Coercive forms of sexual risk and associated violence perpetrated by male partners of female adolescents

CONTEXT: Partner violence is associated with STDs among female adolescents, but the mechanisms underlying this association remain unclear. Sexually coercive and deceptive behaviors of male partners that increase female STD risk may be factors in this relationship. METHODS: A sample of 356 females aged 14–20 who attended adolescent health clinics in Greater Boston between April and December 2006 were assessed for physical and sexual violence perpetrated by male partners and for exposure to sexual risk factors. Adjusted logistic regression models were used to examine the associations between intimate partner violence and standard sexual risk behaviors (e.g., multiple partnerships) and coercive or deceptive sexual risk factors (e.g., coerced condom nonuse). RESULTS: More than two‐fifths of the sample had experienced intimate partner violence. In adjusted analyses, adolescents reporting intimate partner violence were more likely than others to report standard sexual risk behaviors—multiple partners, anal sex and unprotected anal sex (odds ratios, 1.7–2.2). They also were more likely to report coercive or deceptive sexual risk factors—partner sexual infidelity, fear of requesting condom use, negative consequences of condom request, and coerced condom nonuse (2.9–5.3). CONCLUSION: The high prevalence of intimate partner violence against young women attending adolescent clinics strongly indicates the need to target this population for abuse‐related interventions. This need is underlined by the observed association between partner violence and sexual risk involving coercion or deception by male partners. Clinic‐based STD and pregnancy prevention efforts should include assessment of sexual risk factors that are beyond the control of young women, particularly for those experiencing abuse.     

Prevention of high-risk behaviors in adolescent women.

PURPOSE: To better delineate the impact of health risk behaviors on adolescent women's current and future health and development. METHOD: The Commonwealth Fund Survey of Adolescent Health, a national survey of adolescents in Grades 5-12 designed to better understand their health and health care needs, was used as the basis for this study. Survey data were collected in 1997 from a total of 6730 adolescents (3568 females, 3162 males). Areas examined include smoking, drinking, use of other drugs, violence, safety, reproductive risks, and the prevention of risk behaviors in adolescent women. RESULTS: Adolescent women are almost equally likely to smoke, drink, and engage in other substance use as their male counterparts, but with increased health risks. Different motivations for engaging in risk behavior also are evident. Adolescent women are also more likely than adolescent men to experience physical abuse, and they are twice as likely to be sexually abused. CONCLUSIONS: Effective prevention programs need to recognize that the motivations for engaging in risk behaviors may differ by gender. Developmental awareness, proper assessment, and pivotal institutions can provide and shape what is needed for healthy development.     

Rural Adolescent Health: The Importance of Prevention Services in the Rural Community

Context: Adolescence is a pivotal developmental period for the establishment of positive health and health practices. However, developmentally propelled risk behaviors coinciding with barriers to health services may increase the propensity for untoward health outcomes in adolescence. In addition, the sociocultural context of the rural environment can present challenges to the health of adolescents. Limited data on rural adolescent health, particularly among population subgroups, hinder the ability to adequately advocate for adolescent health prevention services. Methods: A secondary analysis of the 2005 California Health Interview Survey Adolescent questionnaire was conducted. Selected survey items corresponding to the Healthy Youth 2010 objectives were analyzed for 663 adolescents aged 12‐17 residing in rural regions of California. Adolescent subgroup analysis included race/ethnicity, age, and poverty level. Findings: Adolescent health issues of particular concern in this study include sexual health, substance use, mental health, and risk factors for obesity. Predictably, risk behaviors increase with the age of the adolescent. Minority and poor youth demonstrate the greatest vulnerability to untoward health outcomes. Conclusion: Significant risk behaviors and health concerns exist among the rural adolescent population, particularly among poor and minority youth, arguing for the creation and preservation of prevention services for youth in the rural community. Future research using alternative sampling methodologies may be necessary to adequately represent the higher‐risk adolescent in the rural community. More data are needed on vulnerable adolescent populations in the rural community in order to adequately advocate for prevention services.     

