Risk Factors for Adolescent Sexual Behavior, Fertility, and Sexually Transmitted Diseases
Santelli, John S., Beilenson, Peter, Journal of School Health
Understanding the risk factors related to adolescent sexual behavior, pregnancy, and sexually transmitted diseases (STDs) is essential for early identification and care of "at risk" teens and for the design of primary and secondary prevention programs for schools and communities. Early identification of sexually active teens based on risk factors can facilitate timely entry into health counseling and use of contraceptive services. Early identification of pregnancy can allow adolescents to explore pregnancy options or can improve birth outcomes by facilitating entry into prenatal care.
Knowledge of risk factors will inform the work of school nurses, health educators, and other school health personnel concerned with "children having children." School nurses may be involved in early identification and counseling of sexually active or pregnant students. Health educators are involved in early identification and, through classroom education, are essential to primary and secondary prevention. All school professionals can be involved by ensuring that comprehensive, schol-based prevention programs are firmly grounded in an understanding of young people's fertility-related behavior.
Much was learned in the 1970s and 1980s about the factors that encourage and limit teen-age sexual activity, the use of contraception, and the decision to continue or terminate a pregnancy. (1-3) Studies of adolescent female fertility have grown increasingly sophisticated with the use of multiple regression techniques that allow one to assess the relative importance of multiple factors simultaneously. (2) However, much remains to be understood about the relative importance of individual risk factors.
In this review, the current understanding of the risk factors for adolescent initiation of sexual activity, use of contraception, pregnancy, and STDs is examined. From the enormous volume of recent research on adolescent fertility, findings that have particular relevance to school health or reflect new understandings of adolescent sexuality are summarized. In selected cases prevention programs that build directly on an understanding of these risk factors are cited. More indepth analysis of risk factors is contained elsewhere. (1,2,4)
INTERMEDIATE DETERMINANTS OF FERTILITY
While cultural and certain biological factors have an enormous influence on adolescent fertility, numerous biopsychosocial factors (Figure 1) affect the sequence of fertility only through intermediate factors: intercourse, conception, and pregnancy outcome. Davis and Blake' first described this analytic framework. Hofferth (1) elaborated on this model focusing on the interactions among psychosocial and biological variables in explaining the initiation of intercourse. While the biological reality of this framework seems self-evident, it often is ignored in discussions about teen-age pregnancy prevention that focus on general strategies such as raising self-esteem. Given this framework for fertility among all women, among teen-agers, childbearing is most influenced by 1) age at first intercourse, 2) use of contraception, and 3) pregnancy termination. Frequency of intercourse also is important though less is known about frequency than age at initiation of intercourse. (6)
[FIGURE 1 OMITTED]
Biopsychosocial risk factors that are most influential at one step in the sequence of adolescent fertility-related behaviors may not be as influential at other steps. Based on the 1988 National Survey of Family Growth, (7,8) race has declined in importance as a predictor of sexual activity initiation for older teens. However, race continues to have a sizeable influence on the likelihood of using contraception. Sexual experience, ever having had coitus, and sexual frequency show different demographic patterns. (6) In a similar way, research (9-11) suggests that family communication has little or no influence on an adolescent's "decision" to engage in sexual activity. …