RESEARCH ARTICLE

Adolescents Sexually Transmitted Disease Protective Attitudes Predict Sexually Transmitted Disease Acquisition in Early Adulthood

RICHARD A. CROSBY, PhDa FRED DANNER, PhDb

ABSTRACT
BACKGROUND: Estimates suggest that about 48% of nearly 19 million cases of sexually transmitted diseases (STDs) occurring annually in the United States are acquired by persons aged 15-24 years. The purpose of this study was to test the hypothesis that adolescents attitudes about protecting themselves from STDs predict their laboratory-conrmed prevalence of STDs in early adulthood. METHODS: Wave 3 of the National Longitudinal Study of Adolescent Health assessed Chlamydia trachomatis, Neisseria gonorrhoeae, and Trichomonas vaginalis. This wave 3 data were regressed on data collected in wave 1 (when those followed were teens). A single-item measure (with a 5-point response option) assessed adolescents attitude: It would be a big hassle to do the things necessary to completely protect yourself from getting an STD. RESULTS: Valid urine specimens were provided by 8297 adolescents who also completed the self-reported measures needed for this study. Overall, 6.4% of the weighted sample tested positive for at least 1 of the 3 STDs. Controlling for age, gender, minority status, and age of sexual debut (all of which are well-established predictors of STD prevalence), attitude toward STD protection achieved signicance (P , .001). Each additional point on the 5-point scale increased adolescents odds of testing positive for an STD in early adulthood by about 13%. Of interest, the attitudinal measure did not interact with any of the other variables. CONCLUSIONS: Findings provide evidence suggesting that safer sex programs may benet adolescents by fostering positive attitudes toward practices that avert STD acquisition. Keywords: communicable diseases; human sexuality; risk behaviors.
Citation: Crosby RA, Danner F. Adolescents sexually transmitted disease protective attitudes predict sexually transmitted disease acquisition in early adulthood. J Sch Health. 2008; 78: 310-313.

Professor, (crosby@uky.edu), College of Public Health, University of Kentucky, 121 Washington Ave, Lexington, KY 40506-0003. Professor, (fdanner@uky.edu), College of Education, University of Kentucky, 121 Washington Ave, Lexington, KY 40506-0003.

Address correspondence to: Richard A. Crosby, Professor, (crosby@uky.edu), College of Public Health, University of Kentucky, 121 Washington Ave, Lexington, KY 40506-0003.

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exually transmitted diseases (STDs) are a common source of morbidity for adolescents and young adults.1,2 Estimates suggest that about 48% of nearly 19 million cases of STDs occurring annually in the United States are acquired by persons aged 15-24 years.2 Sequelae of Chlamydia trachomatis and Neisseria gonorrhoeae, for example, include infertility and pelvic inammatory disease.1 Evidence indicates that female infection with Trichomonas vaginalis causes chronic purulent vaginal discharge, vulvovaginal irritation, dysuria, dyspareunia, and leads to pregnancy complications.3-7 These (and other) STDs also magnify the risk of acquiring human immunodeciency virus.8-10 The scope of the STD epidemic among youth in the United States varies greatly as a function of sex and race.11,12 For example, reported rates of Chlamydia among 15- to 19-year-old U.S. residents vary from a high of 8969.7 (per 100,000) among African American females to a low of 153.9 for white males. African American females were 6.3 and 3.1 times more likely to be diagnosed with Chlamydia than their white and Hispanic counterparts, respectively. Among males, African American teens were 13.9 and 4.0 times more likely to be diagnosed with Chlamydia than their white and Hispanic counterparts, respectively. The development of effective intervention programs that stem the epidemic of STDs among adolescents is contingent upon the identication of protective factors.12 Ideally, these factors should be identied through long-term prospective studies, using laboratoryconrmed outcome measures (ie, STD prevalence). Fortunately, the National Longitudinal Study of Adolescent Health (Add Health) has provided this opportunity, as the third wave of follow-up included urine-based testing for Chlamydia, gonorrhea, and trichomoniasis. Indeed, a recent study, conducted by Kaestle et al, using this data set conrmed that early age of sexual debut predicts an apparent trajectory of sexual risk culminating in greater odds of testing positive for an STD at wave 3 follow-up (early adulthood).13 Unfortunately, the study did not evaluate the effect of adolescents attitudes toward STD prevention on the outcome. Because attitudes are frequently a focal point of behavioral intervention for adolescents,14 learning more about their potential as a protective factor is clearly important. Accordingly, this study employed prospective data from Add Health to test the hypothesis that adolescents attitudes about protecting themselves from STDs predict their laboratory-conrmed prevalence of STDs in early adulthood, and this effect occurs independently from the predictive effect of sexual debut age. METHODS Study Design and Sample The most recent wave of Add Health data collection assessed C. trachomatis, N. gonorrhoeae, and T. vaginalis.
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This wave 3 data were regressed on data collected in wave 1 (when those followed were teens). Wave 1 was conducted in 1995. Wave 3 was conducted in 2001 and 2002 among 15,170 wave 1 participants. Of these, 8297 (54.7%) adolescents provided valid urine specimens and also completed the self-reported measures needed for this study. Data Collection Wave 1 of Add Health contained a single-item measure that assessed adolescents attitudes about STD protection. They were asked to indicate their level of agreement with the following statement: It would be a big hassle to do the things necessary to completely protect yourself from getting an STD. Response alternatives ranged from strongly disagree (1) to strongly agree (5). Data from wave 3 were used to assess adolescents age of sexual debut. Wave 3 also collected rst-catch urine specimens that were assayed for C. trachomatis and N. gonorrhoeae using the Abbott LCx Probe System (Abbott Park, IL). Specimens were stored at 2-8C and analyzed within 96 hours after donation. Aliquots were assayed for the presence of T. vaginalis using an inhouse polymerase chain reactionenzyme-linked immunosorbent assay with established and acceptable estimates of sensitivity and specicity.15,16 Data Analysis We used STATA software (version 8.0; StataCorp, College Station, TX) to take full advantage of the complex design weights in the Add Health data set.17 Simple logistic regression procedures, adjusted by STATA for complex survey designs, were used to test the study hypothesis that hassles with STD protection would predict subsequent STDs. To control for type 1 error, we set the signicance level at P , .01. To graphically display the predictive relation between adolescent protection hassles and STDs as young adults, separate odds ratios (ORs) for male and female and minority and nonminority participants were calculated, holding age and sexual debut age constant at their means. These ORs were then converted to probabilities, using the formula: probability of an STD = odds/(1 1 odds).18 RESULTS Prevalence of STDs Table 1 displays sex and racial/ethnic characteristics of the sample. At wave 3, participants were 21-27 years of age (mean age = 22.97, SD = 1.13). Overall, 6.4% of the weighted sample tested positive for at least 1 of the 3 STDs. Chlamydia was the most prevalent infection (4.3 %), followed by trichomoniasis (2.5%) and gonorrhea (0.4%).
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Table 1. Sex and Racial/Ethnic Composition of the Sample (N = 8297)

