Sexual Risk and Protective Factors

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Sexual Risk and Protective Factors
Factors Affecting Teen Sexual Behavior, Pregnancy, Childbearing
And Sexually Transmitted Disease:
Which Are Important?
Which Can You Change?
By
Douglas Kirby, Ph.D.,
Gina Lepore, B.A.
and
Jennifer Ryan, M.A.
ETR Associates
August 2005
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Introduction
Nearly half of U.S. high school students (9th-12th graders) have had sexual intercourse
and over 60 percent report having had sex by the time they graduate.1 This demonstrates
that many adolescents are confronted at some point during their teen years with choices
about whether or not to have sex and, if they do, whether or not to use condoms and/or
other contraceptives. Many factors affect those choices. Parents, educators, and other
adults working with youth ha ve learned that they cannot directly control the sexual
behavior of teens. While parents might wish to monitor their sons or daughters 24 hours
a day to prevent them from having sex, or at the very least, unprotected sex, they cannot
do this. Instead, parents and others concerned about youth can only try to affect those
factors that, in turn, affect the sexual decision-making of young people. For example,
they might try to affect factors such as the teens’ values about sexual behavior, their
perceptions of family values and peer norms about sex, their attitudes about condoms and
other forms of contraception, their educational and career plans, or their connection to
their parents, their schools, and their faith communities, all of which are likely to affect
whether or not teens have sex and whether or not they use protection against pregnancy
and sexually transmitted disease (STD).
Understanding important factors related to sexual behavior is important not only to
change that behavior; it is important to identify those teens who are most at risk of having
sex and unprotected sex. First people can use these factors to identify those teens at
greater risk; then they can address the important factors affecting their behavior.
This report identifies many of these factors and explains their implications for those
working to help youth avoid risky sexual behaviors and potential consequences.
In this report, the relevant factors are divided into two categories: risk factors and
protective factors. “Risk factors” are those that encourage one or more behaviors that
might lead to pregnancy or sexually transmitted disease (e.g., initiating sex at a young
age or having sex frequently and with many sexual partners) or discourage behaviors that
might prevent pregnancy or sexually transmitted disease (e.g., using contraception, or
condoms in particular). Similarly, “protective factors” are those that do just the opposite
– they discourage one or more behaviors that might lead to pregnancy or STD or
encourage behaviors that might prevent them.
The words “encourage” and “discourage” are used because they imply causality, and
causality is important, because the goal of most interventions is to change behavior. That
is, if a factor is only correlated with a behavior but does not actually affect that behavior,
then changing the factor will not change the behavior. (Note that causality is not
important when using risk and protective factors to simply identify teens at greater risk of
pregnancy and STD.)
All factors included in this report were found to be associated with certain behaviors and
must have been present before that behavior occurred. Consequently, often, but not
always, they causally affect that behavior. In addition, either research or common sense
1 Centers for Disease Control and Prevention. Surveillance Summaries, May 21, 2004. MMWR
2004:53(No.SS-2).
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sometimes tells us that particular factors are, in fact, causally related to certain teen
sexual behaviors. For example, hormonal changes and puberty are factors causally
affecting sexual initiation, because common sense tells us these phenomena increase
young people’s sexual desire, increase their sexual attractiveness to others, and increase
their chances of having sex. Similarly, having less permissive attitudes toward premarital
sex may directly affect decisions about having sex at an early age. However, sometimes
causality (as opposed to mere association) is not well-established by research or assumed
through common sense. For example, smoking cigarettes is associated with having first
sex at a younger age, but it is unlikely to cause early intercourse. Instead, youth who
engage in a variety of risk-taking behaviors may be more likely to smoke cigarettes and
to have first sex earlier.
Unfortunately, it is difficult for research to demonstrate causality. Thus, for some of the
factors discussed in this report, it is not certain whether the factor causally affects a
behavior or is simply correlated with it. Where causality is especially uncertain, it will be
noted.
If parents and other adults concerned with youth cannot directly change behavior and can
only address risk and protective factors, an important question arises: Which risk and
protective factors should they target in order to affect sexual behaviors and reduce teen
pregnancy and/or STD rates?
In terms of preventing pregnancy or sexually transmitted disease, neither risk factors nor
protective factors are inherently more important to address than the other. Instead, if
people wish to reduce teen pregnancy or sexually transmitted disease, then they should
address those risk and protective factors that meet two criteria:
1. They have a significant causal impact on one or more sexual behaviors affecting
the incidence of teen pregnancy or STDs.
2. The factors, in turn, can be markedly changed by parents or other people or
organizations concerned with this issue.
Logically, if a risk or protective factor satisfies only one of these two criteria, it is not
worth targeting. For example, if a factor can be changed but does not affect sexual
behavior, then changing that factor will not reduce pregnancy or STD rates. Similarly, if
a factor does affect sexual behavior but cannot be changed markedly, then it is not useful
to pursue either. Thus, both criteria for selecting a factor must be met, before people
should target that factor to prevent pregnancy or STD.
This conclusion raises two very important questions:
1. Which factors have the greatest causal impact on adolescent sexual behaviors?
2. Which factors can be changed the most?
This report attempts to answer both questions, especially the first.
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Methodology
For many years, researchers have attempted to determine which behaviors affect teen
pregnancy and STD transmission and to identify the risk and protective factors related to
both. Not surprisingly, pregnancy is primarily affected by the initiation of sex, the
frequency of sex, and the use of contraception (See Figure 1). Similarly, the transmission
of sexually transmitted disease is primarily affected by the initiation of sex, the frequency
of sex, the number of sexual partners, and the use of condoms.2 Because of the
importance of risk and protective factors, researchers have published hundreds of studies
evaluating the impact of risk and protective factors on these five behaviors and on teen
pregnancy, childbearing and STD transmission.
This report summarizes the results of those studies that meet the following criteria.
Studies included here had to:
· Be conducted in the United States
· Examine the impact of factors on the following behaviors: initiation of sex,
frequency of sex, number of partners, condom or other contraceptive use,
pregnancy, childbearing, or sexually transmitted disease
· Be based on a sample of teenagers, roughly 18 years of age or younger
· Have a sample size of at least 100 for significant results and a sample of at least
200 for non-significant results
· Meet scientific criteria required for publication in professional peer reviewed
research journals or other publications
· Be published between 1990 and 2004 inclusive
· Include multivariate analyses
In fact, the vast majority of these studies had much larger sample sizes; many also
conducted multivariate statistical analyses statistically controlling for numerous other
relevant factors. These analyses helped identify those factors that were the most
important.