Health risk behaviors and associated risk and protective factors among Brazilian adolescents in Santos, Brazil.

OBJECTIVE: To describe the prevalence of health risk behaviors and identify risk and protective factors that are associated with several health risk behaviors (cigarette smoking, drug use, onset of sexual intercourse before age 15, pregnancy, gun-carrying, suicidal ideation, and suicide attempts) among adolescents in Brazil, as well as to explore gender differences. METHODS: We estimated prevalence rates, evaluated bivariate associations, and explored multivariate analyses using logistic regression on data from a 1997 survey of adolescent health among 2059 eighth- and 10(th)-grade students in Santos, Brazil. RESULTS: Youth in Santos, Brazil report high rates of gun-carrying, suicidal thoughts and attempts, sexual intercourse, and pregnancy. Factors associated with diminished involvement for nearly all health risk behaviors, for both boys and girls, included having good family relationships, and feeling liked by friends and teachers. Factors associated with increases in nearly all health risk behaviors were: gun-carrying and gun availability in the home, drug use, and sexual abuse. CONCLUSIONS: Factors that are associated with a wide range of health risk behaviors among adolescents in Brazil appear to parallel those found in industrialized countries: access to guns, substance use, and sexual abuse. Likewise, connectedness to family, school, and peers is consistently the protective factor associated with diminished risky behaviors.     

"When you got nothing to do, you do somebody": A community's perceptions of neighborhood effects on adolescent sexual behaviors

This study explores community members’ perspectives regarding the relationship between neighborhood characteristics and adolescent sexual behaviors in two rural, African American communities. The data were collected as part of a community needs assessment to inform the development of HIV prevention interventions in two contiguous counties in northeastern North Carolina, USA. We conducted eleven focus groups with three population groups: adolescents and young adults aged 16–24 (N = 38), adults over age 25 (N = 42), and formerly incarcerated individuals (N = 13). All focus groups were audio-recorded, transcribed and analyzed using a grounded theory approach to content analysis and a constant comparison method. Six major themes emerged from the discussions linking neighborhood context and adolescents sexual behavior: the overwhelming absence of recreational options for community members; lack of diverse leisure-time activities for adolescents; lack of recreational options for adolescents who are dating; adolescent access to inappropriate leisure time activities that promote multiple risk behaviors; limited safe environments for socializing; and cost-barriers to recreational activities for adolescents. In addition, lack of adequate parental supervision of adolescents’ time alone and with friends of the opposite sex, as well as ineffective community monitoring of adolescent social activities, were thought to create situations that promoted sexual and other risk behaviors. These findings allowed us to develop a conceptual model linking neighborhood structural and social organization factors to adolescent sexual behaviors and provided insights for developing interventions tailored to address local socioeconomic realities.     

Sexually transmitted diseases, unintended pregnancy, and adolescent health promotion

Adolescence is a critical period in the development of sexual behaviors that may lead to acquiring sexually transmitted diseases (STDs), including human immunodeficiency virus (HIV), and to unintended pregnancy. Understanding adolescent sexual behavior is essential for understanding adolescents' risk of pregnancy and STD/HIV infection and for planning and evaluating health promotion activities. This chapter reviews the sexual behaviors and psychosocial factors associated with STDs and unintended pregnancy among adolescents as well as school-, community-, and clinic-based interventions designed to reduce risk behaviors and promote adolescent sexual health.     

Sexual intercourse, abuse and pregnancy among adolescent women: does sexual orientation make a difference?