Characteristic Sex Male Female Race/ethnicity White African American Native American Asian Other race/ethnicity n 3991 4306 4998 1800 119 598 755 Percent of Sample 48.1 51.9 60.4 21.8 1.4 7.2 9.1

adolescents and subsequent STDs for males and females who were and were not minority group members. Age and age of sexual debut were held constant at their respective means. DISCUSSION Evidence from this nationally representative sample suggests that adolescents who perceive that protecting themselves from STDs is a big hassle, experience an added risk of STD acquisition in early adulthood. This effect was observed even after controlling for the powerful effects of age, gender, minority status, and age of debut. It is particularly important to note that adolescents attitudes at wave 1 predicted an outcome several years into their future. This suggests that the attitude regarding STD-protective behaviors may be quite stable during and beyond adolescence. If the attitude was volatile, a nonsignicant association between this measure and STD prevalence would have resulted. The fact the signicance was achieved despite the elapse of several years is clearly noteworthy. Another important point to consider is that the attitudinal measure was summative in nature. Assessing agreement with the idea that it would be a big hassle to do the things necessary to completely protect yourself from getting an STD yielded a general measure that probably captured the collective concept of safer sex practices (eg, abstinence from penile-vaginal and penile-anal sex, limiting number of sex partners, using condoms, and being tested for STDs). Thus, the measure may be conceptualized as an indicator of adolescents predilection toward the multiple behaviors that constitute safer sex. The implications of the ndings are that schooland community-based health promotion programs may benet adolescents by instilling positive attitudes toward the practices that comprise safer sex (including abstinence) and teaching skills pertaining to safer

Regression Findings Table 2 presents the ORs associated with each of the predictors in the model. The ndings supported the hypothesis. Controlling for age, gender, minority status, and age of sexual debut (all of which are wellestablished predictors of STD prevalence), attitude toward STD protection achieved signicance. Each additional point on the 5-point scale increased adolescents odds of testing positive for an STD in early adulthood by about 13%. Of interest, the hassles measure did not interact with any of the other variables. Figure 1 illustrates the predictive relation between favorable attitudes (ie, strongly disagree that STD protection is a big hassle) and unfavorable attitudes (ie, strongly agree that STD protection is a big hassle) of

Table 2. Predictors of Testing Positive for STDs in Early Adulthood (N = 8297)

