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1.  The Intersection of Youth, Technology, and New Media with Sexual Health: Moving the Research Agenda Forward 
Youth bear a significant proportion of the sexually transmitted infection (STI)/HIV burden in the United States, CDC, 2010. Available at:, with rates of some STIs increasing among youth of color and young men who have sex with men. Technology use among youth also continues to increase. The ubiquitous nature of technology use among youth offers a multitude of opportunities to promote youth sexual health and to prevent disease transmission and unplanned pregnancies. To date, there have been a handful of peer-reviewed articles published regarding the feasibility, acceptability, and effectiveness of using new media and technology for sexual health promotion. Despite recent publications, there is still a real need for high-quality research to understand the impact of different forms of new media use on youth sexual health, as well as to determine the best ways to harness technology to promote safer sex behaviors, both for the short- and long-term. In March 2011, Internet Sexuality Information Services (ISIS), National Institute of Mental Health (NIMH), and the Ford Foundation convened a meeting of scientists and technology experts to discuss how to effectively conduct sexual health promotion research using new forms of technology. The meeting was structured to cover the following topic areas: (i) research–community partnerships, (ii) institutional review board and ethical issues, (iii) theoretical frameworks, (iv) intervention approaches, (v) recruitment methods, and (vi) assessing impact. Presentations included case studies of successful technology-based HIV/STI prevention interventions for youth, which led to broader discussions on how to conduct research in this area. This article summarizes the meeting proceedings, highlights key points, offers recommendations, and outlines future directions.
PMCID: PMC4330086  PMID: 22921129
Sexuality; Reproductive health; Adolescents; Young adults; Social networking sites; Short message service
2.  [No title available] 
PMCID: PMC3946951  PMID: 23968881
3.  [No title available] 
PMCID: PMC3946969  PMID: 24064282
4.  [No title available] 
PMCID: PMC3947006  PMID: 24113495
5.  Physical Activity Trajectories and Multi-Level Factors among Adolescent Girls 
Although the decline of physical activity in adolescent girls is well-documented, there are girls whose physical activity does not follow this pattern. This study examined the relationships between physical activity trajectories and personal, psychosocial and environmental factors among adolescent girls.
Participants were from the University of Maryland field site of the Trial of Activity for Adolescent Girls. Of 730 girls measured in 8th grade, 589 were re-measured in 11th grade. Moderate to vigorous physical activity was assessed by accelererometers; participants were categorized as active maintainers (n=31), inactive maintainers (n=410), adopters (n=64), or relapsers (n=56). Height and weight were measured, personal and psychosocial information was collected from surveys, and distance from home to school and parks was assessed from Geographical Information Systems. Multivariable logistic regression was used for data analysis.
Variables at individual, social, and environmental levels predicted active maintainers and inactive maintainers, while only individual-level variables predicted adoption. None predicted relapse. Higher (favorable) scores for physical self-concept, perceived body fat, friend and family physical activity support, frequency of physical activity with friends, and shorter distance from home to a park predicted active maintainers. Overweight/obese status, earlier age at menses, and lower scores for physical self-concept, perceived body fat, friend physical activity support, and frequency of physical activity with friends, and further distance from home to school predicted inactive maintainers. High physical self-concept and not being overweight/obese predicted adopters.
Multi-level factors appear to predict behavior maintenance rather than actual change.
Implications and Contribution
Although physical activity declines among girls during adolescence, some maintain and others increase their physical activity. Our results identified factors across individual, social, and environmental levels that predicted physical activity maintenance over 3 years. These may guide future interventions to enhance adolescent girls’ physical activity and combat the overall decline.
PMCID: PMC3872172  PMID: 23992761
6.  Substance Use and Sexual Intercourse Onsets in Adolescence: A Genetically Informative Discordant Twin Design 
The objective of this study was to examine if earlier onset of drinking and smoking behaviors predicted early sexual intercourse onset using a genetically informed, discordant twin analysis.
3424 adult same-sex twins from the Australian Twin Registry completed a structured interview which included retrospective reports on onsets of smoking, drinking, intoxication and sexual intercourse and conduct disorder symptoms. A two-level frailty model estimated within-twin-pair and between-twin-pair comparisons. Onsets of smoking, drinking, drunkenness and conduct disorder symptoms were estimated as sexual intercourse onset predictors.
After controlling for conduct disorder, smoking and drinking onset did not predict sexual intercourse onset for either within-twin-pair or between-twin-pair comparisons. Drunkenness onset had a significant effect on sexual intercourse onset, such that twins who first experienced alcohol intoxication at a younger age than their co-twins were also more likely to have sex earlier than their co-twins.
