Risky Sexual Behaviors in Teens

Running head: RISKY SEXUAL BEHAVIOR IN TEENS 1

Proposal for the ‘My Life/ My Plan’ Program

Based on the Precaution Adoption Process Model. Andrea Eden Shingleton Concordia University Nebraska

MPH 515: Health Behavior Theory 8/16/2015

Introduction

Many young people engage in sexual risk behaviors (unprotected sex, multiple partner sex) that can result in unintended health outcomes. Pregnancy and sexually transmitted diseases RISKY SEXUAL BEHAVIOR IN TEENS 2

(STDs), including human immunodeficiency virus/acquired immune deficiency syndrome

(HIV/AIDS) are negative consequences that result in extravagant social, economic, and health costs, not just for the affected persons, but also their children and society. This paper contains relevant background information, epidemiologic characteristics and biostatistics related to the adolescent population, in order to justify a new health promotion program ‘My Life/My Plan’ based on the Precaution Adoption Process Model. It is intended for the Cincinnati Public Schools with school-based health care facilities.

Background

The CDC (2013) has identified the six priority health risk behaviors which contribute to the leading causes of morbidity and mortality among youth. Risky sexual behaviors that contribute to unintended pregnancy and STDs, including HIV infection are one of the priorities defined in the Youth Risk Behavior Surveillance System (YRBSS). Current data about the sexual behaviors among high school students (grades 9-12) is available in the YRBSS. This report affirms that 47% of high school students have had sexual intercourse, putting half of America’s youth at risk for negative outcomes (CDC, 2012). Investigating trends for five developed countries, Darroch, Singh, & Frost (2001) found that the large majority of young women have first intercourse as teenagers. The proportion of women who had first intercourse before age 20 varies from 75% in Canada to 86% in Sweden, with the United States (81%), France (83%) and

Great Britain (85%) in between (Darroch, Singh, & Frost, 2001). With nearly the same percentage of teens having sex, trending the patterns of risky sexual encounters for teens is more informative.

The percentage of sexually active people who have had two or more sexual partners in the past year is often used as an indicator of potential risk for unintended pregnancy, STDs and RISKY SEXUAL BEHAVIOR IN TEENS 3

HIV. The YRBSS asserts that 19 % of U.S. teens had sexual intercourse with 4 or more persons

(CDC, 2012). Put side by side, the relative amount of those who were sexually active with two or more sexual partners is substantially higher among teenagers in the U.S. than in Canada, Great

Britain, France or Sweden (Darroch, Singh, & Frost, 2001).The prevalence of multiple partners sexual activity is a high risk sexual behavior among U.S. teens along with lack of consistent and correct contraceptive use.

Darroch, Singh, & Frost (2001) maintain the proportion of adolescent women who are participating in the risky sexual behaviors of unprotected sex is greater in the U.S. than in the other study countries. U.S. teens still use contraception or condoms much less consistently than their peers in Europe. Researchers for Advocates for Youth (2011) measuring the use of contraceptives found that German, French, and Dutch youth were significantly more likely to be well protected at their most recent sex than were their U.S. peers. The lack of use of the pill in the U.S. is the greatest disparity in contraceptive use among females. French young women were more than twice as likely to have been using contraceptive pills at last intercourse, German youth five times as likely, and Dutch youth almost six times as likely as teens in the U.S. (Advocates for Youth, 2011) Higher teenage pregnancy rates and the epidemic teen STD rate in the U.S. appears to be likely associated with these national differences.

Epidemiology and Biostatistics

Birth Rates

According to the Center for Disease Control (CDC, 2015) the U.S. teen birth rate is substantially higher than in other western industrialized nations including Canada and the United

Kingdom. In 2013, the U.S. teen live birth rate was 26.5 births for every 1,000 adolescent females (United Nations Statistics Division, 2015). This equates to nearly 300 thousand babies RISKY SEXUAL BEHAVIOR IN TEENS 4 born to women aged 15–19 years in one year. Locally, the U.S. Department of Health and

Human Services (2014) reports that Ohio was ranked 23 out of 51 (50 states + the District of

Columbia) in 2011 for teen births rates among females aged 15-19. As of 2013, the Ohio teen birth rate was 27.2 births per 1,000 teen girls (age 15-19) (The National Campaign, 2015). All 50 states are at historic lows for not only teen birth rates, but also adolescent pregnancy rates.