To identify studies meeting these criteria, ETR Associates and the University of
Minnesota exhaustively reviewed computerized databases of references3, searched all
issues of many important journals, reviewed the references in previous reviews of risk
and protective factors, and searched their own files. Ultimately, they identified more than
400 studies of risk and protective factors meeting the above criteria.4 All of them were
2The transmission of sexually transmitted diseases is, of course, also determined by whether a sexual
partner has an STD, which is affected by testing and treatment. However, because this review focuses on
prevention, testing and treatment of STDs are beyond its scope.
3 These databases included Medline, Sociological Abstracts, Psychological Abstracts, Popline, Bireme,
PsychInfo, Dissertation Abstracts, ERIC, CHID, Biologic Abstracts, PERRY (CDC) and the Alan
Guttmacher Institute database.
4 A substantial number of these studies were secondary analyses of well-known samples, such as the
National Longitudinal Study of Adolescent Health, the Youth Risk Behavior Surveys, the National Survey
of Family Growth or the National Longitudinal Survey of Youth. These studies benefit from being based
on large, nationally representative samples. However, this also means that results from different studies of
the same samples are not completely independent. For example, diffe rent secondary analyses of the
National Longitudinal Study of Adolescent Health may be based on the same sample or on overlapping
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reviewed for this study and are listed as references in Matrix in the appendix of this
report. (The University of Minnesota also reviewed studies conducted in developing
countries.5)
Which Factors Affect Teen Sexual Behavior?
This review provides an overview of the factors affecting adolescent sexual and
contraceptive behavior and the potential outcomes, such as pregnancy, childbearing and
sexually transmitted disease. It is not designed to be a thorough analysis of any particular
factor.
The matrix of risk and protective factors in the found at the end of this document
identifies all the potential factors tha t were analyzed in the studies6. Thus, it includes
those that one or more studies have found to be related to sexual behavior, as well as
those that proved unrelated to sexual behavior.
That matrix reveals that there are more than 400 different factors that affect one or more
of the five important teen sexual behaviors (initiation of sex, frequency of sex, use of
condoms, use of other contraception, and number of partners), and/or outcomes
(pregnancy, childbearing or STDs).
It is important to keep in mind that some of the factors included in the matrix might have
been significant for only particular groups of youth, might have been significant only at
particular points in time, might have been significant only when the factor was measured
in a particular way, and/or might have been significant only when other factors were (or
were not) controlled in a study. It is also possible that some of the factors were found to
be significant only because of chance. On the other hand, many of the factors included in
the matrix were significant in multiple studies, with many groups of adolescents and at
different times.
It should also be emphasized that, although these factors increase or decrease the chances
of individuals engaging in sexual risk-taking, nearly all youth experience pressures of
some kind to have sexual intercourse and are at risk for pregnancy and STD. It is not the
case that only one group of teens, only one ethnic group, only low- income youth, only
youth in a particular neighborhood, or only yo uth in “other” schools engage in sex and
become pregnant or contract an STD. Sexual activity, pregnancy and sexually
transmitted disease cut across all of these perceived boundaries. Nevertheless, as the
sub-samples and, thus, do not provide independent confirmation of particular findings. Some of the studies
were based on much smaller, less representative samples, but they sometimes examined the impact of a
wider range of risk and protective factors.
5 Blum, R. and Mmari, K.(2005). Risk and Protective Factors Affecting Adolescent Reproductive Health in
Developing Countries. Division of General Pediatrics and Adolescent Health, Center for Adolescent
Health. University of Minnesota: Minneapolis, MN
6 Because Matrix provides references for each entry in the table, references are not provided for all the
statements in the report’s text that are based on Matrix.
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number of risk factors in a teen's life increases and as the number of protective factors
decreases, that teen's chances of having sex and becoming pregnant (or causing a
pregnancy) or contracting an STD increase.
Some of the 400 plus factors are characteristics of the teens themselves; others are
characteristics of their families, romantic partners, peers, schools, faith communities,
their communities more generally, and even their states. Still others describe the teens’
relationships with these individuals, groups, or institutions in their environment. Some
factors involve sexuality directly (e.g., values about sexual behavior); while others do not
(e.g., connection to parents). Some are risk factors (e.g., community disorganization or
permissive attitudes towards sex); others are protective factors (e.g., doing well in
school). Together, they paint a detailed picture of the factors that affect sexual behavior
among teens and its potential consequences.
Because so many factors affect teen sexual behavior, focusing on only one factor is
unlikely to have much impact on teens’ sexual behavior unless that factor is an extremely
important one. Targeting several important factors is a more promising approach.
To that end, the large number of factors in the matrix can be better understood when: 1)
the most important factors are identified, 2) the dominant themes among the factors are
recognized, and 3) their causal structure is better understood. Understanding the causal
structure will also help program designers who create logic models to design their
programs. These three topics are discussed in order below.
Most Important Factors Affecting Sexual Risk Behavior
Table 1 includes factors from the larger matrix that have the strongest and most
consistent evidence of significantly affecting teen sexual behavior. To be included in
Table 1:
1. The overall pattern of results across studies indicating that a particular factor is a
significant risk or protective factor for any particular behavior could not have
occurred by chance.
2. Of the studies measuring impact of a factor on any behavior, at least two-thirds of
the studies had to consistently show that a particular factor was a risk factor (or a
protective factor) as opposed to being not significant or having significant results
in the opposite direction. This “2 to 1” rule excluded many factors, but increased
the chances that a factor would be important in each community.
3. There had to be at least 3 multivariate studies consistently supporting the
conclusion that a particular factor was a risk (or protective) factor for the same
behavior. At least one of these studies had to have a large sample size.
4. There had to be a reasonable chance that the factor had a causal impact on
behavior that was not questioned by the results of multiple studies.
Although these criteria are relatively objective, the authors’ judgment occasionally had to
be used for a small number of factors. Furthermore, as additional research is completed,
factors may need to be added to or deleted from Table 1 in the future.
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Consistent with Matrix, Table 1 includes factors related to the teens themselves, their
states, communities, families, peers, partners, and, of course, themselves. These factors
support a wide variety of theories about risky adolescent sexual behavior — theories
involving social disorganization in their communities, theories involving parenting
practices and parent values about adolescent sexuality, biological theories, theories
suggesting that sexual risk taking is part of a larger syndrome of risk-taking or deviant
behavior, and social psychological theories of rational behavior. Overall, the factors
summarized in these tables clearly demonstrate that no single theoretical perspective is
sufficient; the total picture is much more complex.
Environmental Factors
Community characteristics. The communities that teens live in influence their sexual
behavior. In particular, if communities are disorganized – if they have higher rates of
substance use, violence and hunger – then teens in those communities are more likely to
engage in sex earlier and to have higher rates of childbearing.