Relationships between substance use and sexual intercourse onsets may be due mostly to shared underlying factors; there was only a small relation between intoxication onset and sexual intercourse onset, and no direct relation between smoking and drinking onset and sexual intercourse onset.
PMCID: PMC3872214  PMID: 23992762
Twin study; sexual intercourse onset; substance use onset; problem behavior theory
7.  The Long-Term Effects of Maternal Depression: Early Childhood Physical Health as a Pathway to Offspring Depression 
Cross sectional and retrospective studies have highlighted the long-term negative effects of maternal depression on offspring physical, social, and emotional development, but longitudinal research is needed to clarify the pathways by which maternal depression during pregnancy and early childhood affects offspring outcomes. The current study tested one developmental pathway by which maternal depression during pregnancy might negatively impact offspring mental health in young adulthood, via poor physical health in early childhood.
The sample consisted of 815 Australian youth and their mothers who were followed for 20 years. Mothers reported on their own depressive symptoms during pregnancy and offspring early childhood. Youth completed interviews about health-related stress and social functioning at age 20, and completed a questionnaire about their own depressive symptoms two to five years later.
Path analysis indicated that prenatal maternal depressive symptoms predicted worse physical health during early childhood for offspring, and this effect was partially explained by ongoing maternal depression in early childhood. Offspring poor physical health during childhood predicted increased health-related stress and poor social functioning at age 20. Finally, increased health-related stress and poor social functioning predicted increased levels of depressive symptoms later in young adulthood. Maternal depression had a significant total indirect effect on youth depression via early childhood health and its psychosocial consequences.
Poor physical health in early childhood and its effects on young adults’ social functioning and levels of health related stress are one important pathway by which maternal depression has long-term consequences for offspring mental health.
PMCID: PMC3872221  PMID: 24060574
Depression; child and adolescent health; social adjustment; community sample
8.  Predictors and patterns of cigarette and smokeless tobacco use among adolescents in 32 Countries, 2007–2011 
This study compared data from 32 countries to assess predictors and patterns of cigarette and smokeless tobacco (SLT) use among students aged 13–15 years old.
Data from the 2007–2008 Global Youth Tobacco Surveys were analyzed for students aged 13–15 years in 31 countries located in all six WHO regions. In addition, the 2011 National Youth Tobacco Survey was analyzed for U.S. students aged 13–15 years. Country-specific prevalence of current smoking, current SLT use, and concurrent use patterns were assessed.
The national prevalence of current cigarette smoking among students aged 13–15 years ranged from 1.8% (Rwanda) to 32.9% (Latvia) whereas current SLT use ranged from 1.1% (Montenegro) to 14.4% (Lesotho). In the U.S. and most European countries surveyed, current smoking prevalence was significantly higher than SLT prevalence, in contrast to patterns observed in low and middle income countries (LMICs). Also, in most of the surveyed countries outside of Europe and the U.S., SLT use among girls was as common as their use of cigarettes, and not significantly different from use by boys. When compared to U.S. adolescents, the odds of SLT use were highest among African adolescents (aOR=3.98; 95%CI: 2.19–7.24) followed by those in the South-East Asian region (aOR=2.76; 95%CI: 1.38–5.53).
Region specific patterns of tobacco use were noticed. Furthermore it is alarming that in several LMICs, the prevalence of SLT use among females did not differ from that among males, suggesting the possibility of a future shared burden of disease between both males and females.
PMCID: PMC3872244  PMID: 24060573
Smoking; adolescents; Cigarette; Smokeless tobacco; Addiction
9.  A Trajectory Analysis of Alcohol and Marijuana Use Among Latino Adolescents in San Francisco, California 
We examined alcohol and marijuana use trajectories among Latino adolescents in the San Francisco Bay Area.
A total of 410 Latino adolescents aged 14–19 years were recruited from community venues from years 2001 to 2004 and followed up for 2 years. In separate models, we identified groups with similar temporal patterns of alcohol and marijuana use using semi-parametric latent group trajectory modeling. Multivariable multinomial logistic regression was used to identify factors associated with the probability of trajectory group membership.
The use of alcohol (76%) and marijuana (55%) in the previous 6 months was common. Three alcohol-use trajectories were identified: low users (18%), moderate users (37%), and frequent users (45%). Low alcohol users (vs. moderate users) were found to be younger in age, preferred Spanish language, and had more parental monitoring. Frequent users were more likely to be male, sexually active, gang exposed, and have less parental monitoring than moderate users. Similarly, three marijuana-use trajectories were identified: low users (36%), moderate users (35%), and frequent users (28%), with similar correlates of group membership.
