1. Multi-level Correlates of Adolescent Sexual Behavior and Risk for STD Kathleen A. Ethier, Ph.D. Christine J. De Rosa, Ph.D., Deborah H. Kim, MPH, Abdelmonem Afifi, Ph.D., Peter R. Kerndt, MD

2. Social/Ecological Model Individual Personal relationships: Family, peers, partners Institutions and Communities: School, Health Care Society and Policy

3. Multiple behaviors pose risk for HIV/STD and teen pregnancy Early age at first intercourse Multiple/new sex partners Unprotected intercourse Lack of STD screening Niccolai, et al. 2004; Fortenberry et al.,2005; Celentano, 2004; Weller & Davis, 2005; Paz-Bailey et al, 2005; Coker, et al., 1994; Van Ranson, et al., 2000; Kaestle, et al., 2005

4. Multiple social context level factors impact adolescent sexual behavior Parental monitoring Parental communication Family relationship quality School involvement After school supervision Health care services –School-based health services and referrals, STD screening, condom and contraceptive availability) Forehand et al., 1997; Miller, Kotchick & Forehand, 1999; Romer et al., 1999; Baker et al., 1999;Dittus, Jaccard & Gordon, 1999; Holtzman & Rubison, 1995; Miller, Levin, Whitaker & Xu, 1998; Romer et al., 1999; Whitaker, Miller, May & Levin, 1999; Karofsky et al., 2000; Hutchinson et al 2003; McNeely et al, 2002; Billy, Brewster, & Grady, 1994; Lammers et al., 2000; Manlove, 1998; McNeely et al., 2002; Bonny et al., 2000; Lonczak, 2002; Cohen et al., 2002; Miller et al., 1998; Sabo et al., 1998; Kirby, 2002

5. The Questions for STD Prevention Do multiple social context factors relate to sexual behavior that puts adolescents at risk for STD? Do relationships vary by specific behavior? Are there particular social context factors or combinations of factors that, if intervened on, will give us the most impact on STD risk?

6. Methodology Classroom-based survey of high school students (n=5930). Classrooms were randomly selected from a list identified as classes all students would have to take (e.g., social studies) and would contain a single grade level. Parental consent was obtained for all students under 18 years. Survey took approximately 30 minutes. Questions covered four social context areas (family, school, health care and community factors) and a wide range of sexual behaviors.

7. Analyses Step 1 A set of bivariate logistic regression analyses for each of five STD risk factors –ever had sex (yes/no) –consistent condom use –4 or more lifetime partners (yes/no) –new partner in the last 3 months (yes/no) –ever tested/treated for an STD (yes/no) 21 social context factors –7 family factors –5 school factors –4 health care factors –6 community factors

8. Analyses Step 2 A series of logistic regression analyses for each of the five STD risk factors –Included any social context factor that was significant at p<.10 in bivariate analyses –Controlled for age, race/ethnicity, and gender

9. Sample Characteristics Race/ethnicity –Latino = 76.6% –African American = 11.4% –White = 2.1 % –Other = 9.8% Grade –9th = 24.1% –10th = 19.7% –11th = 24.3% –12th = 31.9% Gender –Male = 44.7% –Female = 55.3% 67.4% received free or reduced lunch.

10. STD Risk Behavior 47.7% have ever had sex 40.0% used condoms every time/last 3 months* 18.3% have had 4+ lifetime sex partners* 12.3% had a new partner/last 3 months* 22.7% ever screened or treated for an STD* * Among those who had ever had sex

11. Ever Had Sex OR95% CI p Parental Monitoring.768.692-.852.001 Family Rules.599.551-.652.001 Communication about Delaying Sex.739.633-.861.001 Communication about Consequences 1.5291.283-1.822.001 Communication about Protection 1.2221.070-1.394.003 Parental Relationship Satisfaction.753.667-.849.001 Family Bond.997.984-1.010.671 Unsupervised from 3-5pm 1.2881.095-1.515.002 School Bond.881.754-1.031.114 Length of time living in neighborhood.953.914-.995.028 Family involvement in neighborhood.910.740-1.120.375 Neighborhood safety.885.774-1.013.076 Neighborhood satisfaction 1.081.944-1.236.259 Supportive adults.890.768-1.031.121