In addition, if teens live in communities with higher rates of foreign-born residents, then
they are more likely to delay initiation of sex. According to at least one study, this may
reflect the less permissive sexual values of the foreign-born parents.
Although this section of this review is focusing on the factors that were consistently
found to be related to sexual behavior, it is worth noting here a factor that was not
consistently related to behavior and possible explanations for this lack of consistency.
Even though average household income in a community (or its inverse – poverty) is
commonly believed to be related to teen sexual behavior and its outcomes, the results in
Matrix do not fully support this view. Thirteen studies produced 30 results in the matrix
that measured the impact of average income (or socio-economic status) on sexual
behavior or its consequences. Only 6 of the 30 found it to be a protective factor, 15 of
them found it to be insignificantly related to behavior, and 5 found it to be a risk factor.
Why? First, an analysis of a few of the studies indicated that average household income
or other measures of poverty may have been markers for a larger constellation of factors,
e.g., educational level, unemployment, employment opportunities, and when many of
these factors were included, the explained variance was divided among them and the
impact of each was reduced. Second, when only community factors were included in the
multivariate analyses, average income level/poverty was more often a risk factor, but
when family or individual characteristics were included, the community factors
sometimes ceased being significant. That is, the family or individual factors appeared to
be more important than the community factors. And finally, average income
level/poverty may have been a more important factor for females than for males. For
example, of five studies that measured impact of average community income on actual
birth rates, four found it to be a protective factor for childbearing, but of two studies
measuring impact of average income on males reporting whether or not they were fathers,
both found no impact. This gender difference may reflect actual difference in the impact
of community income/poverty on parenting or it may reflect different methods of
measuring birth rates (actual community birth rates versus self reports by males).
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Family characteristics. The characteristics of teens’ families also are very important in
determining risk. When teens live with both parents and enjoy close relationships with
them, they are less likely to have unprotected sex and become pregnant. More
specifically, when teens live with both biological parents (instead of only one parent or
step-parents), they are less likely to have sex, have sex less frequently, and have fewer
sexual partners. A majority of studies (but not two-thirds) also demonstrate that they are
less likely to become pregnant (or cause a pregnancy) or give birth (father a child).
Finally, if parents divorce or separate, their teens are more likely to initiate sex at an early
age than if their parents do not divorce or separate.
When teens have parents with higher levels of education, they are less likely to become
pregnant than are teens with parents who have lower levels of education. A majority (but
not two-thirds) of the studies also found that they were less likely to initiate sex at an
early age. When teens have parents with higher income, a majority of the studies found
that the teens were less likely to become pregnant or to bear children. These findings
involving parents’ education and income may be due to the increased emphasis that some
parents place upon obtaining an education, pursuing a career, and avoiding early
childbearing; and/or in part to the greater resources they have to support their teens in
these pursuits.
If teens experience considerable parental support and feel connected to their parents, they
are less likely to initiate sex at an early age and have sex less frequently. If parents
monitor and supervise their teens appropriately, then those teens have fewer sexual
partners than if their parents do not monitor them (or, according to at least one study,
monitor them too excessively). At the extreme, if teens have been maltreated and
physically abused by their families, then they are much more likely to have sex at an
early age and to become pregnant.
If family members abuse alcohol or illegal drugs, then teens have sex more frequently
and with more partners. Family substance abuse may encourage youth to drink and use
drugs themselves (which may lead to more frequent sex with more partners), or family
substance abuse may simply be a marker for more general family dysfunction that may
lead to teen sexual activity.
If family members, especially parents, express values or model behavior consistent with
sexual risk taking or early childbearing, teens are more likely to have unprotected sex and
become pregnant (or get their partners pregnant). Parents may do this in a variety of
ways, including conveying permissive attitudes about premarital sex or teen sex, voicing
negative attitudes about contraception, or by having been teen parents themselves.
Similarly, if teens’ older siblings model early sex or childbearing, then the teens are more
likely to have sex at an earlier age. In contrast, if parents disapprove of teens having sex,
then teens are less likely to have sex, and if parents support contraceptive use, then teens
are more likely to use contraception if they do have sex.
If parents communicate their beliefs and values about sex, condoms and other forms of
contraception, then under some circumstances this communication may lead to less
sexual risk-taking. When parents have conversations with their children about sex and
contraception well before their teens become sexually active, the conversations may
delay the initiation of sex or increase the use of condoms or other contraceptives. This
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effect is most likely to occur when the teen is a daughter (as opposed to a son), when the
parent is the mother (as opposed to the father), when the teens and their parents feel
connected to one another, when the parents disapprove of teens having sex or support
contraceptive use, and when parents can discuss sexuality in an open and comfortable
manner.
Peer characteristics. As is commonly recognized, youth are influenced by their peers
and peers influence teens’ sexual behavior. If peers are older, receive poor grades, use
alcohol or drugs, or engage in other negative behavior, then the teens are more likely to
have sex. When teens believe that their peers have more pro-childbearing attitudes, have
permissive values about sex, or are actually having sex, then they are much more likely to
have sex too. If teens believe their peers support condom or other contraceptive use or
actually use condoms, they are more likely to use condoms or other contraceptives
themselves.
Characteristics of romantic partners. While simply having a romantic partner increases
the chances of sexual activity, having an older romantic partner increases them even
further. Having an older romantic partner also decreases the chances that contraception
will be used and increases the chances of pregnancy and contracting a sexually
transmitted disease. If teens’ partners support condom or contraceptive use, then the
teens are more likely to use them if they have sex.
Individual Factors
Biological factors – age, physical development and gender. When considering teens
themselves, studies have found that biological factors dramatically affect their sexual
behavior. As one might expect, as youth become older, they become much more likely to
have sex. If they physically mature early, begin menarche early, and appear older than
their age, the y are also more likely to initiate sex at an earlier age.
Some of the effects of factors related to age are strictly biological, including physical
maturity and higher testosterone levels, which may lead to a greater desire for intimacy
and sex and/or to greater sexual attractiveness. Other factors are social, such as,
increased pressure from peers to have sex; changes in perceived norms about sexual and
contraceptive behavior; and increased opportunities to have sex that come with greater
freedom and independence as one ages.
In addition, as youth get older, they become more likely to have sex more often and with
more partners. They also become more likely to use contraception. When teens first
have sex, they are more likely to use condoms (in part because they have sex
sporadically), and as they become older, they are more likely to use longer- lasting forms
of contraception (e.g., oral contraceptives or Depo Provera). As teens grow older, they
are also more likely to become pregnant (or to impregnate someone) and to parent a
child. (Because more teens have sex as they grow older, they become more likely to
become pregnant, even though they are also more likely to use contraception.)