Urban Latino adolescents’ substance use is shaped by complex cultural and environmental influences. Patterns of substance use emerge by early adolescence highlighting the need for timely intervention.
PMCID: PMC4269327  PMID: 21094433
Latinos; Adolescents; Substance use; Acculturation; Gangs; Marijuana; Alcohol
10.  Alcohol and Marijuana Use in Middle School: Comparing Solitary and Social-Only Users 
Middle school students with a history of solitary substance use are at elevated risk for substance problems by young adulthood. Understanding how these students differ from social-only users on substance use behaviors and consequences, normative beliefs, social influences and attitudes can inform efforts to reduce solitary use and its related negative consequences.
6th–7th grade students completed an in-school survey. We compared those with a history of solitary vs. social-only alcohol use (n=202 and n=616, respectively) and marijuana use (n=92 and n=208, respectively) on a range of substance use-related characteristics.
Any solitary use was reported by 25% of lifetime alcohol users and 31% of lifetime marijuana users. Those with a history of solitary use of either substance were more likely to hold positive expectancies about their use, but also reported more negative consequences during the past year. Solitary users tended to have greater exposure to substance using peers and more difficulty resisting offers to use. Compared to social-only drinkers, those with a history of solitary drinking perceived that more of their peers were alcohol users. Significant group differences were not found on negative outcome expectancies or attempts to cut down on substance use.
Solitary use is an important, yet overlooked problem among middle school students who have just begun drinking or using marijuana. Results suggest that positive expectancies, peer influences, resistance self-efficacy, and normative beliefs may be important areas to target in reducing solitary use and the risk it poses for problematic use in young adulthood.
PMCID: PMC4252711  PMID: 25223477
11.  The influence of sexual partner on condom use among urban adolescents 
The influence of partner context (e.g., drinking alcohol in the 2 hours prior to sex, ≥ 3 years age discordant, met in public) on adolescent boys’ and girls’ condom use is unclear. Among an urban cohort of primarily (86%) minority 17–18 year olds who reported having sex (n=1469), we assessed the association between condom use and partner characteristics for the most recent sexual experience.
We used logistic regression to examine the odds of condom use by measured partner familiarity (casual or unexpected) and context characteristics. Analyses were stratified by gender.
Adolescent boys and girls were twice as likely to use condoms with partners they considered casual or unexpected. Adjusting for partner familiarity risk, adolescent boys’ tended to decrease condom use with risky context partners. Adjusting for partner familiarity risk, adolescent girls were half as likely to use condoms with partners drinking alcohol two hours prior to sex [Odds Ratio (OR)=0.6, 95% Confidence Interval (CI) =0.4–0.9]; ≥ 3 years age discordant (OR=0.5, 95% CI =0.3–0.8); or met in public places (OR=0.6, 95% CI =0.4–0.8).
Regardless of partner familiarity risk, adolescent boys and girls faced barriers to condom use with risky context partners. Increased understanding of adolescents’ perceptions of and control over partner risk and condom use with risky context partners is needed. Interventions aimed at decreasing adolescent sexually transmitted infections should include strategies for adolescents to choose less risky context partners and negotiate condoms with risky context partners.
PMCID: PMC3836835  PMID: 23932008
sexual partners; condom use; adolescents; alcohol use; age discordance
12.  A longitudinal examination of psychological, behavioral, academic, and relationship consequences of dating abuse victimization among a primarily rural sample of adolescents 
It is widely held that being victimized by a dating partner during adolescence has negative consequences, yet few longitudinal studies have examined those consequences. This longitudinal study examined the effects of psychological and physical (which included sexual) dating abuse victimization on internalizing symptoms, substance use, academic aspirations and grades, and relationships with friends and family.
This four-wave longitudinal study (N = 3,328), conducted in two rural North Carolina counties, spanned grades 8 to 12. Random coefficient analyses were used to examine prospective lagged effects of each type of dating abuse on each outcome and to examine sex and grade as moderators of lagged effects.
Consequences varied by type of dating abuse experienced and sex. For both boys and girls, psychological victimization predicted increased alcohol use and physical victimization predicted increased cigarette use. For girls, physical victimization predicted increased marijuana use, and psychological victimization predicted increased internalizing symptoms; the latter effect was only marginally significant for boys. Physical victimization marginally predicted decreases in the number of close friends for boys. Neither type of victimization predicted increased family conflict or decreased academic aspirations or grades, nor was there evidence that consequences varied by grade.