CONTEXT: Although a limited amount of research has retrospectively explored the childhood and adolescent heterosexual experiences of lesbians, little is known about the prevalence of heterosexual behavior and related risk factors or about pregnancy histories among lesbian and bisexual teenagers. METHODS: A secondary analysis was conducted using responses from a subsample of 3,816 students who completed the 1987 Minnesota Adolescent Health Survey. Behaviors, risk factors and pregnancy histories were compared among adolescents who identified themselves as lesbian or bisexual, as unsure of their sexual orientation and as heterosexual. RESULTS: Overall, bisexual or lesbian respondents were about as likely as heterosexual women ever to have had intercourse (33% and 29%, respectively), but they had a significantly higher prevalence of pregnancy (12%) and physical or sexual abuse (19-22%) than heterosexual or unsure adolescents. Among sexually experienced respondents, bisexual or lesbian and heterosexual women reported greater use of ineffective contraceptives (12-15% of those who used a method) than unsure adolescents (9%); bisexual or lesbian respondents were the most likely to have frequent intercourse (22%, compared with 15-17% of the other groups). In the sample overall, among those who were sexually experienced and among those who had ever been pregnant, bisexual or lesbian women were the most likely to have engaged in prostitution during the previous year. CONCLUSIONS: Providers of reproductive health care and family planning services should not assume that pregnant teenagers are heterosexual or that adolescents who say they are bisexual, lesbian or unsure of their sexual orientation are not in need of family planning counseling. Further research should explore the interactions between adolescent sexual identity development and sexual risk behaviors.     

Rapid repeat pregnancy and experiences of interpersonal violence among low-income adolescents

CONTEXT: Rapid repeat pregnancy (RRP) among adolescents, usually defined as pregnancy onset within 12-24 months of the previous pregnancy outcome, has frequently been the target of public health interventions, due to the exacerbation of negative consequences associated with recurrent adolescent pregnancy (and more specifically with childbearing). OBJECTIVE: To examine what, if any, relationship exists between RRP and the experience of interpersonal violence and abuse among low-income adolescents at one semi-urban health center. DESIGN: Case-control study using retrospective chart review. PARTICIPANTS AND SETTING: 100 women aged 13-21 who received prenatal care at one independent nonprofit health center that serves adolescents and their children from June 1994 through June 1996. MAIN OUTCOME MEASURES: Number and timing of pregnancies, occurrence of physical or sexual abuse; other psychosocial risk factors were evaluated. RESULTS: In this population, the experience of any form of physical or sexual violence during the study interval was associated with RRP within 12 months (p = 0.01, OR = 3.46) and 18 months (p = 0.013, OR = 4.29). Other previously reported predictors of RRP, including family stress, financial stress, and other environmental stressors did not reach statistical significance at either 12 months or 18 months in this sample. Of additional note, young women who experienced any form of abuse during the 12-month study interval were substantially more likely to miscarry than were their nonabused peers, and spontaneous abortion was also very strongly associated with RRP (p < 0.00001; OR = 22.6). CONCLUSIONS: The experience of interpersonal violence is correlated with rapid repeat pregnancy among low-income adolescents. This study strongly suggests a need for both extensive screening for partner and family violence among pregnant and postpartum adolescents, and follow-up safety planning support in combination with family planning interventions.     

The Association Between Smoking and Unhealthy Behaviors Among a National Sample of Mexican-American Adolescents

ABSTRACT: This study examined the relationship between smoking and participation in unhealthy behaviors among Mexican-American adolescents through a secondary analysis of national data. Mexican-American adolescents (N=580), ages 10 through 18 years who were interviewed as part of the 1993 Teenage Attitudes and Practices Survey (TAPS II), were selected for analysis. Data collected included smoking status of the adolescent and participation in certain unhealthy behaviors. Among girls in the study, smokers were more likely to not wear a seat belt, be involved in physical fighting, not be involved in organized sports, perform poorly in school, say they like to do risky things, and ride in a car with a drunk or high driver. For boys, smoking was significantly associated with liking to do risky things, fighting, not attending church, and poor academic performance. These results suggest that Mexican-American adolescents who smoke may be at higher risk for engaging in behaviors that could compromise their health and safety, and for not being involved in activities that may exert a protective influence. (J Sch Health. 1998;68(9):376–380)     