According to half the studies, the risk of contracting an STD also increases as teens grow
older. Although younger teens are physically more susceptible to contracting some STDs,
as youth grow older, their number of sexual partners increases and they become more
likely to contract an STD.
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Another very important biological factor is sex/gender. Overall, males initiate sex earlier
than females, report more sexual partners, and greater use of condoms. However,
females are more likely to contract sexually transmitted disease.
Both age and gender interact with other factors. For example, although having an older
romantic partner increases the chances of having sexual intercourse, this factor is more
potent for younger teens (e.g., in middle school) than for older teens (e.g., in high
school). This factor is also more important for females than for males.
A practical implication of these individual biological factors is that there are some
important factors that simply cannot be changed. However, agencies working with youth
can still use these factors to identify youth who may be at greater risk of sexual risktaking.
Furthermore, agencies can change some factors associated with the biological
factors, e.g., perceptions of gender roles or expectations of sexual activity for different
age groups.
Race/ethnicity. Compared to non-Hispanic whites, African Americans are more likely to
have sex at an earlier age, to have more sexual partners, to become pregnant, to give birth
and to contract an STD. However, research findings are mixed regarding condom use,
with a few studies indicating that African American teens are more likely to use condoms
than whites.
Compared to non-Hispanic whites, Hispanic teens are less likely to use contraception and
are more likely to become pregnant. However, most studies indicate they are not more
likely to have sex at an early age.
It is important to note that when controlling for family or community education,
employment or income, some of the relationships between race/ethnicity and teen
pregnancy diminish. That is, it is not simply minorit y status per se that affects teen
sexual behavior, pregnancy and STD risk, but rather the poverty and lack of opportunity
that is often associated with being a member of those minority groups. However, the
relationship between minority status and sexual behavior or teen pregnancy does not
entirely disappear when controlling for socio-economic status. Cultural values (e.g.,
greater emphasis on the family, greater acceptance of early childbearing, expectations of
submissiveness to males) and other factors also contribute.
Connection to family. Connection to family is both an individual characteristic and a
family characteristic. It is discussed above under family characteristics.
Connection to school and success in school. When teens stay in school, feel connected
to their schools, earn good grades, do not fall behind in school, have plans for higher
education beyond high school, and/or avoid problems in school, they initiate sex later and
are less likely to become pregnant (or get their partners pregnant ). If they earn good
grades, they are also less likely to parent a child.
While several studies have found that involvement in school organizations is related to
lower levels of sexual risk-taking, a methodologically strong study of the impact of
involvement on teen non-marital childbearing found that mere membership in school
organizations was not related to early childbearing. However, a substantial level of
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involvement in school organizations was related, particularly in school-based religious
organizations among whites and school clubs among African Americans.
Connection to faith communities. Teens who describe themselves as more religious,
who attend religious services more frequently, and who have a stronger religious
affiliation are less likely to initiate sex. They also have sex less frequently if they do
have sex. These associations are particularly strong if the teens are involved with faith
communities with conservative values about sexual behavior.
However, in all of these cases, the direction of causality is not entirely clear. Just as
attachment to faith communities may affect sexual behavior, sexual behavior may also
affect attachment to faith communities. For example, teens who have had sex may feel
less comfortable in places of worship and may be less likely to attend services.
Connection to other community organizations or adults. A few studies suggest that
when teens are more involved in their communities and have mentors, they are less likely
to engage in sexual behavior.
Involvement in gangs. Several studies suggest that teens who belong to gangs are more
likely to have sex, to have more sexual partners, and to become pregnant. It is not clear
whether gang membership per se produces this risk or simply the fact that teens in gangs
have other risk factors.
Alcohol and drug use. Numerous studies have found relationships between teens’ use of
alcohol and illegal drugs and increased likelihood of having sex, having sex more often,
having sex with more partners, and pregnancy. Studies have also found that those teen
who use drugs are less likely to use condoms and more likely to contract an STD. It is
plausible that drinking alcohol and using drugs may lower inhibitions, reduce ability to
assess risks, or increase sexual aggression. However, it is also possible that part or all of
the measured relationship between alcohol and drugs and sexual activity and condom use
is caused by other common factors, such as poor performance in school, general risktaking
or sensation-seeking propensities, lack of parental monitoring, etc. One study
attempted to control for some of these factors and found that, when other variables were
controlled, use of alcohol and other drugs was not related to sexual activity for either
gender, nor was it related to use of female methods of contraception. However, drinking
alcohol was negatively related to male use of condoms. Another study found that, while
both alcohol and drug use in the past was related to condom use, alcohol/drug use during
last sex was not related to use of condoms at that time. This suggests that a more general
mechanism of taking risks may explain the relationship, rather than disinhibition caused
by substance use at the time of sex. Still other studies either have found no relations hip
between substance use and sexual risk-taking or failed to find significant relationships
when other factors were statistically controlled. Although alcohol and other drug use are
included in Table 1, this caveat about questionable causality should be kept in mind.
Aggression. Physical fighting and carrying weapons are also related to having sex, more
sexual partners and pregnancy. Causality is unclear.
Involvement in problem or sensation-seeking behavior. Engaging in other problem or
sensation-seeking behavior is also related to early initiation of sex, frequency of sex,
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pregnancy and childbearing. Again, these behaviors may expose teens to norms favoring
sexual risk-taking or more opportunities or desires to have sex. Alternatively, the
relations hip between problem behavior and sexual risk-taking specifically may simply
reflect family or community characteristics such as poverty, single parent homes, lack of
supervision or general risk-taking propensities. Again, causality is not entirely clear.
Paid work. Several studies have indicated that teens with paying jobs, especially those
who work more than 20 hours per week, are more likely to have sex. This may be
because it increases both the teens’ sense of independence, mobility, and opportunities to
have sex.
Involvement in sports. A few studies have found that, for teen girls, but not teen boys,
participation in sports is related to delayed initiation of sex, less frequent sex, greater use
of contraception, and lower pregnancy rates. These studies suggest that young women’s
participation in sports motivates them to want to avoid pregnancy, which, in turn, delays
initiation of sex. However, among young women, the relationship between participation
in sports and pregnancy is less clear. It may be caused by the fact that female athletes are
more likely than non-athletes to be young, better educated and non-Hispanic white,
characteristics that reduce their risk of becoming pregnant.
Cognitive and personality traits. Teens with a higher level of cognitive development are
less likely to have sex and more likely to use contraception if they do have sex. Teens
with a greater internal locus of control have sex less frequently, use condoms more
frequently, and are less likely to become pregnant. Plausibly, both factors are causal.