Although causation cannot be concluded with longitudinal designs, our findings suggest that being victimized by a dating partner may result in detrimental consequences for adolescents. The findings demonstrate the importance of identifying and implementing evidence-based interventions for preventing dating abuse, including efforts to prevent psychological abuse specifically.
PMCID: PMC3838452  PMID: 23910572
Adolescent dating abuse; consequences of dating abuse
13.  The Effects of Acute Sleep Restriction on Adolescents' Pedestrian Safety in a Virtual Environment 
Over 8,000 American adolescents ages 14-15 require medical attention due to pedestrian injury annually. Cognitive factors contributing to pedestrian safety include reaction time, impulsivity, risk-taking, attention, and decision-making. These characteristics are also influenced by sleep restriction. Experts recommend adolescents obtain 8.5 hours of uninterrupted sleep each night, but most American adolescents do not. Inadequate sleep may place adolescents at risk for pedestrian injury.
Using a within-subjects design, fifty-five 14- and 15-year-olds engaged in a virtual reality pedestrian environment in two conditions, scheduled a week apart: sleep-restricted (4 hours sleep previous night) and adequate sleep (8.5 hours). Sleep was assessed using actigraphy and pedestrian behavior via four outcome measures: time to initiate crossing, time before contact with vehicle while crossing, virtual hits/close calls and attention to traffic (looks left and right).
While acutely sleep restricted, adolescents took more time to initiate pedestrian crossings, crossed with less time before contact with vehicles, experienced more virtual hits/close calls and looked left and right more often compared to when adequately rested. Results were maintained after controlling for age, gender, ethnicity and average total sleep duration prior to each condition.
Adolescent pedestrian behavior in the simulated virtual environment was markedly different, and generally more risky, when acutely sleep restricted compared to adequately rested. Inadequate sleep may influence cognitive functioning to the extent that pedestrian safety is jeopardized among adolescents capable of crossing streets safely when rested. Policy decisions might be educated by these results.
PMCID: PMC3838462  PMID: 24012066
Sleep; Adolescence; Safety; Injury
14.  Contextual Amplification or Attenuation of the Impact of Pubertal Timing on Mexican-origin Boys’ Mental Health Symptoms 
To examine the role of neighborhood contextual variation in the putative association between pubertal timing and internalizing and externalizing symptoms among Mexican-origin boys.
In a sample of 7th grade Mexican-origin boys (N = 353; x̄age = 12.8 years) we assessed a range of secondary sexual characteristics, internalizing, and externalizing symptoms. Reports on all secondary sexual characteristics were collapsed and age-standardized to represent total pubertal timing. We also distinguished between the timing of physical changes driven by adrenal versus gonadal maturation. Boys’ residential addresses were geocoded and American Community Survey data were used to describe neighborhoods along two dimensions: ethnic concentration and socioeconomic disadvantage. Three years later (in 10th grade) we re-assessed internalizing and externalizing symptoms. We examined the moderating influence of neighborhood ethnic concentration and neighborhood socioeconomic disadvantage on the prospective associations between puberty timing (total, gonadal, adrenal) and internalizing and externalizing symptoms.
Earlier total pubertal timing predicted increases in externalizing symptoms, but only when Mexican-origin boys lived in neighborhoods low on ethnic concentration. Total timing results for externalizing symptoms were replicated for adrenal timing. Further, early adrenal timing predicted increases in internalizing symptoms, but again, only when boys lived in neighborhoods low on ethnic concentration. No effects were observed for gonadal timing specifically.
Early pubertal timing, especially advanced physical changes initiated and regulated by adrenal maturation, have important implications for Mexican-origin boys’ internalizing and externalizing symptoms, but these implications depend on neighborhood characteristics. Ethnically concentrated neighborhoods are protective for early-maturing Mexican-origin boys.
PMCID: PMC3838466  PMID: 23992760
15.  Parental Support and Mental Health Among Transgender Adolescents 
Family support is protective against health risks in sexual minority individuals. However, few studies have focused specifically on transgender youth, who often experience rejection, marginalization, and victimization that place them at risk for poor mental health. This study investigated the relationships among parental support, quality of life, and depression in transgender adolescents.
Sixty-six transgender youth presenting for care at Children’s Hospital Los Angeles completed a survey assessing parental support (defined as help, advice and confidante support), quality of life, and depression. Regression analyses assessed the associations between parental support and mental health outcomes.
Parental support was significantly associated with higher life satisfaction, lower perceived burden of being transgender, and fewer depressive symptoms.
Parental support is associated with higher quality of life and is protective against depression in transgender adolescents. Interventions that promote parental support may significantly impact the mental health of transgender youth.
