Improve Sexual and Reproductive Health Outcomes for Youth: Improve Sexual and Reproductive Health Outcomes for Youth Robert Wm. Blum, M.D. M.P.H. Ph.D. Professor & Director and Kristin Nelson-Mmari, Dr.PH. Research Associate Center for Adolescent Health and Development University of Minnesota Minneapolis, MN Prepared for: HIV Prevention for Young People in Developing Countries July 24, 2003


Slide2: The WHO Risk and Resilience Study in ASRH To identify the empirical findings from intervention and risk and resilience research from developing as well as industrialized countries.


Slide3: ASRH Outcomes Sexual initiation Number of sexual partners Condom use Contraceptive use (other than condom) Sexually transmitted infection (non-HIV) HIV/AIDS Pregnancy Sexual abuse/sexual exchange Childbearing/abortion.


Slide4: Databases Searched Medline Psyc. Abstracts Soc. Abstracts Popline BIREME EMBASE WHO Library AGI FOCUS


A total of 11,102 published & unpublished manuscripts were identified.: A total of 11,102 published & unpublished manuscripts were identified. Published 1990 or later; Primary age group 10-24 year olds; Risk and protective factor studies must have used multivariate design. Inclusion Criteria:


Slide6: Articles were coded based on abstract and those articles that were likely to be empirical, multivariate studies were retrieved. Based on abstracts over 2200 publications were identified of which 1850 were retrieved; Of those, 289 articles met the criteria of: Being from developing countries; Using multivariate analyses Focused on risk and protective factors.


Slide7: An Ecological Model of Resilience Macro-level Environment Political Realities Youth Laws/Policies Macrolevel Economics Historical Events


Slide8: An Ecological Model of Resilience Community Environment • Single parent household • Child headed households • Rural to urban migration • Percent unemployed • Rural residence • Received family planning from health care provider Macro-level Environment Risk Protection


Slide9: Family • mother opposed to contraception • non-nuclear family • frequent parental fights • mother a teen mom • parents use physical punishment • not living with parents • father’s education low • mom’s death • mom’s education low • live with parents/mother • mom’s interest in school • mom’s education higher • higher income • mother/mother-in-law discussed family planning • husband approves of contraception • discuss family planning with partner (may be risk in some contexts) • parents exert behavioral control • parent connectedness Community Environment Macro-level Environment An Ecological Model of Resilience Risk Protection


Slide10: • multiple sexual partners (concurrent) • sex with CSWs • more lifetime partners • friend’s use of alcohol/drugs • engaged to be married • boyfriend approves of contraception • perceived contraceptive use by peers An Ecological Model of Resilience Family Community Environment Macro-level Environment Peers/Partners Risk Protection


Slide11: • school failure • attention deficit hyperactivity disorder Lack of safety/security in school • attended Family Life Education program • higher educational aspirations • secondary school or higher • regular school attendance • school connectedness An Ecological Model of Resilience Family Community Environment Macro-level Environment Peers School Risk Protection


Slide12: • low education • drug, alcohol, tobacco (inc. IV drugs) • unemployment • anal sex • history of STIs • being older • early age 1st sex • sometime condom use • unprotected intercourse • HSV 2 • physical/sexual abuse • early puberty/early marriage • consistent condom use • older age 1st sex • circumcision (in certain contexts) • abstinence • high self-esteem • higher family planning knowledge An Ecological Model of Resilience Risk Protection


Slide13: Macrolevel Environment An Ecological Model of Resilience Adolescent Sexual & Reproductive Health


Slide15: Participating Countries


Slide16: Risk and Protective Factors Associated with Early Sexual Debut Skipped school 1.64*** – Rage 1.62*** 1.78*** Physical/sexual abuse 1.52*** 2.40*** Connected to family 0.57*** 0.30*** Odds Ratio Boys Girls p< .05 ** p < .01 *** p< .001


Slide17: Risk Factors Associated With Lifetime Sexual Partners† Skipped school 1.40*** – Rage 1.24* 1.95*** Physical/sexual abuse – 1.57** Odds Ratio Boys Girls † > 3 partners p< .05 ** p < .01 *** p< .001


Slide18: Risk and Protective Factors Associated with Condom Use Skipped school 1.40** 1.40** Physical/sexual abuse 1.45** 1.66*** Above average school performance 0.63** – Connected to family 0.46*** – Odds Ratio Boys Girls p< .05 ** p < .01 *** p< .001


Slide19: Risk Factors Associated with Pregnancy/Caused Pregnancy Will not live to 25 2.53*** 1.87** Physical/sexual abuse 2.39*** 1.89** Rage 1.33* – Odds Ratio Boys Girls p< .05 ** p < .01 *** p< .001


Slide20: Summary of ASRH Risk and Protective Factors Risk Rage Skipped school Abuse Protective Family connectedness Religion/religiosity School connectedness


Slide21: Sexual Intercourse: Probability of Sexual Involvement in Relation to the Presence of Risk Factors (holding protective factors constant)


Slide22: Sexual Intercourse: Probability of Sexual Involvement in Relation to the Presence of Risk Factors (holding protective factors constant)


Slide23: Sexual Intercourse: Probability of Sexual Involvement in Relation to the Presence of Risk Factors (holding protective factors constant)


Slide24: Sexual Intercourse: Probability of Sexual Involvement in Relation to the Presence of Risk Factors (holding protective factors constant)


Slide25: Sexual Intercourse: Probability of Sexual Involvement in Relation to the Presence of Protective Factors (holding risk factors constant)


Slide26: Sexual Intercourse: Probability of Sexual Involvement in Relation to the Presence of Protective Factors (holding risk factors constant)


Slide27: Sexual Intercourse: Probability of Sexual Involvement in Relation to the Presence of Protective Factors (holding risk factors constant)


Slide28: Sexual Intercourse: Probability of Sexual Involvement in Relation to the Presence of Protective Factors (holding risk factors constant)


Slide29: What Protects Youth from ASRH Risk Behaviors Family School Partners Beliefs


Slide30: Connectedness to parents matters Parental expectations matters School completion Age at marriage Sexual behaviors Family Environment Counts


Slide31: School connectedness matters Family life education matters Academic performance matters Number of years of education matters A safe school environment matters School Environment Counts


Slide32: Number of lifetime partners matters Partner expectations matters Partner support of contraception/condoms matters Partner fidelity matters Partners Count


Slide33: Belief that I can control my sexual and reproductive future matters Belief that condoms and contraception work matters Belief that sexually active peers contracept matters; and… Beliefs Count


Slide34: A belief in an attainable future is the best contraception. Beliefs Matter Marion Wright Edelman