Although high self-esteem and positive self-concept are commonly believed to be
protective factors for sexual risk-taking, the results are actually quite mixed. A few
studies, including some with large nationally representative samples, have found that
self-esteem and positive self-concept are protective factors for initiation of sex, use of
contraception and pregnancy, the rather large majority of studies that self-esteem and
self-concept were not significantly related to sexual behavior. A few studies have found
self-esteem to be protective only for girls or only for middle school (as opposed to high
school) students. Finally, at least one study even found that having sex can increase selfesteem.
Thus, the relationships between these factors and sexual behavior are unclear
and may be quite complex.
Conversely, suffering from emotional distress (including stress, depression, thoughts of
suicide or fear of untimely death) increases teens' chances of having sex. Such distress
may affect teens’ motivation to avoid pregnancy or STDs, diminish their ability to assess
risks, or lead them to want to escape through sexual involvement. Alternatively, these
factors may also reflect more negative environments that actually cause sexual risktaking.
Sexual beliefs, attitudes and skills. Of all the risk and protective factors, teens' own
sexual beliefs, values, attitudes, and skills are the factors most strongly related to sexual
behavior. Teens are more likely to have sex if they have permissive attitudes toward
premarital sex, perceive personal and social benefits and few costs to having sex, would
feel guilt if they had sex, took a virginity pledge and have greater self-efficacy to refrain
from sex. Sexually active teens are more likely to use condoms and other forms of
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contraception if they perceive that males share responsibility for pregnancy prevention,
believe that condoms do not reduce sexual pleasure, believe their partner will appreciate
their condom use, have positive attitudes towards condoms and other forms of
contraception, perceive more benefits and fewer costs and barriers to using condoms,
have greater confidence in their ability to demand and use condoms or other forms of
contraception, have greater motivation to use condoms or forms of contraception and to
thereby avoid pregnancy and HIV/STD, intend to use condoms, and actually carry
condoms.
All of these sexual beliefs, attitudes, skills and motivations can be considered "proximal"
factors that affect sexual behavior. This is because they are conceptually and logically
closely linked to their related behaviors. For example, values regarding sex are
conceptually more closely related to actually having sex than is the proportion of the
community that is foreign born. The latter is considered more “distal.”
While both common sense and research indicate that these factors have an impact on
sexual behavior, it is also true that having sex and using or not using condoms and other
contraceptives may very well affect these factors. For example, having sex and using
condoms may affect attitudes about having sex, perceptions of peer norms about sex, and
perceived ability to use condoms. Thus, causality may operate in both directions.
These proximal sexual factors are partic ularly important for several reasons. First, they
are well supported by social psychological theory. Second, they are conceptually more
closely related to their sexual and contraceptive behaviors than are other factors. Third,
as noted above, they are more highly related statistically to some of the sexual and
contraceptive behaviors than are most of the other factors. Finally, some of these factors
have formed the theoretical basis for many of the sex and HIV education programs that
have reduced sexual risk taking.
Relationships with romantic partners and previous sexual behavior. Not surprisingly,
when teens begin dating frequently, go steady, and kiss and neck, they are more likely to
have sex. These early romantic relationships may provide greater desire, opportunity,
and pressure to have sex. Furthermore, sex within a romantic relationship may be more
consistent with teens' values and perceived norms than sex in casual relationships.
When the romantic partner of a teen is three or more years older, then the teen is
especially likely to have sex. The impact of this age gap is quite large, especially among
middle school girls.
Youth who begin having sex at an earlier age may naturally accumulate a greater number
of lifetime sexual partners by any given later age. This, in itself, contributes to a higher
STD rate. In addition, youth who initiate sex at an earlier age are less likely to use
condoms or other contraceptives and thus are more likely to become pregnant and to
become a parent. In part, because they have more sexual partners and are less likely to
use a condom, about half the studies indicate that they are more likely to contract an
STD. In addition, young females are not fully physically mature and are more
susceptible to STDs.
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The relationship between number of sexual partners and sexually transmitted disease is
especially well established. Many studies have demonstrated that having a large number
of sexual partners greatly increases the chances of contracting an STD.
Regarding condom and contraceptive use, several studies have shown that teens often
used condoms initially in sexual relationships, but as their relationships continue and they
have sex more frequently, they use longer term hormonal contraceptives such as oral
contraceptives or Depo Provera instead.
Studies consistently show that when teens discuss HIV and other STDs and methods for
preventing transmission, they are more likely to use condoms. Similarly, when they
discuss methods of preventing pregnancy, they are more likely to use contraception.
Not surprisingly, youth who use condoms or other contraceptives the first time they have
sex are more likely to use them on subsequent occasions. However, this may reflect
other common factors and may not be causal.
Being married reduces the number of sexual partners (as one would expect), and also
increases the chances of pregnancy. Because pregnancy can also lead to marriage, the
direction of causality is not entirely clear.
Being pregnant previously (or previously getting someone pregnant) increases the risk
that condoms will not be used during sex and also increases the risk of an additional
pregnancy. Similarly, having previously contracted an STD increases the risk of
contracting an STD again. However, causality is unclear because a history of pregnancy
or STD reflects all the risk and protective factors discussed above that in turn continue to
increase the risk of pregnancy and STD.
Prior sexual abuse is an especially important risk factor for early initiation of sex, greater
number of sexual partners, poor condom use, poor contraceptive use, pregnancy, and
sexually transmitted disease. Youth who have been sexually abused have been exposed
to a variety of risk factors. In addition, their past sexual abuse may dis tort their
understanding of appropriate sexual and contraceptive behavior and may reduce their
ability to reject sex or to use contraception.
Finally, prior experience with same-gender sexual behavior is also a risk factor for
heterosexual risk-taking. Youth who engage in same-sex sexual behavior are more likely
to have heterosexual sex and to have more sexual partners. A few studies also indicate
they are more likely to become pregnant (or get their partners pregnant) or to contract an
STD, while other studies do not.
Generalizability across Different Sub-Groups of Youth
When people are developing programs for teens in their own communities, they are faced
with the question of whether or not the risk and protective factors in Table 1 will apply to
the particular group of youth they are targeting. (Of course, the best and only rigorous
method of assessing the impact of the important factors is to design and conduct research
on those particular youth. Typically, however, limited time and resources preve nt that
from being done.)
15
Fortunately, as noted above, virtually all the factors in Table 1 were found to be
significant in at least two-thirds of the studies that measured its impact. Given that these
studies often sampled varied groups of youth, this increases the chances that these factors
will be significant in any particular community. In addition, these studies demonstrated
that most of these factors do have an impact among different sub-groups, especially
across the three largest ethnic groups and often among both males and females.
On the other hand, this is not always the case. For example, the following factors appear
to be effective for only some sub-groups.
· Participating in sports appears to be a protective factor only for girls.
