Abstract
Considering that current trends in sexual behavior and alcohol use among adolescents pose a significant public health risk, more research is needed in this area. Using a cross-sectional design, this study examined sex and alcohol behaviors among middle school and high school students in southeastern North Carolina. The findings suggested that there were strong associations between overall drinking patterns and sexual behaviors. Further analyses examined the effect of several demographic and behavioral factors on sexual experience and condom use for both middle and high school students. Alcohol, race, and age were significant determinants of sexual experience for all students while gender was significant for middle school students. None of the measured factors, including AIDS education, significantly increased condom use among sexually active students. The results suggested that sexuality and alcohol education methods and content should be reevaluated and should begin in or before middle school.
INTRODUCTION
Responsible sexual behavior to prevent unintended pregnancy and sexually transmitted diseases (STDs) among adolescents is a national priority, as indicated in Healthy People 2010 (U.S. Department of Health and Human Services [USDHHS], 2000). Although prevalence rates of sexual intercourse among adolescents (grades 9–12) in the United States have declined over the past decade (53% in 1995 to 46.8% in 2005), the Youth Risk Behavior Surveillance Report in 2005 indicated that approximately 33.9% of high school students are sexually active; and among these currently sexually active high school students, 37.2% failed to use a condom during their last sexual intercourse and 23.3% had drunk alcohol or taken drugs before their last sexual intercourse (Centers for Disease Control and Prevention [CDC], 2006a). Adolescents who use alcohol are more likely to be at risk for STDs and teen pregnancy (Stueve & O’Donnell, 2005).
Adolescents who use alcohol are more likely to be at risk for STDs and teen pregnancy.
There are approximately 15 million new cases of STDs each year, with 4 million of these occurring in adolescents (USDHHS, 2000). Although rates of teen pregnancy have steadily declined since 1991, approximately 1 million teenage girls in the United States have unintended pregnancies each year, and nearly half of the unintended pregnancies end in abortion (USDHHS, 2000). These numbers have always been alarming, and they call for an ongoing effort to develop and implement effective intervention and prevention, because all of the above factors put adolescents at risk for multiple problems, including HIV, unplanned pregnancy, and a variety of other STDs.
In an effort to reduce the incidence of adolescent risky sexual behavior, the CDC has conducted intensive surveillance of adolescents’ self-reported sexual risk and protective behaviors since 1989 (Sussman, Jones, Wilson, & Kann, 2002). Using the Youth Risk Behavior Survey (YRBS) data from the CDC and other sources of national- or state-level data, correlates or predictors of sexual behaviors have been determined. However, since much research focused on the high school population, there is a lack of information about the middle school population. In addition, because previous reports generally include large-scale national or state data, local community-level data are not readily available. Considering that current trends in sexual behavior and alcohol use among adolescents pose a significant public health risk (Ramisetty-Mikler, Caetano, Coebert, & Nisgimyra, 2004; Stueve & O’Donnell, 2005), more research is needed in this area. The purpose of the study was to examine the relationship between sexual behaviors and alcohol use among middle and high school students in a small, urban southeastern North Carolina county. The data from the current study indicate that the overall prevalence rate of sexual behavior of this county is relatively higher than the rate in North Carolina and the United States. The results of the study will not only provide baseline data for this county, but also suggest possible intervention and prevention strategies to promote responsible sexual behaviors and alcohol use education among middle and high school students in this county.
REVIEW OF THE LITERATURE
High-risk sexual behavior among adolescents is a well-documented problem in the United States. Generally, the previous reports indicate that the risk of being sexually active and having multiple partners increases with age (Grunbaum et al., 2004; Santelli, Lindberg, Abma, McNeely, & Resnick, 2000). Ethnicity and gender have also been reported as correlates of sexual behaviors. Overall, previous studies indicate that Black students are significantly more likely to report engaging in sexual intercourse, initiating sex at younger ages, and having four or more lifetime partners than Caucasian or Hispanic students (Grunbaum et al., 2004; Helpern et al., 2004; Santelli et al., 2000).
High-risk sexual behavior among adolescents is a well-documented problem in the United States. Generally, the previous reports indicate that the risk of being sexually active and having multiple partners increases with age.