Risk Reduction for HIV-Positive African American and Latino Men with Histories of Childhood Sexual Abuse

While the HIV epidemic has disproportionately affected African American and Latino men who have sex with men (MSM), few HIV prevention interventions have focused on African American and Latino men who have sex with both men and women (MSMW). Even fewer interventions target HIV-positive African American and Latino MSM and MSMW with histories of childhood sexual abuse (CSA), a population that may be vulnerable to high-risk sexual behaviors, having multiple sexual partners, and depression. The Men's Health Project, a small randomized clinical trial, compared the effects of two 6-session interventions, the Sexual Health Intervention for Men (S-HIM), guided by social learning theory and aimed at decreasing high-risk sexual behaviors, number of sexual partners, and depressive symptoms, and a standard health promotion control (SHP). A community sample of 137 HIV-positive gay and non-gay identifying African American and Latino MSM and MSMW with histories of CSA was recruited. Results were based on an "intent to treat" analyses of baseline to post, 3 and 6 month follow-ups. The sample as a whole reported reductions in sexual risk behaviors and number of sexual partners from baseline to post-test, and from the 3 to 6 month follow-ups, although the decrease in sexual risk behavior from baseline to post-test was significant only for S-HIM participants. No significant differences between conditions were reported for depressive symptoms, but the total sample reported a significant decrease at 6 months. These findings highlight the importance of addressing sexual decision-making and psychological adjustment for ethnic men, while being sensitive to CSA histories and sexual minority status, and suggest the need to develop additional strategies to heighten HIV risk reduction over time.     

Physical activity, fitness and psychosocial functioning of obese adolescents

Obesity is associated with an array of negative physical and psychosocial symptoms in adolescents. Numerous interventions have emerged to address this significant public health concern. However, few have focused on African American females, a group at particularly high risk for negative health behaviors and associated complications. Moreover, although investigations with adults have yielded promising findings regarding psychosocial changes associated with increased physical activity and fitness, much less research has examined this relationship in adolescents. The current study addressed these gaps in the research and examined psychological outcomes of adolescent participants in TEENS, a culturally sensitive, multidisciplinary weight loss pilot intervention. From baseline to post-testing, participants demonstrated significant improvements in physical, emotional, and social functioning, as well as significant reductions in body dissatisfaction. Moreover, increases in physical activity and fitness were associated with significant enhancements in psychological well-being. Outcomes provide evidence for the psychological benefits of physical activity and highlight the importance of detailed cardiorespiratory fitness assessment to evaluate the complex relationship between physical and mental health in future obesity interventions.     

Rural and Urban Differences in Sexual Behaviors Among Adolescents in Florida

The national teen birth rate is higher in rural compared to urban areas. While national data suggest rural areas may present higher risk for adverse sexual health outcomes among adolescents, it is unknown whether there are differences within the state of Florida. Overall, Florida has poorer sexual health indicators for adolescents compared to national rates. The purpose of this study was to assess differences in sexual behaviors among Florida adolescents by rural–urban community location. This study includes baseline data from a randomized controlled trial conducted in Florida high schools. Of the 6316 participants, 74% were urban and 26% were rural. Participants responded to questions on sexual behaviors, sexual behavior intentions, and demographics. We estimated the effect of rural–urban status on risk outcomes after controlling for demographic variables using generalized linear mixed models. More teens from rural areas reported ever having sex (24.0%) compared to urban teens (19.7%). No significant differences were observed for most of sexual behaviors assessed. Nonetheless, urban participants were less likely to intend to have sex without a condom in the next year compared to rural participants (aOR?=?0.76, 95% CI 0.63–0.92). Overall, there were no major differences in sexual behaviors between rural and urban adolescents in Florida. However, sexual intentions differed between rural and urban adolescents; specifically, rural adolescents were more likely to intend to have sex without a condom in the next year compared to urban adolescents. Understanding the specific disparities can inform contraception and sexual health interventions among rural youth.     

