on IPTp with SP are available; the 2013 World Malaria Report provides details of the current global malaria situation
The US Centers for Disease Control and Prevention also provides information on malaria; a personal story about malaria in pregnancy is available
Information is available from the Roll Back Malaria Partnership on all aspects of global malaria control, including information on malaria in pregnancy
The Malaria in Pregnancy Consortium is undertaking research into the prevention and treatment of malaria in pregnancy
MedlinePlus provides links to additional information on malaria (in English and Spanish)
More information about the trial protocol is available
doi:10.1371/journal.pmed.1001735
PMCID: PMC4172537  PMID: 25247995

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