PMCID: PMC3838484  PMID: 24012067
transgender; adolescents; parental support; depression; quality of life
16.  Health Insurance Coverage Predicts Lower Childbearing among Near-Poor Adolescents 
The impact of health insurance on adolescent childbearing takes on increased salience in the context of the ongoing U.S. healthcare debate. Health insurance coverage is important for accessing healthcare services, including reproductive health services, yet prior research has not examined the association between insurance coverage and childbearing. Consequently, the role of insurance in the prevention of adolescent childbearing has been unclear.
Using three panels (2001, 2004, and 2008) of the nationally representative Survey of Income and Program Participation (SIPP) data, hierarchical multilevel logistic regression models test the association between pre-pregnancy health insurance coverage and childbearing for a sample of 7,263 unmarried adolescent women (aged 16–19), controlling for known correlates of adolescent childbearing. Analyses examine variations in the association based on family income.
The odds of reporting childbearing are almost twice as great for adolescents who were uninsured compared with those who were insured before a pregnancy occurred. Interaction models demonstrate this effect for near-poor adolescents (who are less likely to have health insurance coverage) compared to poor and more advantaged adolescents.
The findings of the current nationally-representative study suggest that health insurance coverage is associated with a lower probability of childbearing for near poor adolescents. Future research should examine potential mechanisms through which insurance coverage influences adolescent childbearing.
PMCID: PMC3838490  PMID: 23945054
adolescent childbearing; health insurance; fertility; reproductive behavior
Youth living with HIV account for over one-third of new HIV infections and are at high risk of adverse psychosocial, everyday living, and health outcomes. HIV-associated neurocognitive disorders (HAND) are known to affect health outcomes of HIV-infected adults even in the era of combination antiretroviral therapy (cART). Thus, the current study aimed to characterize the prevalence and clinical correlates of HAND in youth living with HIV. Here we report baseline neurocognitive data for behaviorally HIV-infected youth enrolled in a prospective study evaluating strategies of antiretroviral treatment initiation and use.
Two hundred twenty participants, age 18-24, naïve to treatment (except for prevention of mother to child HIV transmission; n=3), completed a comprehensive neurocognitive, substance use, and behavioral health assessment battery.
64.7% of youth met criteria for HAND (96.4% asymptomatic, 3.5% syndromic), with deficits in episodic memory and fine-motor skills emerging as the most commonly affected ability areas. Multivariable models showed that lower CD4 count, longer time since HIV diagnosis, and high risk alcohol use were uniquely associated with neurocognitive deficits.
Over two-thirds of youth with behaviorally acquired HIV evidence neurocognitive deficits, which have modest associations with more advanced HIV disease as well as other factors. Research is needed to determine the impact of such neuropsychiatric morbidity on mental health and HIV disease treatment outcomes (e.g., non-adherence) and transition to independent living responsibilities in HIV-infected youth, as well as its long-term trajectory and possible responsiveness to cognitive rehabilitation and pharmacotherapy.
PMCID: PMC3878875  PMID: 23972941
HIV; Adolescent; Neurocognitive Functioning; Substance Use; HIV-Associated Neurocognitive Disorder (HAND)
18.  Racial disparities in human papillomavirus vaccination: Does access matter? 
To examine the association between race/ethnicity and HPV vaccine initiation and to determine how access to healthcare influences this relationship.
We used nationally representative data from the National Survey of Family Growth to assess HPV vaccine initiation in 2,168 females aged 15–24. A series of regression analyses were performed to determine the independent effect of race/ethnicity on HPV vaccine initiation after controlling for socio-demographic variables and healthcare access measures. Age-stratified regression analyses were also performed to assess whether the relationship between race/ethnicity and HPV vaccine initiation differed between females aged 15–18 and 19–24.
There were significant racial/ethnic disparities in HPV vaccination with US-born Hispanics, foreign-born Hispanics, and African-Americans less likely to have initiated vaccination than whites (p<0.001). Adjusting for socio-demographic characteristics attenuated the disparity for both US-born and foreign-born Hispanics (adjusted odds ratio (AOR): 0.76; 95% confidence interval (CI): 0.50–1.16 and AOR: 0.67; 95% CI: 0.37–1.19) but not for African-Americans (AOR: 0.47; 95% CI: 0.33–0.66). Adding healthcare access measures further attenuated the disparity for US-born and foreign-born Hispanics (AOR: 0.85; 95% CI: 0.54–1.34 and AOR: 0.84; 95% CI: 0.45–1.55). African-Americans, however, remained less likely than whites to have initiated vaccination (AOR: 0.49; 95% CI: 0.36–0.68). These racial/ethnic trends were similar for females aged 15–18 and 19–24.