Cumulative abuse experiences, physical health and health behaviors

PURPOSE: Our purpose was to investigate the complex relationship between a range of lifetime abuse experiences with current physical health and health behaviors. METHODS: Between October 1998 and May 1999, interviews were conducted with 557 ethnically diverse women seen at two urban primary care centers. Seven forms of abuse were measured: childhood physical and sexual abuse, past physical and sexual intimate partner violence (IPV), and recent emotional, physical, and sexual IPV. Severity was measured for six of these forms. Multiple non-specific physical symptoms were measured with a modified PRIME-MD, and four health behaviors were ascertained. RESULTS: Approximately 10% of women never experiencing abuse reported multiple non-specific physical symptoms, compared with 25.8% to 78.4% of women reporting a range of abuse experiences. Increases in recent IPV, past IPV, child abuse, and economic hardship were associated with increases in reported symptoms. Women who experienced IPV were more likely to report smoking cigarettes, binge drinking, and having poor nutritional habits. CONCLUSIONS: Recent IPV is associated with physical symptoms and risky health behaviors beyond the effects of child abuse, past IPV, and economic disadvantage. Understanding a person's IPV experiences may inform interventions for health behaviors, such as smoking cessation programs.     

Violence perpetration across peer and partner relationships: co-occurrence and longitudinal patterns among adolescents.

PURPOSE: To examine the co-occurrence and consistency over time of peer violence, sexual aggression, and dating violence among European American and Mexican-American adolescent boys and girls. METHODS: One-hundred-twelve girls and 135 boys who were either European American or Mexican-American were recruited from a large health maintenance organization. They were interviewed by telephone at baseline (at ages 16 to 20 years) and at one-year follow-up. Variable-centered and person-centered analyses examined the co-occurrence of violent behavior across domains, and whether adolescents who engaged in violent behavior at baseline also engaged in violent behavior during the following year. RESULTS: Results indicated that adolescent boys who engaged in violence in one domain were more likely to engage in violence in other domains during the same time period. Results for girls were less consistent. For boys but not girls, perpetration of either sexual aggression or peer violence was a significant predictor of the same behavior at follow-up. Person-centered analyses indicated that boys who perpetrated both peer violence and sexual aggression at baseline were most likely to perpetrate later violence. CONCLUSIONS: These results suggest that adolescent boys who engage in peer violence are also at risk for perpetrating sexual aggression or dating violence. Boys who perpetrate peer violence and sexual aggression are at high risk for later violence. Interventions with a dual focus on peer and partner violence may be valuable.     

Influences on adolescents' decision to postpone onset of sexual intercourse: a survival analysis of virginity among youths aged 13 to 18 years.

BACKGROUND: Previous research has focused on risk factors associated with early onset of sexual intercourse among adolescents. This study hypothesizes that protective factors identified for other health compromising behaviors are also protective against early onset of sexual intercourse. The study sample included 26,023 students in grades 7-12 (87.5% white, 52.5% male) who did not report a history of sexual abuse in a statewide survey of adolescent health in 1988. METHODS: Bivariate analyses were stratified into early (13-14 years), middle (15-16 years) and late (17-18 years) adolescence and by gender. Cox proportional hazards survival analysis, stratified by gender, was used to determine risk and protective factors associated with delayed onset of sexual intercourse. RESULTS: Variables showing a significant bivariate association with lower levels of sexual activity across all age groups and genders were: dual-parent families, higher socioeconomic status (SES), better school performance, greater religiosity, absence of suicidal thoughts, feeling adults or parents cared, and high parental expectations. High levels of body pride were associated with higher levels of sexual activity for all age and gender groups. In the multivariate survival analyses, variables significantly associated with delayed onset of sexual activity for both males and females included: dual-parent families, higher SES, residing in rural areas, higher school performance, concerns about the community, and higher religiosity. High parental expectations were a significant protective factor for males but not for females. CONCLUSION: While many protective factors are not subject to intervention, the present analyses indicate that teen pregnancy prevention may be enhanced by addressing family and educational factors.     