Gender differences in sexual behaviors have also been reported from studies based on YRBS data and nationally representative samples. At any adolescent age, engagement in risky behaviors and in multiple-risk behaviors is more likely among males than among females (Lindberg, 2000). From the data in the National Longitudinal Study of Adolescent Health Wave 1, using 13,990 Black and White participants, Helpern and colleagues (2004) reported that gender has significant effects on sexual activity, and males were more likely than females to engage in high levels of sexual activity. This report also showed ethnic differences in sexual activity; Blacks were more likely than Whites to be sexually active. While Black males were more likely than White males to be involved in high-risk sexual behaviors, Black females generally were the least likely to engage in high-risk behaviors but the most likely to report STDs (Helpern et al., 2004).
At any adolescent age, engagement in risky behaviors and in multiple-risk behaviors is more likely among males than among females.
The association between alcohol use and risky sexual behavior has been well documented in the literature. Adolescents who use alcohol are more likely to be sexually active than abstainers and potentially engage in unsafe practices, such as multiple sex partners, resulting in STDs and teen pregnancy (Ramisetty-Mikler et al., 2004; Stueve & O’Donnell, 2005). Stueve and O’Donnell (2005) examined the relationship between early alcohol use and subsequent alcohol use and risky sexual behaviors among a total of 1,034 urban Black and Hispanic students in 7th to 10th grade. They reported that early drinking was associated with alcohol and sexual risks through mid-adolescence. Early drinkers were more likely to report subsequent alcohol problems, unprotected sexual intercourse, multiple partners, being drunk or high during sexual intercourse, and pregnancy.
Adolescents who use alcohol are more likely to be sexually active than abstainers and potentially engage in unsafe practices, such as multiple sex partners, resulting in STDs and teen pregnancy.
METHODS
This study was designed to assess associations between sexual behaviors and alcohol use using the YRBS. A representative sample of middle and high school students participated in this cross-sectional design research. This study was approved by the University of North Carolina Wilmington Institutional Review Board (IRB).
Sample and Procedure
In April of 2005, the Safe Schools, Healthy Students Grant Initiative and the CDC administered the YRBS over a 2-week period. The CDC collected data from two middle and high schools in New Hanover County, North Carolina. The Project Director of Safe Schools Healthy Students randomly selected 5 classrooms within each of the middle and high schools not surveyed by the CDC. As a result, a total sample of 619 middle school students and 375 high school students participated in the current study. Under the guidance of the Project Director, six evaluators administered YRBSs in assigned classes. Evaluators read standardized directions to each class and monitored completion of the survey. It took approximately 1 hour to complete the survey.
Measurement
The YRBS, a standardized survey developed by the CDC in 1989, monitors behaviors that place adolescents most at risk for premature morbidity and mortality (Sussman et al., 2002). The surveys were first conducted in 1990 and have been conducted biennially since 1991 by local and state departments of health or education in collaboration with the CDC. YRBS questionnaires have proved reliable over time (Brener, Kann, McManus, & Kinchen, 2002). While the middle school survey includes 49 questions, the high school questionnaire has 87 questions, and both include demographic information about gender, age, grade, and ethnicity. Although YRBS assesses six categories of priority health-risk behaviors, the current study focuses on sexual behaviors and alcohol use.
Sexual Behaviors. Ten measures of sexual behaviors were selected. The first four measures of sexual behaviors are as follows: (a) lifetime sexual experience (ever engaged in sexual intercourse); (b) age of initiation; (c) current sexual experience (currently sexually active); and (d) number of sex partners (lifetime). Two other measures were related to the use of contraceptive methods, including (a) condom use and (b) use of contraceptive methods during the last sexual intercourse. The risky sexual behaviors were assessed by (a) use of alcohol or drugs before having sexual intercourse; (b) dating-violence (have been hit, slapped, or physically hurt on purpose by a boyfriend or girlfriend during the past 12 months); and (c) physically forced sex (have been physically forced to have sexual intercourse when they did not want to). The final measure asked whether adolescents have been taught about AIDS or HIV infection in school.
Alcohol Use. Four measures of alcohol behaviors were selected. The first two measures were related to drinking history, including (a) ever drank alcohol and (b) age of initiation. Two other measures were related to current drinking patterns: (a) currently drinking (at least one drink of alcohol during the past 30 days), and (b) binge drinking (5 or more drinks in a row during the past 30 days).