Pregnancy Rates

The National Campaign to Prevent Teen and Unplanned Pregnancy (2015) reports the

U.S. pregnancy rate in 2010 as 57.4 pregnancies per 1,000 teen girls (age 15-19.) In Ohio, the pregnancy rate was 54 pregnancies per 1,000 teen girls (age 15-19) (The National Campaign,

2015). This equates to more than 21,000 teen pregnancies regionally. The city of Cincinnati is located in Hamilton County; the Ohio Department of Health (ODH, 2012) reports their pregnancy rate in 2010 as 60.6 pregnancies per 1,000 teen girls (age 15-19.) Comparatively, a lower proportion of teenage pregnancies are resolved through abortion in the U.S. than in other countries; American teenagers still account for the highest number of abortions by age group

(Darroch, Singh, & Frost, 2001). Pregnancy is not the only negative outcome for teens.

Sexually Transmitted Disease Rate

Sexually transmitted diseases (STD) are putting American teens and their children at risk for various medical, social and economic consequences. Darroch, Singh, & Frost (2001) found that the incidence of chlamydia among adolescents in the United States (1,132 cases per

100,000) is nearly twice that in Canada and Sweden, five times that in England, and 20 times that in France. Many STDs lack acute symptoms, but they can still be detrimental and contagious.

Nationally, there are about 20 million new cases of STDs each year and about half of these are in people between the ages of 15 and 24 (CDC, 2013). STDs are too common. For example, the RISKY SEXUAL BEHAVIOR IN TEENS 5

ODH (2012) reported 53,297 cases of chlamydia and 16,552 cases of gonorrhea in Ohio.

Although 15-24 year olds made up 14% of the total Ohio population in 2012, 74% of chlamydia infections and 62% of gonorrhea infections in the state were diagnosed in this age group (ODH,

2012b). There is a high disparity for STD infections in teens. Adolescents are at greater risk of contracting an STD for several reasons: 1) biologically more susceptible, 2) do not get the recommended tests for early detection, 3) hesitant to talk openly and honestly with a doctor or nurse about their sex lives, 4) lack of insurance or transportation to access testing and treatment and 5) more than one sex partner (CDC, 2013).The combination of a STD and pregnancy can cause miscarriage, early labor and delivery and infection to the infant; all requiring increased medical and economic interventions (CDC, 2015b). Having a STD infection like syphilis, gonorrhea, and herpes increases the risk of having HIV (CDC, 2013) All STDs are harmful, but one is potentially deadly; HIV is a public health concern for teens.

Rate of HIV/AIDS

In 2005, HIV/AIDS was the fourth leading cause of death for African Americans aged

25-34 (Office of Statistics and Program National Center for Injury Prevention and Control,

2005.) It is likely that many of these young adults were infected during adolescence given the long latency period from HIV infection to the development of AIDS or death from it (Miller, et al., 2009). The CDC (2014) attests that nationally only 12.9% of high school students had ever been tested for HIV. In Ohio the largest proportion of new diagnoses of HIV infections were among males aged 20-24 years (22 percent) and females aged 20-24 years (15 percent) (ODH,

2012a, p. 36). The racial disproportion of the HIV infection rate is evident in Ohio. The rate among Blacks/African American Ohioans are more than six times higher compared to whites

(572.1 for blacks/African Americans, compared to 92.0 for whites) and Hispanic/Latino RISKY SEXUAL BEHAVIOR IN TEENS 6

Ohioans, the rate was almost three times higher than among whites (229.6 per 100,000 population for Hispanic/Latinos) (ODH, 2012a, p. 23).

Problem Risky Sexual Behavior Poses for Public Health

Risky sexual behavior resulting in pregnancy, STDs and HIV is a public health priority.