Lower rates of HPV vaccination among African-American females do not appear to be explained by differential access to healthcare. More research is necessary to elucidate factors contributing to HPV vaccination in this population.
PMCID: PMC4058822  PMID: 23992645
race/ethnicity; HPV; NSFG; disparities; vaccination
19.  Gender Differences in Adolescent Premarital Sexual Permissiveness in Three Asian Cities: Effects of Gender-Role Attitudes 
Gender is an important factor in understanding premarital sexual attitudes and behaviors. Many studies indicate that males are more likely to initiate sexual intercourse and have more permissive perceptions about sex than females. Yet few studies have explored possible reasons for these gender differences. With samples of unmarried adolescents in three Asian cities influenced by Confucian cultures, this paper investigates the relationship between underlying gender norms and these differences in adolescents’ premarital sexual permissiveness.
16,554 unmarried participants aged 15–24 were recruited in the Three-City Asian Study of Adolescents and Youth, a collaborative survey conducted in 2006–2007 in urban and rural areas of Hanoi, Shanghai and Taipei, with 6204, 6023 and 4327 from each city respectively. All of the adolescents were administered face-to-face interviews, coupled with Computer Assisted Self Interview (CASI) for sensitive questions. Scales on gender-role attitudes and on premarital sexual permissiveness for both male and female respondents were developed and applied to our analysis of the data. Multi-linear regression was used to analyze the relationship between gender-role attitudes and sexual permissiveness.
Male respondents in each city held more permissive attitudes towards premarital sex than did females with both boys and girls expressing greater permissiveness to male premarital sexual behaviors. Boys also expressed more traditional attitudes to gender roles (condoning greater inequality) than did girls in each city. Adolescents’ gender-role attitudes and permissiveness to premarital sex varied considerably across the three cities, with the Vietnamese the most traditional, the Taiwanese the least traditional, and the adolescents in Shanghai in the middle. A negative association between traditional gender roles and premarital sexual permissiveness was only found among girls in Shanghai and Taipei. In Shanghai, female respondents who held more traditional gender role attitudes were more likely to exercise a double standard with respect to male as opposed to female premarital sex (OR=1.18). This relationship also applied to attitudes of both girls and boys in Taipei (OR=1.20 and OR=1.22, respectively).
Although with variation across sites, gender differences in premarital sexual permissiveness and attitudes to gender roles among adolescents were very significant in each of the three Asian cities influenced by Confucian-based values. Traditional gender norms may still be deeply rooted in the three cities, especially among females, while it is important to advocate gender equity in adolescent reproductive health programs, the pathway of traditional gender norms in influencing adolescent reproductive health outcomes must be understood, as must differences and similarities across regions.
PMCID: PMC4235609  PMID: 22340852
Gender role; Premarital sex; Attitudes; Asian; Confucian
20.  Media’s Contribution to Sexual Knowledge, Attitudes and Behaviors for Adolescents and Young Adults in Three Asian Cities 
Evidence in western countries indicates that the media have associations with adolescents’ and young people’ sexual behavior that may be as important as family, school and peers. In this new study of Asian adolescents and young adults in the three cities of Hanoi, Shanghai and Taipei, the associations between exposure to sexual content in the media and adolescents’ and young adults’ sex-related knowledge, attitudes and behaviors are explored in societies with traditional Confucian culture, but at different stages in the process of modernization.
The data are from a questionnaire-based cross-sectional study conducted from 2006 to 2007 where a sample of 17,016 adolescents and young adults aged 15–24 years from Shanghai, Hanoi and Taipei completed face-to-face interviews coupled with computer-assisted self-interviews (CASI) for sensitive questions. For the objectives of this paper, analysis was restricted to the 16,554 unmarried respondents. Exposure to sexual content in the mass media (including the Internet and traditional media), pornographic videos, and a preference for western/Asian movies/videos were the main media influence measures. Sex-related knowledge, premarital sexual permissiveness, and sex-related behaviors were the main outcome measures. The impact of each of four contexts including family, peer, school and media on sex-related knowledge, attitudes and behaviors were assessed using multiple linear regression stratified by gender and city, controlling for age, urban/rural residence, education and economic status. The change in adjusted R2 from the multiple linear regression analysis was adopted to indicate the contribution of family, peer, school and media variables to respondents’ sex-related knowledge, attitudes and behaviors.
The contextual factors, including family, peer, school and media, explained 30–50% of the variance in sex-related knowledge, 8–22% of the variance in premarital sexual permissiveness and 32–41% of the variance in sex-related behaviors. Media variables explained 13–24% of the variance in sexual knowledge, 3–13% in premarital sexual permissiveness and 3–13% in sex-related behaviors, which was comparable to that of family, peer and school variables. These associations differed by city and gender.