Data Analysis
The data were analyzed separately for middle school and high school levels. Descriptive statistics were used to analyze the demographic characteristics of respondents and to determine the degree of sexual behavior and alcohol use. Bivariate statistics were used to examine the associations among sexual behavior, alcohol use, and demographic characteristics. Finally, logistic regression analysis was used to predict sexual experience from age, gender, race, drinking experience, and HIV/AIDS education among all students. Among the sexually active students, additional logistic regression analyses were used to predict the number of sex partners and condom use from variables of age, gender, race, drinking experience, and HIV/AIDS education. A p value less than 0.05 (2-sided) was defined as statistically significant.
RESULTS
A total of 619 middle school students and 375 high school students participated in the survey, with an age range of 10–18 years. There was a slightly lower proportion of male students (47.2% and 44.7% in middle and high school, respectively). The majority of students were White (60.2% and 65.2% in middle and high school, respectively), with 24.8% (middle school) and 24% (high school) being Black. The Hispanic students constituted 5% (middle school) and 1.9% (high school) of the respondents. Due to the small proportion of Asian students, they were included in the “Other” category.
While 20.2% of the middle school students were sexually experienced, 50.4% of the high school students reported that they had had sexual experiences. Among the 12th graders, 73.5% reported sexual experiences.
While 20.2% of the middle school students were sexually experienced, 50.4% of the high school students reported that they had had sexual experiences. Among the 12th graders, 73.5% reported sexual experiences. Table 1 displays the overall percentage of middle and high school students reporting each of the 10 sexual behaviors and 4 alcohol-use variables.
Among the sexually active students, condom use during the most recent sexual encounter was reported by 67.6% (n = 69) in middle school, and 62.1% (n = 102) in high school. Use of birth control pills was less common with 14.4% (n = 26), followed by no use of contraceptive method to prevent pregnancy (12.2%, n = 22) among the sexually active high school students. About 75% of the middle school students and 87% of the high school students had been taught in school about AIDS or HIV. Over 10% of the high school students had been physically forced to have sexual intercourse when they did not want to, and 11.5% of the students had been hit, slapped, or physically hurt on purpose by their boyfriends or girlfriends during the 12 months preceding the survey.
Among the currently sexually active high school students, 25.4% (n = 47) had drunk alcohol or used drugs before having sexual intercourse during the past 3 months; almost half of all 12th graders reported drinking alcohol or using drugs before having sexual intercourse during the past 3 months. Approximately 34.9% of the middle school students and 86.7% of the high school students had had drinking experience. Moreover, 43.2% of the high school students had had one or more drinks of alcohol during the 30 days preceding the survey; and 25.7% of the high school students reported episodic heavy drinking (5 or more drinks in a row during the past 30 days).
Approximately 34.9% of the middle school students and 86.7% of the high school students had had drinking experience.
Sexual Behaviors and Drinking Behaviors
Preliminary analyses (Chi square, ANOVA, t tests) implied that significant associations exist between sexual behaviors and the variables of “age,” “race,” and “drinking behaviors” in the current study. Consistently, age was associated with all 10 sexual behavior variables. Overall, sexual behaviors occurred more frequently among the older students and higher grades. However, no gender difference was noted except for dating violence among high school students. Similar to age and grade, the prevalence rates of overall sexual behaviors were higher among Blacks than Whites. Expectedly, dating violence was strongly associated with physically forced sex and alcohol experience among high school students.
. . . dating violence was strongly associated with physically forced sex and alcohol experience among high school students.
As shown in Table 2, drinking patterns were strongly associated with the overall sexual behaviors, except for AIDS or HIV education. Among the middle school students, alcohol experience and initiation of alcohol use were significantly associated with sexual experience, initiation of sex, number of partners, and condom use. All four alcohol behaviors (alcohol experience; initiation of alcohol; current drinking; and binge drinking) were associated with sexual experience, initiation of sex, number of partners, currently sexually active, condom use, alcohol and drug use before sex, forced sex, and dating violence, among the high school students.
The findings of logistic regression analyses indicated that significant predictors of sexual experience included age, Black, and drinking experience among the high school students; and age, gender, Black, Other race (not White or Black), and drinking experience in the middle school students. Among the sexually experienced, males were likely to have more sexual partners than females in the middle school group; while Other race students were likely to have less sexual partners than Whites among the high school group. Finally, no significant predictors of condom use were found in either group; however, Black and Other race students among the middle school students and gender and drinking experience among the high school students approached significance.