Leading to poor health outcomes, teen pregnancy and reproductive organ infections bring substantial social and economic costs through immediate and long-term impacts on teen and their children (CDC, 2015b). The economic cost is high; in 2010, teen pregnancy accounted for at least $9.4 billion in costs to U.S. taxpayers for increased health care and foster care, increased incarceration rates among children of teen parents, and lost tax revenue because of lower educational attainment and income among teen mothers (The National Campaign to Prevent

Teen and Unplanned Pregnancy, 2015). Locally, in Ohio teen pregnancy cost taxpayers at least

$340 million in 2010 (The National Campaign to Prevent Teen and Unplanned Pregnancy,

2015). Economically and socially, teen pregnancy and birth are significant contributors to high school dropout rates among girls; only about 50% of teen mothers receive a high school diploma by 22 years of age, versus approximately 90% of women who had not given birth during adolescence (Perper, Peterson, & Manlove, 2010). The next generation is also significantly compromised; the children of teenage mothers are more likely to have lower school achievement and drop out of high school, have more health problems, be incarcerated at some time during adolescence, give birth as a teenager, and face unemployment as a young adult (Hoffman, 2008).

Unfortunately, these effects remain for the teen mother and her child even after adjusting for those factors that increased the teenager’s risk for pregnancy, such as growing up in poverty, having parents with low levels of education, growing up in a single-parent family, and having poor performance in school (Hoffman, 2008). RISKY SEXUAL BEHAVIOR IN TEENS 7

Sexually transmitted diseases are preventable, but the necessary public health initiatives lack the support of the public, policymakers, and health care professionals (Health People 2020,

2015). The cost of STDs to the U.S. health care system is estimated to be as much as $15.9 billion annually. STDs cause many harmful, often irreversible, and costly clinical complications like pelvic inflammatory disease and infertility. HIV is expensive; it is a chronic disease that requires a lifetime of close medical monitoring and a daily handful of antiretroviral medications.

The federal budget for fiscal year 2014 totaled $29.7 billion for domestic HIV and AIDS spending (United Nations Statistics Division, 2015).

Reasons for a Health Promotion Program

Preventing risky sexual behaviors in teens is a priority for the CDC, Healthy People

2020 and for the new health promotion program, ‘My Life/My Plan’ The National Campaign to

Prevent Teen and Unplanned Pregnancy (2015) stresses that nearly all teen pregnancies are unplanned, in fact 82 % are unintentional. The CDC (2012) recognizes that teens are more susceptible to STDs and suffer from more complications. Deaths from HIV infections in the young adults could be avoided with adolescent prevention. Teen pregnancy is closely linked to a host of other critical social issues—poverty and income, overall child well-being, out-of-wedlock births, responsible fatherhood, health issues, education, child welfare, and other risky behavior

(CDC, 2015a). Not to mention the substantial public costs associated with adolescent childbearing.

PAPM Constructs and Concepts

The Precaution Adoption Process Model (PAPM) attempts to explain how a person comes to the decision to take action and how he or she translates that decision into action.

Adoption of a new precaution or cessation of a risky behavior requires deliberate steps unlikely RISKY SEXUAL BEHAVIOR IN TEENS 8 to occur outside of conscious awareness (Weinstein, Sandman, & Blalock, 2008). The seven distinct stages in PAPM take an individual from lack of awareness to maintenance of a new behavior (Glanz & Rimer, 2005, p. 18). In the first stage of the PAPM, a person may be completely unaware of a risky behavior. People who are unaware of an issue face different barriers from those who have decided not to act. When the person becomes conscious of the issue, but remains unengaged by it; stage 2 is complete. After that the person faces a decision about acting (Stage 3); may decide not to act (Stage 4) or may decide to act (Stage 5) (Glanz &

Rimer, 2005, p. 19). Developing specific intervention steps for individuals who have decided to act, but face barriers to acting is a necessity (Weinstein, Sandman, & Blalock, 2008). Finally, the stages of action (Stage 6) and maintenance (Stage 7) conclude the model. According to the

PAPM, an individual passes through each stage of without skipping any of them. It is possible to move backwards from all later stages to earlier ones except stage one (Glanz & Rimer, 2005).

PAPM Applied to Risky Sexual Behavior

The Precaution Adoption Process Model (PAPM) seeks to identify all the stages involved when people commence health-protective behaviors and to determine the factors that lead people to move from one stage to the next (Glanz & Rimer, 2005). Everyone is unaware of all sexual activities including unsafe behaviors at one point in their life. Using PAPM, teens can be easily assessed about their understanding of risky sexual behaviors with a questionnaire.