Access to and use of mass media and the messages it presents are influential factors on sex-related knowledge, attitudes and behaviors of unmarried Asian adolescents and young adults, and should be considered in future research and intervention programs attempting to improve reproductive health outcomes.
PMCID: PMC4235612  PMID: 22340853
Mass media; Unmarried; Sex-related knowledge; Attitude; Sexual behavior; Asian city; Multi-center study
21.  The Relationship between Sexual Behavior and Non-sexual Risk Behaviors among Unmarried Youth in Three Asian Cities 
Health risk behaviors in adolescents and youth such as smoking, alcohol, drug use, violence, suicide, and unprotected sexual behavior are issues of major public health concern. Addressing the relationship between sexual behavior and non-sexual risk behaviors will make a significant contribution to the design of effective intervention programs for this population of adolescents and unmarried youth.
This cross-sectional study was conducted in three Asian cities with a common heritage of Confucian values: Hanoi, Shanghai and Taipei. Data were collected in 2006 from 17,016 youth aged 15-24 years residing in both urban and rural districts of the three settings. The relationships between sexual behavior and seven non-sexual risk behaviors among unmarried adolescents were examined using χ2 tests, logistic regression models, Cox regression models, and cluster analysis.
Sexual behavior was associated with seven non-sexual risk behaviors, especially with smoking, drinking, drug use and running away from home. In terms of the age at initiation of risk behaviors, smoking and drinking were usually initiated before sexual intercourse. Sexual behavior and non-sexual risk behaviors co-occurred in the high risk group in all three cities. Youth having the highest risk of sexual behavior were more likely to have the highest risk of nearly all non-sexual risk behaviors, with the exception of fighting in Hanoi, and gambling in Shanghai and Taipei.
Sexual behavior among unmarried youth is correlated with non-sexual risk behaviors but with different patterns across the three settings. Interventions aimed at reducing unprotected sex generally focus only on the sexual behavior; however, considering the correlations found here between sexual and non-sexual risk behaviors, they should target multiple risk behaviors.
PMCID: PMC4235615  PMID: 22340860
Sexual behavior; non-sexual risk behaviors; unmarried youth
22.  How does Traditional Confucian Culture Influence Adolescents’ Sexual Behavior in Three Asian Cities? 
To investigate whether and how the presence of Confucian cultural norms influences the sexual behaviors of adolescents and young adults in three Asian cities experiencing different levels of economic development.
Data on this paper were drawn from the international cross-sectional survey on sexual and reproductive health of adolescents and young adults aged 15–24 in three Asian cities (Hanoi, Shanghai and Taipei), conducted in 2006. The original sample consisted of a representative group of 17,016 adolescents, while in this paper, 16,554 never married adolescents were included in the analysis. Both face-to-face interview and Computer Assisted Self-Interview (CASI) approaches were adopted in the survey. Exposure to family concepts, self-cultivation values, gender role concepts and sexual values were the main measures of traditional Confucian cultural influence. Sexual and intimate behaviors were the main outcome measures, multi-Cox regression models were used to assess the association between traditional cultural concepts and values and sexual behavior after adjusting for potentially confounding factors. Data were analyzed with SAS software 9.1.
The traditional Confucian cultural norms were not weakening evenly, with more entrenchment in Hanoi than in Shanghai and Taipei. Prevalences of sexual coitus among adolescent and young adults were lowest in Hanoi and highest in Taipei, while similar profiles of other intimate behaviors were displayed in the three cities. Associations between respondents’ sexual behavior and their cultural concepts and values differed by city. In Hanoi, for all four cultural measures, respondents with more traditional views were less likely to be engaged in sexual activity. This was also true in Shanghai and Taipei with respect to traditional sexual values and self-cultivation values. However, there was an inverse relationship between sexual behavior and traditional family concepts and gender roles in Shanghai and Taipei; those with more traditional values were more likely to have premarital sexual intercourse, except with regard to family values among female youth in Taipei.
The findings suggest that different aspects of Confucian values eroding unevenly in different Asian cities, may have distinct association with adolescent or young adults' sexual behaviors.
PMCID: PMC4235616  PMID: 22340851
Confucian culture; adolescents; premarital sex behavior; Asian city; Multi-center study
23.  Let's Talk!, A South African Worksite-Based HIV Prevention Parenting Program 
South African adolescents have high HIV risk, yet few prevention interventions are effective. Parents play a pivotal role in youths’ healthy sexual development and may be at-risk themselves. We tested whether Let’s Talk!, a worksite-based parenting program, improves parent-child communication about HIV and sexual health, and parent condom use self-efficacy and behavior.
