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Article Excerpt
Adolescents have among the highest rates of sexually transmitted diseases (STDs). The Centers lot Disease Control and Prevention surveillance data indicate that in 1996, there were more than three million STD cases among U.S. teenagers, and these cases accounted for one quarter of all reported STD infections. (1) In addition to the known reproductive health sequelae of STDs, their prevalence also suggests substantial economic and psychological costs to young people. (2) Consequently, primary and secondary prevention of STDs, including HIV and AIDS, continues to be a public health priority, especially for adolescents and young adults.
Although adolescents are a high STD risk subpopulation, until recently it has been difficult to characterize the factors that affect STD acquisition among this population beyond a small number of demographic and behavioral variables. Prior to the release of the National Longitudinal Study of Adolescent Health (Add Health), only the Nation al Survey of Adolescent Males, the National Survey of Family Growth (which sampled females of reproductive age) and the Youth Risk Behavior Surveys could be used to provide general population estimates of adolescent reproductive health outcomes. Add Health is unique in this regard because it includes males and females, detailed race and ethnicity measurement, multiple indicators of reproductive health behaviors and outcomes, and information on multiple social contexts. In addition, it has recorded information on multiple episodes of STD acquisition. Wave 1 interviews took place between April and December 1995; Wave 2, between April and August 1996.
This study exploits the richness of the Add Health data to investigate how school, neighborhood, family and individual factors affect the risk of STD acquisition in a national sample of adolescents. We address tour interrelated questions. First, what are the determinants of ever having had an STD regardless of sexual experience? Second, what are the determinants of age at first intercourse? Third, among sexually experienced adolescents, what are the effects of age at first intercourse on ever having had an STD? Finally, among sexually experienced adolescents, what are the determinants of acquiring an STD between survey waves, and specifically, to what extent do age at first intercourse and STD history contribute to STD risk? To answer these questions, we focus exclusively on self-reported STD. There appears to be no general population survey of adolescents that uses STD biomarkers (e.g., urine tests). *
BACKGROUND
Much of the prior research on STD risk assessment has focused on individual-level determinants, (4) although more recent theoretical and methodological developments cast individual risk within larger social and epidemiological contexts. (5) An emerging model of STD risk incorporates biological, behavioral and social factors. (6) Specifically, biological processes influence individuals' susceptibility, with the biological factors partially determined by sexual and protective practices. Sexual and protective practices, in turn, are influenced by environmental factors, including social context and epidemiological conditions. Consistent with that emphasis, this study focuses exclusively on adolescents, and examines three social contexts that are especially salient for them--their families, neighborhoods and schools.
Adolescents are at increased risk of STD because they are more likely to engage in such risk-taking behaviors as unprotected sex, multiple sexual partners and sexual relationships of short duration, (7) and because of increased physiological susceptibility. (8) Age at first intercourse is correlated with many of these risk-taking behaviors and can be used as a marker for risky sexual behavior. (9) Teenagers with early onset of sexual activity tend to have more recent partners and more lifetime partners, and are less likely to use condoms, than those with later onset. (10) Moreover, early age at first intercourse is independently associated with a positive STD history among sexually active females. (11) In this article, we conceptualize age at first intercourse as a key risk related behavior. Thus, we examine the determinants of age at first intercourse to better understand the effects of school, neighborhood, family and individual factors and STD history.