· Having an older romantic partner is a stronger risk factor for girls than for boys.
· Communicating with parents about sex is a greater protective factor for girls than
for boys.
This short list does not mean that all other factors affect both males and females and
different racial/ethnic groups equally. It simply means that multiple studies show
differential effects of these three factors.
Dominant Themes
The preceding summary of important risk and protective factors and those specified in
Table 1 still involve a large number of factors and may appear overwhelming. To
simplify things, a majority of the most important factors identified in Table 1 (and other
factors in Matrix) can be grouped by four broad themes: 1) individual biological factors;
2) disadvantage, disorganization and dysfunction in multiple domains; 3) sexual values,
attitudes, and modeled behavior in multiple domains; and 4) connection to adults and
organizations that discourage sex, unprotected sex or early childbearing.
These themes became evident during reviews of the studies and the factors in Matrix;
they are not based on any factor analysis or other statistical technique. Thus, other
researchers may review those factors and identify additional themes.
Individual Biological Factors
First, as discussed previously, biological factors such as age, physical maturity, and
gender dramatically affect teen sexual behavior. In fact, they significantly affect nearly
all the behaviors noted in this report.
Disadvantage, Disorganization and Dysfunction
Second, many risk factors involve some form of disadvantage, disorganization, or
dysfunction among the teens’ communities, families or friends or within themselves. At
the community level, disorganization can be manifested in higher rates of hunger (and
poverty it represents), violence and substance use. Among the teens’ families
disadvantage, disorganization and dysfunction is evident in low levels of education and
income, single-parent homes, divorce, lack of family support, and substance use, for
16
example. Among the teens’ peers, dysfunction is revealed in their poor grades, alcohol
and substance use, and participation in deviant activities. Finally, among the teens
themselves, disadvantage and dysfunction are reflected in prior physical or sexual abuse;
gang membership; physical fights; tobacco, alcohol and drug use; lower levels of
cognitive development; few plans for the future; and suicidal thoughts.
Conversely, a substantial proportion of the protective factors include the reverse of these
risk factors, e.g., more functional communities; well educated two-parent families with
higher incomes; parents who provide monitoring and encouragement; teens who are
emotionally healthy, doing well in school, and have plans for the future; and teens with
friends performing well in school and avoiding a wide range of risky behaviors.
Many of the forms of disadvantage, disorganization and dysfunction are interrelated, and
some are simply more extreme forms of others (e.g., homelessness can be an extreme
form of poverty). One implication of these interrelated factors is that changing just one of
them is not likely to have a large impact. Rather more intensive and comprehensive
programs that address several of them may be necessary to significantly change behavior.
Sexual Values, Attitudes and Norms, and Modeling of Sexual Behavior
Third, many factors involve the teens’ own values and attitudes about sexual behavior,
pregnancy, childbearing and sexually transmitted disease, as well as the sexual values and
behaviors of their families, peers, and communities. For example, teens’ own values,
attitudes and concerns about sex, condoms, contraception, pregnancy, childbearing and
STD affect their sexual behaviors. Their values and behavior, in turn, are affected by the
values and norms either expressed verbally or modeled by the behavior of others. For
example, parents’ values about premarital sex and contraception affect teens’ behavior, as
do their mothers’ and siblings’ modeling of sex outside of marriage and early
childbearing. The sexual attitudes and behaviors of peers and romantic partners also
affect teens’ behavior, as do the values expressed by their faith communities.
Connection to Adults and Organizations That Discourage Sex, Unprotected Sex, or
Early Childbearing
Fourth, attachment to people or institutions that discourage sex, unprotected sex and early
childbearing and that encourage responsibility, either sexual responsibility or
responsibility more generally also reduce sexual risk taking. Multiple studies show that
when youth are more strongly attached to their parents, their schools, or their faith
communities, or when they are more involved in their communities, they are less likely to
have sex and unprotected sex.
Connection with parents appears to be a stronger factor than connection with other
groups. For example, as noted previously, when youth feel they have high quality
interactions with their families, when they feel the support of their families, and when
they feel connected to their families, they are less likely to have sex and to become
pregnant. Conversely, at the other extreme, when youth are homeless or physically
abused, they are more likely to become pregnant or contract an STD.
17
However, it is not attachment to parents alone that is important. Studies also demonstrate
that connection to other groups or organizations that discourage sex, unprotected sex, and
early childbearing or that emphasize responsibility is also important. As cited previously,
they can include schools, places of worship, and community organizations. For example,
enrollment in school, a more positive attitude about school, better school performance,
greater participation in school activities, and greater overall connection to school are all
associated with less sexual risk-taking or reduced childbearing. When girls (but not
boys), are involved in sports they are less likely to initiate sex. Similarly, having a
religious affiliation, attending services more frequently, and having greater religiosity are
all protective factors. Finally, a few studies indicate that having a mentor, participating
more in community activities, and being involved in more community organizations also
protect against sexual risk-taking.
When youth are attached to such entities, they may spend less time unsupervised and,
consequently, have less opportunity to take sexual risks.
However, even more important than the supervision provided by these groups may be the
norms about sexual behavior and childbearing that these groups express. Indeed, it is not
attachment, per se, that is protective, but rather attachment to individuals or groups that
express responsible values. For example, connectedness to peers and being very popular
with peers (who often have more permissive attitudes about sex than parents, schools, or
faith communities) and having close friends who are high risk are both associated with
earlier initiation of sex, not later initiation of sex. Similarly, when teens are connected to
their parents, if their parents have more permissive values about teens having sex, then
teens are more likely to initiate sex early than if their parents have less permissive values.
In sum, it is not attachment itself that appears to be important, but rather attachment to
parents and organizations with responsible values about sexual behavior and
childbearing.
It is interesting to note that these four dominant themes, which are based on U.S. studies,
are remarkably consistent with the dominant themes noted in a major study comparing
teen sexual behavior and pregnancy rates in the United States with those in Canada,
England and Wales, France, and Sweden, all of which have much lower teen pregnancy
rates7. That study found that among the important factors that may have contributed to
higher U.S. teen pregnancy rates were socioeconomic disadvantage; values, attitudes and
norms about teen sexual behavior; and support and programs for families and youth
(which may have increased the connection between youth and their families and
communities). That study also identified sexual and reproductive health services as
another important theme. Although that theme did not surface in this review, it may be
because there has been relatively little recent research on it in the United States.
However, state funding for family planning services has been shown to be related to
lower teen childbearing rates in two different studies published after 1990 (and two more
published before 1990 and not included in this review).
The implications of the four dominant themes identified in this report are that pregnancy
and STD prevention initiatives need to address 1) socioeconomic disadvantage and
7 The Alan Guttmacher Institute. (2001) Teenage Sexual and Reproductive Behavior in Developed
Countries: Can More Progress Be Made? New York, NY: The Alan Guttmacher Institute.