We culturally adapted Let’s Talk! in two languages, drawing on formative research and community stakeholder input. We then conducted a small randomized test at a large public worksite in Cape Town. The intervention consisted of five weekly two-hour group sessions for parents of youth aged 11–15. Sixty-six parents [64% female] and their 64 adolescents [41% female] completed surveys before and 1–2 weeks post-intervention; surveys assessed comfort with talking about sex, communication about 16 HIV- and sex-related topics, and parents’ condom use self-efficacy and behavior. Thirty-four Black-African (Xhosa-language) and 32 Coloured (mixed-race; Afrikaans-language) parent-child dyads participated. Parents were randomized to intervention (n=34) and control (n=32) groups; randomization was stratified by language.
Multivariate regressions indicated that the intervention significantly increased parents’ comfort with talking to their adolescent about sex, b(SE)=0.98(0.39), p=0.02, and the number of sex- and HIV-related topics discussed with their adolescent, b(SE)=3.26(1.12), p=0.005. Compared to control parents, intervention parents were more likely to discuss new sex- and HIV-related topics not discussed before the intervention, b(SE)=2.85(0.80), p<.001. The intervention significantly increased parents’ self-efficacy for condom use, b(SE)=0.60(0.21), p=0.007.
Let’s Talk! holds promise for improving parent-child communication, a critical first step in preventing HIV among youth.
PMCID: PMC3707983  PMID: 23566563
South Africa; HIV; adolescents; parents; communication
24.  Timing and Circumstances of First Sex among Female and Male Youth from Select Urban Areas of Nigeria, Kenya, and Senegal 
To examine the timing and circumstances of first sex among urban female and male youth in Kenya, Nigeria, and Senegal.
Recently collected data are used to examine youth sexual behaviors in Kenya, Nigeria, and Senegal. In each country, a large, representative sample of women (ages 15–49) and men (ages 15–59) was collected from multiple cities. Data from youth (ages 15–24) are used for the analyses of age at sexual initiation, whether first sex was premarital, and modern family planning use at first sex. Cox proportional hazard models and logistic regression analyses are performed to determine factors associated with these outcomes.
Across all three countries, a greater percentage of male youth than female youth report initiating sex with a non-marital partner. More educated youth are less likely to have initiated sex at each age. In Nigeria and Senegal, poor female youth report earlier first sex than wealthier female youth. In Kenya, richer female youth are more likely to have premarital first sex and to use contraception/condom at first sex than their poorer counterparts. Older age at first sex and youth who report that first sex was premarital are significantly more likely to use a method of contraception (including condom) at first sex. City specific distinctions are found and discussed for each outcome.
Programs seeking to reduce HIV and unintended pregnancy risk among urban youth need to undertake needs assessments to understand the local context that influences the timing and circumstances of first sex in each city/country-specific context.
PMCID: PMC3805698  PMID: 23871802
Sexual Initiation; Premarital Sex; Condom Use; Kenya; Nigeria; Senegal; Urban
25.  Predictors of Dental Care Use: Findings from the National Longitudinal Study of Adolescent Health 
To examine longitudinal trends and associated factors in dental service utilization by adolescents progressing to early adulthood in the United States.
Data Source
The National Longitudinal Study of Adolescent Health from Waves I (1994-95), II (1996), III (2001-2002) and IV (2007-2008).
Study Design
This is a retrospective, observational study of adolescents' transition to early adulthood. We obtained descriptive statistics and performed logistic regression analyses to identify the effects of baseline and concurrent covariates on dental service utilization from adolescence to early adulthood over time.
Principal Findings
Dental service utilization within the prior 12 months peaked at age 16 (72%), gradually decreased until age 21 (57%), and thereafter remained flat. Whites and Asians had a 10-20 percentage points higher proportion of dental service utilization at most ages compared to Blacks and Hispanics. Dental service utilization at later follow-up visits was strongly associated with baseline utilization with OR= 10.7, 2.4 and 1.5 at the 1-year, 7-year and 13-year follow-ups respectively. These effects decreased when adjusted for current income, insurance and education. Compared to Whites, Blacks were consistently less likely to report any dental examination.
Dental service utilization was highest in adolescents. Gender, education, health insurance and income in young adulthood were significant predictors of reporting a dental examination. Blacks had lower odds of reporting a dental examination either as adolescents or as young adults.
PMCID: PMC3805715  PMID: 23850156
Adolescents; dental service utilization; racial/ethnic minority; adulthood

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