DISCUSSION
The findings of the current study revealed that 20.2% of the middle school students had had sexual experience and 34.9% had had alcohol experience. Considering that a review of youth risk behavior literature noted the paucity of research on middle school students, the current study may contribute to knowledge in this area. From the current study, more than one fifth of middle school students had had sexual encounters; moreover 10.8% of them had sexual intercourse with more than one partner, and 7.1% had sexual intercourse for the first time before age 11. Although 71.2% of parents believed that sex education should begin in 7th grade in the 2003 North Carolina Parent Opinion Survey (North Carolina Department of Health and Human Services [NCDHHS], 2004), these findings confirmed the need for early preventive education starting before or during 5th grade, with a focus on safe sexual behavior (Porter, Oakley, Guthrie, & Killion, 1999). In addition, considering that 17.1% had had a drinking experience for the first time before age 11, and initiation of alcohol use was strongly associated with sexual experience, initiation of sex, and number of partners, the scope of early preventive education should address the negative influence of alcohol.
. . . more than one fifth of middle school students had had sexual encounters; moreover 10.8% of them had sexual intercourse with more than one partner, and 7.1% had sexual intercourse for the first time before age 11.
This study found a considerable increase in the prevalence rates of overall sexual behaviors between middle and high school students. Compared with the middle school students, high school students demonstrated significant increases in overall sexual experiences. Moreover, approximately 75% of the 12th graders reported that they had experienced sexual intercourse. These findings confirm the need for comprehensive and accurate information about contraception and/or protected sex for the large proportion of sexually experienced adolescents (Santelli et al., 2006). A sexually active female adolescent has a 90% chance of becoming pregnant within 1 year if she does not use some form of contraception. In addition, estimates indicate that 25% of teens will develop an STD before they graduate from high school (Schmiedl, 2004). Therefore, it is important that sexuality curriculum should consider the needs of sexually active adolescents.
These findings confirm the need for comprehensive and accurate information about contraception and/or protected sex for the large proportion of sexually experienced adolescents.
The current study provided baseline data for the school district and the local community for the development of potential intervention strategies. New Hanover County is one of only seven school districts in North Carolina that has a comprehensive curriculum (abstinence-based) along with an abstinence-only curriculum. However, the findings indicate that the current abstinence-only or abstinence-based policies and programs need to be re-evaluated. As previously reported, the overall prevalence rate of sexual behavior of this county is higher than in the United States in general. Teen pregnancy and STD prevention education in North Carolina teaches that the expected standard for 5th through 12th graders is abstinence until marriage, which follows the General Statute (G.S.) 115C-81 (NC Healthy Schools, 2006); therefore, the discussion topics are very restricted. North Carolina, for example, requires that any discussion of contraception include “accurate statistical information on [contraceptive methods’] effectiveness and failure rates for preventing pregnancy and sexually transmitted diseases, including AIDS, in actual use among adolescent population and shall explain clearly the difference between risk reduction and risk elimination through abstinence” (Gold & Nash, 2006, p. 4). The current Federal guidelines and policies do not reflect the learning needs of sexually experienced adolescents and their parents, do not reflect public opinion, and ignore research recommendations (Santelli et al., 2006). From the 2003 North Carolina Parent Opinion Survey, a majority of parents believed that a significant amount of time should be devoted to sexuality instruction and topics not included in the current sexuality education curriculum (NCDHHS, 2004). The majority of the middle and high school students have received AIDS or HIV education (75.1% and 86.9%, respectively); however, the findings of the study found that the current AIDS or HIV education was not a factor that affected any of the overall sexual behavior variables, including condom use, sexual experience, and number of sexual partners. The findings imply that current AIDS education methods also need to be re-evaluated.
The current Federal guidelines and policies do not reflect the learning needs of sexually experienced adolescents and their parents, do not reflect public opinion, and ignore research recommendations.