Predictor Female Minority Age Debut age Protective attitude Adjusted OR 1.32 4.00 0.94 0.93 1.13 95% Confidence Interval 1.05-1.66 3.00-5.34 0.84-1.06 0.89-0.97 1.05-1.22 P .019 .000 .31 .001 .001

Figure 1. STDs as a Function of Gender, Minority Status, and Perceived Protection Hassles
20

Predicted Percent With STDs

18 16 14 12 10 8 6 4 2 0 Low Hassle High Hassle

Male White Female White Male Minority Female Minority

Degree of Perceived Protection Hassle

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sex. Like most behaviors, STD protection is likely to be perceived as less of a hassle for those who possess the skills needed to achieve safer sex. These skills could include refusing unwanted sex, limiting the number of sex partners, and using condoms correctly and consistently. Each skill is likely to involve a negotiation component and each involves learning selfrestraint during states of sexual arousal. Thus, the nding of this nationally representative study provides longitudinal support for many of the practices that have been included in STD prevention programs designed for adolescents.19-21 Finally, the limitations of this study should be noted. Clearly, retention is a genuine challenge in a prospective study of this magnitude, and therefore, the high rate attrition between waves 1 and 3 represents a potential bias to the ndings. Although also limited by the validity of the self-reported data and the use of a single-item measure to assess adolescents attitude toward STD prevention, ndings from this study provide unique evidence suggesting that safer sex programs may benet adolescents by fostering positive attitudes toward protective behaviors that avert STD acquisition.

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6. Quinn TC, Kreiger JN. Trichomoniasis. In: Warren KS, Mahmoud AAF, eds. Tropical and Geographic Medicine. New York, NY: McGraw-Hill; 1990:358. 7. Heine P, MCgregor JA. Trichomonas vaginalis: a reemerging pathogen. Clin Obstet Gynecol. 1993;36:137-144. 8. Laga M, Monoka A, Kivuvu M, et al. Non-ulcerative sexually transmitted diseases as risk factors for HIV-1 transmission in women: results from a cohort study. AIDS. 1993;7:95-101. 9. Sorvillo F, Kernott P. Trichomonas vaginalis and amplication of HIV-1 transmission. Lancet. 1998;351:213-214. 10. Wasserheit JN. Epidemilogical synergy: interrelationships between human immunodeciency virus infection and other sexually transmitted diseases. Sex Transm Dis. 1992;19:61-72. 11. Centers for Disease Control and Prevention. Sexually Transmitted Disease Surveillance, 2006. Atlanta, Ga: U.S. Department of Health and Human Services; 2007. 12. DiClemente RJ, Crosby RA. Sexually transmitted diseases among adolescents: risk factors, antecedents, and prevention strategies. In: Adams GR, Berzonsky M, eds. Blackwell Handbook of Adolescence. Oxford, UK: Blackwell Publishers Ltd; 2003:573-605. 13. Kaestle CE, Halpren CT, Miller WC, Ford CA. Young age at rst sexual intercourse and sexually transmitted infections in adolescents and young adults. Am J Epidemiol. 2005;161:774-780. 14. Robin L, Dittus P, Whitaker D, et al. Behavioral interventions to reduce incidence of HIV, STD, and pregnancy among adolescents: a decade in review. J Adolesc Health. 2004;34:3-26. 15. Kaydos SC, Swygard H, Wise SL, et al. Development and validation of a PCR-based enzyme-linked immunosorbent assay with urine for use in clinical research settings to detect Trichomonas vaginalis in women. J Clin Microbiol. 2002;40:89-95. 16. Kaydos-Daniles SC, Miller WC, Hoffman I, et al. Validation of a urine-based PCR-enzyme-linked immunosorbent assay for use in clinical research settings to detect Trichomonas vaginalis in men. J Clin Microbiol. 2003;41:318-323. 17. Chantala K, Tabor J. National Longitudinal Study of Adolescent Health: Strategies to Perform a Design-Based Analysis Using the Add Health Data. Chapel Hill, NC: Carolina Population Center, University of North Carolina at Chapel Hill; 1999. 18. Tabachnick B, Fidell L. Using Multivariate Statistics. 4th ed. Boston, Mass: Allyn & Bacon; 2001. 19. Centers for Disease Control and Prevention. Compendium of HIV Prevention Interventions with Evidence of Effectiveness. Atlanta, Ga: Department of Health and Human Services; 1999. 20. DiClemente RJ, Wingood GM, Harrington KF, et al. Efcacy of an HIV prevention intervention for African American adolescent females: a randomized controlled trial. JAMA. 2004;292:171-179. 21. DiClemente RJ, Milhausen R, McDermott J, Salazar LF, Crosby RA. A programmatic and methodological review and synthesis of clinic-based risk-reduction interventions for sexually transmitted infections: research and practice implications. Semin Pediatr Infect Dis. 2005;16:199-218.

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