18
dysfunction, 2) values and norms about sexual behavior, childbearing and sexually
transmitted disease, and perceptions of those norms by youth, and/or 3) attachment to
parents, groups or institutions that emphasize responsible sexual behavior. For all
practical purposes biological factors cannot be changed and, therefore, cannot be
addressed in the same manner as the other factors.
Causal Structure
The discussion above, in combination with Matrix, 1) identified a large number of risk
and protective factors from the research literature, 2) identified those factors that have the
strongest evidence for a significant causal impact on one or more sexual behaviors among
teens (Table 1), and 3) discussed the four important themes that summarize those factors.
This section now describes a possible causal structure involving these factors.
Many people who have developed programs that effectively changed teen sexual
behavior either explicitly or implicitly developed logic models to do so. These models
typically identified 1) the health-related goals to be achieved, 2) the behaviors that
needed to be changed, 3) the risk and protective factors that affect those behaviors, and 4)
the interventions designed to change those risk and protective factors. Increasingly,
people are using logic models to design effective teen pregnancy prevention and/or STD
prevention programs or to pursue other health goals.8
Understanding the causal structure of all these factors can help program designers when
they develop their own logic models. Understanding the causal structure can also be
helpful in its own right.
Before discussing a possible causal structure among these factors, it must be recognized
that the real world is complex and not simple, that many factors affect each other as well
as affecting behavior and that factors affect behavior but in turn that behavior may
subsequently affect the original factor, etc. Thus, the following discussion must
necessarily simplify reality.
Figure 1 depicts some of the causal relationships among key risk and protective factors
and pregnancy and contraction of STDs. The arrangement of factors in this figure is
consistent with many contemporary theories (e.g., cognitive behavior theory, theory of
reasoned action and PRECEDE/PROCEED). However, just as contemporary theorists do
not entirely agree amongst themselves about the causal structure of different factors, so
people knowledgeable about these risk and protective factors will not agree with every
part of this depiction. Nevertheless, this figure can help portray possible relationships
among these factors.
Consistent with the approach used by most causal diagrams, the factors on the left tend to
affect the factors on the right, more than vice versa. However, there may be some
8 At www.etr.org/recapp: “BDI LOGIC MODELS: A Useful Tool for Designing, Strengthening and
Evaluating Programs to Reduce Adolescent Sexual Risk-Taking, Pregnancy, HIV and Other STDs” is
available to download free of charge. This website also offers a free on-line interactive course on
developing BDI logic models.
19
reciprocal causality, meaning that some factors on the right may also affect factors to
their left. For example, attachment to family affects initiation of sex, but initiation of sex
may also affect attachment to family.
Overall, this figure suggests that teen pregnancy and sexually transmitted disease are
affected by individual factors (the upper half of Figure 1), environmental factors (the
bottom half of that figure), and factors linking individual teens with their environments
(e.g., families, faith communities and schools).
The factors in Figure 1 closely match those important factors in Table 1, but they are not
identical. Figure 1 includes a few factors that either common sense or other kinds of
research not meeting the requirements for quantitative research studies have
demonstrated are important. For instance, large quantitative studies have not pointed to
the availability of condoms or other contraceptives as an important factor tied to teen
condom or contraceptive use, but common sense and interviews with youth and
practitioners make clear that if condoms and other forms of contraception are not
available, youth will not use them.
Using Figure 1, the discussion will now describe what is known about the causal links.
The factors are explored from right to left9.
What Behavioral Factors Determine Whether Youth Become Pregnant (Or Cause A
Pregnancy) Or Contract An STD?
Consistent with both common sense and research, behavioral factors affecting pregnancy
include whether youth are abstinent, and, if not, their frequency of sex and use of
contraception. Similarly, behavioral factors affecting STD transmission include whether
youth remain abstinent, frequency of sex, number of sexual partners, and use of condoms.
While teen pregnancy and STD appear in column 1, these behavioral factors appear in
column 2.
Teens’ risk of contracting an STD also depends on whether or not their partners are
infected with one. Because that is determined, in part, by whether or not they have been
tested and treated for STDs, that factor is also included in column 2. However, because it
is an environmental factor, it is among the environmental factors below the dotted line.
The practical implication of these factors thus far is that to prevent teen pregnancy or
STD transmission, programs must either increase abstinence, reduce the frequency of sex
and/or the number of sexual partners, or increase the use of condoms, other
contraception, and testing/treatment for STDs. (All of this is true, even if the program is
a youth development approach that does not focus directly on any sexual behavior.)
9 People familiar with BDI logic models should note that column 1 represents the health goals in BDI logic
models, column 2 specifies the behaviors (B), and columns 3-8 specify the determinants (D) in logic
models. Possible interventions (I) are not included in this figure, but are included in the next section of this
paper.
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What Factors Affect Whether Youth Have Sex, Their Frequency Of Sex, Or Their
Use Of Condoms Or Other Contraceptives?
One key factor is intention. When youth intend to have sex (or to avoid sex), they are
much more likely to do so. When they intend to use condoms or contraception, they are
also much more likely to do so. (Column 3.)
Youth are also more likely to avoid sex or to use condoms or other contraceptives if they
have the skills to resist unwanted sex or to insist on and use contraception when they
intend to do so. However, intentions and skills do not always translate into behavior.
Intentions are affected by factors in the environment that may not be under their control.
For example, teens may intend to avoid sex but may be coerced or forced into doing so.
Even if teens intend to have sex, to use condoms or other contraceptives, or to obtain
STD testing and treatment, those behaviors depend on whether they have the opportunity
to have sex, to obtain condoms or other contraceptives, or to secure STD testing and
treatment. While this is common sense, much of it is also supported by research. These
factors are included in column 3 because they directly affect sexual behaviors. However,
they characterize the teens’ environment and are below the dotted line.
The practical implication of these factors is that efforts to reduce teen pregnancy or STD
rates must also affect intentions to have sex or use condoms or contraception, skills to
avoid sex or use condoms or contraception, opportunity to have sex, coerced or forced
sex, or availability of condoms, contraception and STD testing.
What Factors Directly Affect Intent To Have Or Not Have Sex Or To Use Or Not
Use Condoms Or Other Contraceptives?
Many individual factors directly affect teens’ intention to have or to avoid sex. These
include their personal values about premarital sex or about youth their age having sex;
their perceptions of the benefits of having sex; their expectations of feeling guilt if they
do have sex; their perceived susceptibility of becoming pregnant or contracting an STD;
their perception of family and peer norms about having sex, pregnancy and STDs; their
perceived ability to resist sex if pressured; and taking a virginity pledge. (Column 4.)