There is a debate on whether contraception education, abstinence-only education, or a combination of the two have contributed most to declining teen pregnancy rates (Toffler, Suits, & Wallis, 1999; Yoo, Johnson, Rice, & Manuel, 2004). However, research findings suggest that informing adolescents about contraception does not increase their sexual activity, such as hastening the onset of sexual intercourse, increasing the frequency, or increasing the number of sexual partners (Gold & Nash, 2006; Schmiedl, 2004; Santelli et al., 2006). The findings also suggest that contraception education or comprehensive sexuality education programs increased condom use and/or contraceptive use for sexually active adolescents (Santelli et al., 2006).
Limitations
Limitations of the study include the use of a self-report method and the use of a cross-sectional design. In addition, considering that diverse factors affect sexual behaviors, use of additional tools that are designed to assess the individual, family, and community factors could provide valuable insights to understanding sexual behaviors of adolescents.
IMPLICATIONS FOR SCHOOL NURSING PRACTICE
School nurses could contribute their expertise when implementing a sexuality program by providing consultation regarding school laws, confidentiality, and health consequences of risky sexual behaviors, including alcohol use. The findings imply that sexuality education should address broad areas of influencing factors of adolescent sexual behaviors, which may require interdisciplinary efforts in school systems. For example, the findings showed that drinking experience and patterns were consistently associated with sexual behaviors for both the middle and high school groups, which implies the need for alcohol education in conjunction with sexuality education.
The findings suggest different characteristics regarding sexual behaviors between middle and high school groups, and among different racial groups. For example, while gender seems to affect sexual experience for middle school students, it was not a predictor for high school students. Therefore, group-specific education should be considered, such as targeting male students in middle school. In addition, school health nurses should be proactive in protecting the health of sexually active students. School nurses need to work together with teachers, counselors, and school administrators to evaluate the significance of the problem of sexual behaviors and alcohol use, and implement programs that effectively reduce the prevalence of STDs and pregnancies among the sexually active students.
In addition to providing health care and education for students, as health experts in schools and the local community, school nurses could mobilize diverse personnel to increase family, school, and community awareness of existing health problems among teenagers. The National Association of School Nurses (NASN) position statement recognizes an increasing body of evidence-based research available to guide decision makers (NASN, 2005). Therefore, presenting the local factual data along with relevant research findings to a School Board and PTA meeting may increase family and community awareness. In fact, one of the authors presented the current survey data to local officials and community members and was able to raise awareness of the seriousness of youth risk behaviors. NASN (2005) supports school nurses’ use of their professional preparation and skills to assist school districts in the development and implementation of evidence-based reproductive health education (NASN, 2005). Finally, school nurses could be involved in collaborative actions of other health professional organizations, which support NASN’s position of comprehensive sexual education to address and change the current federal and state policies. The findings of the study implied that the current HIV or AIDS education was not an influencing factor of any sexual behaviors.
Although drinking by persons under the age of 21 is illegal, people aged 12 to 20 years drink almost 20% of all alcohol consumed in the United States.
Reducing alcohol use and risky sexual behavior among youth are two national health objectives in Healthy People 2010 (USDHHS, 2000). Although drinking by persons under the age of 21 is illegal, people aged 12 to 20 years drink almost 20% of all alcohol consumed in the United States (CDC, 2006b), and 34.9% of the middle school students and 86.7% of the high school students in the current study reported that they had had drinking experience. The CDC (2000) stated that alcohol policy could reduce risky sexual behavior and its adverse medical and social consequences. Therefore, school nurses need to become involved in advocating more restrictive state alcohol policies, such as an improved enforcement of the minimum legal drinking age. Reducing underage drinking requires community-based efforts; school nurses could contribute to those efforts by becoming part of a team that monitors the activities of youth, decreases youth access to alcohol, and reduces youth exposure to alcohol advertising (CDC, 2006b).
Therefore, school nurses need to become involved in advocating more restrictive state alcohol policies, such as an improved enforcement of the minimum legal drinking age.
In conclusion, school health nurses could contribute to promote students’ reproductive health status and reduce risk factors by implementing and evaluating appropriate sexuality education programs with the current boundary of state or local regulations. While abstaining from intercourse and alcohol should be encouraged, school nurses cannot ignore the needs of students who are already sexually active. Therefore, school nurses should work as change agents at various levels with parents, teachers, school districts, and communities to promote life skills and healthy choices about alcohol use and sexuality among today’s middle and high school students.