Adolescents' social and demographic characteristics, such as age, gender, race and ethnicity, and nativity status, are associated with STD risk because of group differences in sexual norms, sexual and protective practices, sexual net works, underlying disease prevalence and biology. (12) Older teenagers, because they are more likely to be sexually active and have accrued more sexual experience, have higher STD risk than younger adolescents. (13) Adolescent females are at higher STD risk than males, in part because of their greater biological susceptibility. (14) Although adolescent females tend to have older ages at first sex and fewer sexual partners than adolescent males, (15) they do not have uniformly lower STD risk because of differences in partners' behaviors and sexual networks. (16) Racial and ethnic variability in STD risk reflects differences in the social and cultural contexts within which sexual activity occurs, and these differences translate into differentials in risk-taking behaviors, such as unprotected sex, age at first intercourse and numbers of sexual partners, as well as reflect socioeconomic differences. (17) Racial and ethnic variability in risk-taking behaviors do not explain all variability in STD risk, however, because sexual networks and underlying disease prevalence within those networks also have independent effects. (18) For adolescents, surveillance data indicate that blacks, Hispanics and Native Americans have higher STD rates than whites; that Asians have lower rates; and that gender, race and ethnicity interact to some extent. (19) Lastly, although few previous studies have investigated the effect of nativity status on STD risk, we hypothesize that foreign-born teenagers are at lower STD risk than U.S. born teenagers because they are less likely to engage in high-risk behaviors, including early onset of sexual activity. (20)
Families provide role models, shape sexual attitudes, set standards for sexual conduct, control and monitor adolescents' behaviors, and constitute the most proximate social and economic environments for adolescent development. (21) Adolescents living with both biological parents have the optimal opportunity for overall well-being, (22) and are less likely than those in other family situations to engage in sexual risk-taking behaviors such as early sexual initiation. (23) Thus, we expect teenagers living with both biological parents to be at lower STD risk than those living in other family situations. Family socioeconomic status, partially operationalized as parents' education, is also associated with adolescent reproductive health behaviors. Highly educated parents tend to have higher educational aspirations for their children. These higher aspirations should, to some extent, discourage sexual activity and encourage contraceptive use (e.g., condom use) among the sexually active, (24) which should reduce adolescents" likelihood of experiencing an STD. Family processes, especially parental monitoring and supervision of adolescents' activities, are associated with sexual risk-taking behaviors. Specifically, greater parental monitoring is associated with older ages of sexual initiation, smaller numbers of sexual partners and more consistent contraceptive use, (25) all of which suggest lower STD risk. The extent to which families exert a direct effect on adolescent STD risk is, however, unknown. (26) Thus, we investigate direct and indirect effects (through age at first intercourse) of family background on STD risk.
Adolescents' neighborhoods of residence also may affect STD risk by providing local opportunities, institutional resources, normative environments and epidemiological backdrops that shape their sexual life course. Conceptualizations of neighborhoods typically emphasize structural and social dimensions. These include socioeconomic and demographic composition (structure), and formal and informal networks that shape such social processes as collective monitoring, social control and norm-setting (social dimensions). Social processes are thought to mediate the effects of structural characteristics. (27) A growing literature shows that neighborhood conditions influence adolescent sexual risk-taking behavior, including onset of sexual activity. (28) Studies mapping the sexual networks of populations at high risk of STDs show that neighborhood and sexual network boundaries are correlated. (29) Thus, physical deterioration of neighborhoods is associated with lower socioeconomic status, which in turn is associated with a breakdown in social relations, with fewer effective sanctions and social controls to regulate behavior. (30) In such neighborhoods, high risk behaviors are more prevalent, and STD rates are increased. (31) We investigate whether the Add Health data reveal associations between neighborhood socioeconomic conditions and self-reported STD, and the extent to which age at first intercourse mediates neighborhood effects.
We also hypothesize that adolescents' school contexts are associated with STD risk. Because adolescents spend so much time at school and because the social relationships established at school are instrumental to adolescent development, schools can have a profound impact on adolescent well-being and development. (32) School structural attributes affect norms and attitudes about dating practices and acceptable sexual behaviors. Studies of the effects of school characteristics on sexual risk-taking behaviors have found that racial composition, whether a school is public or private, and other aspects of school social environment are associated with age at first intercourse and number of sexual partners. (33) Consequently, we incorporate school characteristics into our analyses of both the probability of contracting an STD and age at first intercourse.
Lastly, to better characterize STD experiences during adolescence, we also investigate the determinants of STD occurrence between the Wave 1 and Wave 2 interviews. We hypothesize that individual, family, neighborhood and school factors associated with the report of an STD at Wave 1 will also be associated with the report of an STD occurring between waves. We are especially interested in whether age at first intercourse remains a significant determinant of STD acquisition between waves, and whether a positive STD history at Wave 1 predicts subsequent acquisition.
METHODS
Data and Sample
Add Health was designed to assess the general, sexual and reproductive health status of adolescents in the United States. (34) The details of the Add Health study design are described in...
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