Family structure effects on early sexual debut among adolescent girls in Rakai,Uganda

This study assessed the association between household family structure and early sexual debut among adolescent girls, ages 15–19, in rural Rakai District, Uganda. Early sexual debut is associated with detrimental physical, emotional, and social outcomes, including increased risk of HIV. However, research on the family’s role on adolescents’ sexual risk behaviors in sub-Saharan Africa has been minimal and rarely takes into account the varying family structures within which African adolescents develop. Using six rounds of survey data (2001–2008) from the Rakai Community Cohort Study, unmarried adolescent girls (n = 1940) aged 15–17 at their baseline survey, were followed until age 19. Parametric survival models showed that compared to adolescent girls living with both biological parents, girls who headed their own household and girls living with stepfathers, grandparents, siblings, or other relatives had significantly higher hazards of early sexual debut before age 16. Adolescent girls were significantly more likely to debut sexually if neither parent resided in the household, either due to death or other reasons. In addition, the absence of the living biological father from the home was associated with a higher risk of sexual debut, regardless of the biological mother’s presence in the home. Our study’s findings suggest that family structure is important to adolescent girls’ sexual behavior. There is need for research to understand the underlying processes, interactions, and dynamics of both low and high-risk family structures in order to devise and strategically target interventions for specific types of family structures.     

Understanding the Link Between Adolescent Same-Gender Contact and Unintended Pregnancy: The Role of Early Adversity and Sexual Risk Behavior

Past research suggests an apparent paradox: Women who engage in same-gender sexual behavior show higher rates of unintended pregnancy than women with exclusive other-gender sexual behavior. Such women also have disproportionate rates of early adversity (both harshness, such as abuse or neglect, and unpredictability, such as father absence). We used the Add Health data (N?=?5,617 cisgender women) to examine the relative contributions of early adversity, adolescent same-gender sexual behavior, and general sexual risk behavior to women’s risks for adult unintended pregnancy. Women who engaged in adolescent same-gender sexual behavior were more likely to report childhood adversity, and both childhood adversity and adolescent same-gender behavior made independent contributions to subsequent rates of unintended pregnancy. The association between adolescent same-gender sexual behavior and adult unintended pregnancy was partially attributable to the fact that women with adolescent same-gender sexual behavior engaged in greater sexual risk behavior more broadly. These findings suggest that same-gender sexual behavior in adolescence may relate to a broader set of sexual risk behaviors that augment future risk for unintended pregnancy, independent of sexual identity. We draw on life history theory to explain this pattern of results and suggest directions for future research.

     

A Systematic Review of Effective Interventions for Reducing Multiple Health Risk Behaviors in Adolescence