12. Consistent Condom Use OR95% CIp Family Rules1.093.937-1.275.259 Communication about Delaying Sex.999.761-1.313.996 Communication about Consequences.813.589-1.213.210 Communication about Protection1.3821.085-1.761.009 Parental Relationship Satisfaction1.2551.008-1.561.042 School Bond1.268.946-1.701.113 Know about CAP1.5991.074-2.381.021 Ever Used CAP.795.592-1.067.127 Ever got reproductive health care.727.517-1.023.067 Participation in community activities1.006.971-1.043.725 Family involvement in neighborhood1.025.695-1.511.902 Neighborhood satisfaction1.170.934-1.465.172 Supportive adults1.109.851-1.446.444

13. Multiple (4+) Lifetime Partners OR95% CIp Parental Monitoring.689.594-.801.001 Family Rules.787.671-.922.003 Communication about Delaying Sex.982.797-1.210.864 Family Bond1.006.985-1.027.595 Unsupervised from 3-5pm1.044.795-1.372.757 School Bond.827.629-1.087.173 Participation in community activities1.017.983-1.051.330 Neighborhood satisfaction.794.646-.977.029

14. New Partner Last 3 Months OR95% CIp Parental Monitoring.825.726-.938.003 Family Rules.901.796-1.021.101 Parental Relationship Satisfaction.896.759-1.057.193 Family Bond.361.991-1.026.361

15. Ever Screened or Treated for STD OR95% CIp Family Rules.867.728-1.262.110 Communication about Delaying Sex1.071.792-1.313.258 Communication about Consequences1.229.860-1.156.656 Communication about Protection1.044.805-1.755.745 Family Bond1.005.980-1.568.679 School Bond.931.678-1.712.660 Know about CAP.969.585-2.591.904 Ever Used CAP3.2412.343-1.227.001 Access to SBHC1.131.800-1.244.487 Neighborhood safety.875.662-1.424.347 Neighborhood satisfaction.878.678-1.507.326

16. Multi-level Factors Related to Risk Behavior Ever screened for STD Consistent Condom Use Ever had sex Parental Monitoring Connecting lines represent relationships significant at p<.05. Dashed Lines represent relationships in negative directions. Multiple Partners New Partner Family Rules Communication/Delay Communication/Consequences Communication/Protection Relationship Satisfaction Unsupervised 3-5pm Know about CAP Used CAP Time in Neighborhood Neighborhood Satisfaction

17. Level- specific Messages Family factors have high impact. –Monitoring is not only related to initiation of sexual activity, but more monitoring is related to fewer sex partners. –Content specific communication is important. Supervision is more important than where kids are supervised (school, community or home).

18. Multi-level Messages No single level or factor is sufficient to prevent most risk behaviors. Multiple levels of intervention could provide synergistic effects.

19. Acknowledgements Project Connect Study Staff Peter Kerndt – Principal Investigator Christine DeRosa – Co-Investigator and Project Director Deborah Kim, Emily Chung, and Laura Stroud -- Study Coordinators Steve Martinez, Kathy Wong and Jamila Small – School Liaisons The Project Connect Field Staff Project Connect Study Collaborators CDC - Patricia Dittus, Nicole Liddon, HRA - John Copeland, Sharon Hudson, Pamela Mahoney UCLA - Abdelmonem Afifi, Bill Cumberland, Jenny Kotlerman, Mark Schuster Rand - Deborah Cohen LA County Department of Health - Harlan Rotblatt The Los Angeles Unified School District Ric Loya, Linda Ward-Russell, Julie McAvoy The findings and conclusions in this presentation have not been formally disseminated by the Centers for Disease Control and Prevention and should not be construed to represent any agency determination or policy.