Media messages play an importance role in moving adolescents from stage 1 to 2 (Weinstein,

Sandman, & Blalock, 2008). When a youth is made aware, but is unengaged with sexual behaviors they finish stage 2. Progressing from stage 2 to 3 can happen after personal experience, communication with their partner or after hearing mass public health communications (Weinstein, Sandman, & Blalock, 2008). Stage 3 begins when they are RISKY SEXUAL BEHAVIOR IN TEENS 9 undecided about engaging in the behavior; the condition of awareness without personal engagement is quite common (Glanz & Rimer, 2005). Differentiating between the people who have never thought about a behavior and those who have given it some consideration but are undecided is critical in when tailoring communications to the audience (Weinstein, Sandman, &

Blalock, 2008). Deciding not use contraception to prevent pregnancy, STDs or HIV is an example of stage 4. People who have formed a strong position on an issue are the hardest to reach; even if they have not yet acted on their opinions, they are more resistant to persuasion than people who have not formed opinions (Weinstein, Sandman, & Blalock, 2008). This is called perseverance of beliefs. Progressing to stage 5 is the choice to use contraceptives.

Weinstein et al (2005) reaffirm that the gap between intending to act and carrying out this intention (stage 5 to 6) has barriers; providers must include a specific implementation plan to help progression. Obtaining the contraceptive and using it during sex is the sixth stage. Finally, the maintenance stage (7) continues when habitual patterned response develops i.e. consistently and correctly using a contraceptive with every sexual encounter (Weinstein, Sandman, &

Blalock, 2008). Health promotion programs based on PAPM want to move teens from stage 1 to

7 to prevent negative health outcomes and to promote adolescent health.

Literature/ Program Review

A Step Ahead Program

A Step Ahead Foundation ASAF (2015) was established to provide free, long acting, reversible contraception (LARC) to women in Memphis and Shelby County in an effort to prevent unplanned pregnancy, and allow women to plan when and how they choose to have families. Serving women of all ages, including teens, A Step Ahead Foundation (2015) focuses on two goals; community outreach and contraceptive availability. The University of Memphis RISKY SEXUAL BEHAVIOR IN TEENS 10

(2012) completed an evaluation from data collected during the first year and found significant progress towards the two goals. Their outreach program included mass media, community events, health promotion booths and a call center. Goal two was implemented in seven clinics with various locations, full-time professional staff and four choices of LARC are available at no cost to the client. Recommendations for change consisted of increased outreach and clinic locations in neighborhoods with high birth rates, outreach efforts to men and creating partnerships with faith-based and community leaders. A Step Ahead Foundation (2015) used the model of service includes partnering with local health clinics that serve low-income women to provide access to LARC at no charge. Reportedly, founded on an evidence based behavioral theory, ASAF was not forthcoming with which theory they used. The Center for Research on

Women’s approach to research, theory, and programming emphasizes the structural relationships among race, class, gender, and sexuality (University of Memphis;Center for Research on

Women, 2012).

HORIZONS

HORIZONS was developed to address a broad range of risk factors encountered by sexually active African American young women, including personal, relational, sociocultural, and structural factors (DiClemente, Wingood, Rose, Sales, & Lang, 2012). It is delivered in two workshop sessions, each lasting approximately four hours. The overall goals of the intervention are to reduce recurrent STDs and enhance STD/HIV preventive behaviors. HORIZONS demonstrated efficacy of interventions to reduce STD/HIV-associated sexual risk behaviors.

Unfortunately, DiClemente et al (2012) report that not every individual exposed to this program positively changed their sexual risk behaviors (i.e., increase condom use.) Recommendations to optimize the program included identifying barriers for vulnerable youth that differentiate those RISKY SEXUAL BEHAVIOR IN TEENS 11 who increased condom use after intervention from those who did not (DiClemente, Wingood,

Rose, Sales, & Lang, 2012). . Guided by social cognitive theory and the theory of gender and power, the HORIZONS intervention targets several constructs including fear of condom negotiation, partner communication self-efficacy, partner communication frequency, refusal self- efficacy, condom use self-efficacy and STD knowledge (DiClemente, Wingood, Rose, Sales, &

Lang, 2012).