We systematically searched 9 biomedical and social science databases (1980–2012) for primary and secondary interventions that prevented or reduced 2 or more adolescent health risk behaviors (tobacco use, alcohol use, illicit drug use, risky sexual behavior, aggressive acts).We identified 44 randomized controlled trials of universal or selective interventions and were effective for multiple health risk behaviors. Most were school based, conducted in the United States, and effective for multiple forms of substance use. Effects were small, in line with findings for other universal prevention programs. In some studies, effects for more than 1 health risk behavior only emerged at long-term follow-up.Integrated prevention programs are feasible and effective and may be more efficient than discrete prevention strategies.Adolescence is associated with an increased prevalence of health risk behaviors, including substance use, sexual risk, and aggressive behavior.1 The vast majority of substance use is initiated in adolescence.2,3 In the United Kingdom, adolescence is associated with higher rates of sexually transmitted disease and abortion relative to other age groups.4,5 The majority of young people will experience bullying or aggression during adolescence.6 In addition, adolescent mortality has increased relative to other age groups, largely because of accidents and unintentional injuries.7 Early initiation of health risk behaviors is associated with negative outcomes throughout adolescence and adulthood, such as addiction and substance abuse; poor sexual, mental, and physical health; and lower occupational and educational attainment.8,9 The social and economic costs associated with adolescent risk behaviors have made them a key focus of public health policy initiatives internationally.10A growing body of research suggests that health risk behaviors often do not occur in isolation. Smoking, drinking, illicit drug use, sexual risk, and aggressive behaviors are all mutually predictive.11 For drug use and some forms of sexual risk, co-occurrence with other risk behaviors is essentially normative. Previous research suggests that co-occurrence of risk behaviors is driven by shared risk factors such as peer influences or sensation seeking or by state-specific traits such as the direct effects of substance use or aggression on other risk behaviors. Common risk factors can be found in many domains, including social, psychological, family, school, and neighborhood.12–14 Evidence also suggests gateway effects, whereby participation in a given health risk behavior leads to increased risk for others, partially attributable to exposure effects and decreases in perceived danger of such behaviors.15 For example, adolescent smoking and drinking have been linked with subsequent illicit drug use.16This typical co-occurrence is often not reflected in the organization of policies and interventions to reduce adolescent risk behavior. National policy regarding adolescent health risk behavior is often organized in nonoverlapping risk-specific policies.10 Some intervention developers recognize that single-risk interventions for adolescents may trigger effects on other risk behaviors, particularly on multiple forms of substance use.For several reasons, targeting multiple health risk behaviors (MHRBs) simultaneously may be more effective and efficient than targeting a single risk behavior. Limited funding for prevention interventions requires that interventions reduce health risks efficiently, highlighting the importance of synchronized prevention efforts. Time constraints, for example in schools, also make coordinated intervention for multiple risks attractive. Furthermore, it is unclear how discrete interventions might interact in cases where they are not coordinated both theoretically and practically, raising the possibility that uncoordinated interventions could be ineffective or cause harm.17Beyond these logistic concerns, research regarding the mechanisms for MHRBs suggests that integrated interventions may be essential for the effective prevention of risk behaviors. If common risk factors explain co-occurrence of risk behaviors, then targeting those risk factors should prove effective for MHRBs. Gateway theories offer further support for integrated intervention strategies; if a given risk behavior increases risk for another, effective prevention strategies for the latter must also focus on the former. For example, sexual intercourse accompanied by alcohol or illicit drug use is linked to a lower likelihood of condom use,18 so targeting substance misuse may be a feasible approach to reducing unsafe sex.Although the development of integrated interventions for MHRBs requires an understanding of their mechanisms, including common risk factors and gateway effects, the existing literature regarding effective interventions is also a key source of evidence for the development of interventions. The majority of evaluations report on interventions that target 1 risk behavior. However, identifying interventions that have reduced MHRBs can help inform the development of future interventions by indicating which combinations of risk behaviors can be targeted in coordinated approaches, what contexts and approaches are most successful, and what are the other attributes of coordinated interventions, such as duration and participant age.Limited data exist on effective intervention programs to prevent MHRBs. To date, we are aware of only 1 published review that assessed the effectiveness of interventions on MHRBs in young people.13 That review focused exclusively on studies reporting concurrently on substance use and sexual risk outcomes. We expanded on this work by reviewing additional combinations of outcomes. We undertook a systematic review designed to identify randomized controlled trials that reported significant universal or selective intervention effects for at least 2 health risk behaviors among adolescents.     

The changing ethnic makeup of America's adolescents: implications for health

As the percentage of minority adolescents in society increases, behaviors that affect the health of these adolescents will become increasingly important. Both mental and physical health as well as substance abuse and violence need to be addressed, and the ethnicity and culture of the adolescent patient may guide specific approaches and considerations. Many of the health problems affecting adolescents are preventable, and health care providers should aim significant resources at these issues. Gaps in adolescent health care, and especially barriers to entry for some ethnic groups, deserve greater attention to ensure that all groups can enjoy access to quality health care. Options available to health care practitioners for reducing these barriers are offered in the final portion of the article.