Self Center

Advocates for Youth (2008) describe the program as an adolescent health clinic offering reproductive health care, including contraceptive counseling and pregnancy testing as well as other medical services and referrals. Even though the program is administered in conjunction with a school, it provides year round services. The staff work daily in the participating schools providing group sex education lessons in each homeroom, plus individual counseling by social worker and/or nurse is available daily and place a strong emphasis on developing personal responsibility, setting goals, and communicating with parents. An evaluation of the program found that the participants 1)intended to delay sexual intercourse and to use reproductive health services prior to initiating sex, 2) increase their use of contraception while decreasing unprotected sex and 3) pregnancy rate dropped by 30 percent, while it had risen by 58 percent among students in non-program schools (Advocates for Youth, 2008). Identifying the theory, model or framework was not possible with the resources available.

My Life/My Plan

MyLife/ My Plan is a health promotion program set up in conjunction with the

Cincinnati Public School system with school-based health care facility to specifically target at- risk teens involved in risky sexual behaviors. It will include on site staff that present sex RISKY SEXUAL BEHAVIOR IN TEENS 12 education materials in the school and promote sexual health by referring students to the clinic.

The staff will include nurses and social workers specially trained in culturally competent care and counseling of the vulnerable adolescent.

Applying the concepts of PAPM will lead toward meaningful behavior change in the teens attending the My Life/ My Plan program. All current clients of the clinic will be invited to participate in the new program. After consent is obtained each participant will complete a self assessment questionnaire to determine the PAPM stage they are currently in and current beliefs about risky sexual behaviors. The staff will use the My Life/ My Plan algorithm to analyze the survey and refer the client to the appropriate intervention group. Once the groups (based on

PAPM stage) have been established the assigned educator will deliver the stage appropriate materials in a 50 minute group discussion setting. These sessions are scheduled to meet weekly for 12 weeks during the school day and give the recipients’ credit for their health education classes for graduation. At the end of the session the students will complete a post intervention survey in order to assess the new PAPM stage, new beliefs about risky sexual behaviors and to receive credit for attendance. The major goals of this program are to reduce risky sexual behaviors through awareness (stage 2), move students from undecided to action (stage 3 to 5), reduction of cultural and economic barriers to action (stage 5) and maintenance of health behaviors through year round availability of a neighborhood clinic and contraceptives (stage 7).

My Life/ My plan program will incorporate strategies for addressing the problem of risky sexual behaviors meaningfully. One of the strategies is to increase awareness of the negative health consequences related to risky sexual behaviors. The CDC (2015b) affirms that teens are most afraid of body image changes and social stigma. Each session is centered on a topic related to risky sexual behaviors like multiple partners, unprotected sex, unintended RISKY SEXUAL BEHAVIOR IN TEENS 13 pregnancy, STDs and HIV. The education session about adolescent pregnancy incorporates factual consequences and the students experiences i.e. doctors recommend a weight gain of up to

40 pounds, lose your social network, lose of dating relationship, stay home with the baby while your friends are out having fun less likely to finish high school; will be more likely to live poor, expenses related to care of an infant (diapers, formula and child care), increased risk of death and complications. It is recommended that the educator facilitate a discussion, not give the students the answers, teens are more likely to change their behaviors/ beliefs based on peer opinions

(CDC, 2015a). All students with more questions needing one-on-one discussion are invited to a private office at the clinic, which is open daily during school hours and after hours.

Contraceptives will be available at the clinic for no cost to the students.

Conclusion

It is the negative consequences of risky sexual behaviors resulting in unjust social, economic, and health cost to vulnerable teens, their children and society in the Cincinnati area, motivating the creation of the My Life/ My Plan program. With nearly half of America’s youth at risk for pregnancy, STDs and HIV due to risky sexual behaviors, the CDC identified it as a priority to decrease the morbidity and mortality of teens. When comparing the U.S. to other developed countries, the rate of poor outcomes is significantly higher for the age group 15-19 years. It is the goal of researchers to discover why and to propose interventions to address this gap. With a teen pregnancy rate higher than the national and state levels, the high disparity for

STD infections in teens and deaths from HIV in young adults, the City of Cincinnati needs to invest resources into the prevention. The cost effectiveness of implementing a program in an already established educational and clinic setting, the My Life/ My Plan program off sets many barriers and was developed with experts in the field of reproductive health and is evidence based. RISKY SEXUAL BEHAVIOR IN TEENS 14

The PAPM construct of the program allows educators to be confident that the materials they are presenting are appropriate and valuable for vulnerable youth of Cincinnati. RISKY SEXUAL BEHAVIOR IN TEENS 15

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