The factors that affect intent to use condoms or other contraceptives include greater
perceived consequences of pregnancy; perceived male responsibility for pregnancy
prevention (if male); greater motivation to avoid STD/HIV; belief that condoms do not
reduce pleasure; expectation that partner will appreciate condom use; more positive
attitudes towards condoms and contraception; their perception of family and peer norms
about condoms, other contraceptives, pregnancy, and STDs; and their perceived ability to
insist upon and actually use condoms or other contraceptives. (Column 4.)
These factors are sometimes considered “individual proximal sexual factors” because
they are closely linked conceptually to actual sexual behaviors and they may directly
affect those sexual behaviors. Many more distal factors may operate through these
factors. For example, family education and income may affect individual teens’
perceptions of their values and the teens’ motivations to avoid pregnancy. A practical
implication of these factors is that they have a marked impact on sexual behavior and can
21
be influenced by programs. Thus, these factors are often targeted by many sex and
STD/HIV education programs.
What Affects “Individual Proximal Sexual Factors?”
Numerous factors affect individual proximal sexual factors, including the biological
factors in column 6, various behaviors and psychological states in column 5 and most of
the environmental factors in columns 5-7. For instance, when teens have steady partners,
their motivation to have sex increases. If the romantic partner is older, the couple is more
likely to have sex and if the romantic partner supports condom or other contraceptive use,
they are more likely to use them. (Column 5.)
As noted previously, emotional distress can affect teens’ behavior regarding sex and
contraceptive use. If they are depressed or if they have consumed alcohol or used drugs,
their intention and/or ability to avoid sex may diminish. (Column 5.)
Biological factors directly and indirectly affect proximal sexual factors. For example, as
youth become older, their knowledge, values, perceived norms, personal skills, and
ability to access condoms and other forms of contraception change. In addition, they
become more likely to begin dating and to form longer- lasting romantic relationships.
And, as noted, teens who have dated for a long time, are going together and are in love,
are more likely to want to have sex and to intend to have sex. They also are more likely
to have the opportunity to be alone and to actually have sex.
As noted above, the norms and behaviors of their peers strongly affect their own values
and attitudes. If their friends are using drugs or alcohol, going steady, having sex,
parenting, then they are more likely to use drugs or alcohol, go steady, have sex and
parent. The behaviors and norms of their peers influence their own values. (Column 5.)
In addition, community, family and peer characteristics affect individual proximal sexual
factors. For example, social disorganization – high crime rates, high substance use rates
and high rates of non- marital childbearing in the community – may lessen motivation to
avoid childbearing or perceived ability to do so. Family structure may affect the parents’
ability to monitor teens’ behavior, and family education and income levels may affect
expectations about long term education and career goals as well as motivation to avoid
childbearing. Finally, teens’ values about sexual behavior are affected by values
communicated by parents, religious institutions to which the teens belong, as well as
peers and romantic partners.
How Are The Factors Involving Attachment And Involvement Unique?
The factors related to attachment, connection and involvement are different from other
factors in two key ways. First, they describe the relationships between the individuals
and their environments, not precisely the individuals or their environments themselves.
Second, factors involving attachment not only have an impact directly on the individuals’
proximal sexual factors; they also affect the extent to which environmental factors affect
individua ls’ proximal sexual factors. For example, the sexual values of a faith
community may not affect teens if the teens have no attachment to, connection with, or
22
involvement in that faith community. Similarly, the sexual values of parents, peers and
others have a greater impact if the teens are more connected to those people in their lives.
Because these factors describe the connections between the individual teens and their
environment, they are depicted in the Figure 1 as crossing the boundary between
individuals’ factors and the factors describing groups in their environments.
What Are The Relationships Among The Environmental Factors?
Although a thorough discussion of the interrelationships among the environmental factors
is beyond the scope of this paper, a few are noteworthy here. For example, community
characteristics affect family characteristics (e.g., community norms affect family norms).
By the same token, family characteristics partially determine community characteristics
(e.g., family incomes affect the communities in which they can live). All of these, in
turn, have some impact on teens’ friends and whom they choose as friends.
Clearly, Figure 1 cannot depict all the causal relationships among all the factors included
in it; attempting to do so would make it unreadable. However, several important points
are worth mentioning:
· Because many factors affect other factors which, in turn, affect behavior, it is not
necessary for interventions to address every individual factor in order to change
behavior. Instead, it is important to address the particularly important factors.
· In general, the factors that are farthest to the right in Figure 1 (the most proximal
psychosocial sexual factors) have the greatest impact on behavior and outcomes,
such as pregnancy and STD. Thus, interventions that target these factors directly
and successfully improve them may have the greatest chance of actually changing
behavior. Many studies have demonstrated the efficacy of this approach.
· On the other hand, some of the more distal factors on the left in Figure 1 (e.g.,
community disorganization or family values) also affect outcomes like pregnancy
and sexually transmitted disease, in part, because they affect the more proximal
factors. Therefore, addressing distal factors can also be an effective strategy that
has been demonstrated to reduce risky sexual behavior and pregnancy. Although
distal factors may be more difficult to address, they have the potential to affect a
greater variety of factors and behaviors (e.g., substance use, depression, and
violent behavior).
Given that teen pregnancy and STD rates can be affected by addressing proximal and
distal factors, each organization concerned about teen pregnancy or STD must decide
which to focus upon. This decision should be determined in part by considering the
resources of each organization and the factors it can actually change.
23
Which Factors Can Be Changed?
As noted at the beginning of this report, pregnancy and STD prevention initiatives should
focus on those factors that 1) have an impact on sexual behavior and 2) can be markedly
changed. Table 1 identifies factors that have the strongest evidence of an impact on
behavior. Table 2 identifies those factors in Table 1 that can be changed and how.
Which factors can be changed depends somewhat upon the resources and goals of the
organizations involved. For the purposes of this review, a broad definition is used when
describing organizations concerned with preventing teen pregnancy and/or STDs. These
organizations are involved in activities ranging from STD/HIV education and family
planning to youth development and/or parental education. Table 2 divides the important
factors into three groups based on how feasible it would be for most of these
organizations to change these factors. The groups comprise: 1) those factors that are
impossible or extremely difficult for most organizations to change themselves, although
they may be able to do so by working with other community agencies; 2) those factors
that are difficult for most organizations concerned about pregnancy and STD prevention
to change unless they have special programs or capabilities (e.g., youth development
activities or mental health services); and 3) those factors that are more directly related to
sexuality and reproductive health and, thus, most amenable to change by these
organizations.
The only factors that, for all practical purposes, cannot be changed are the biological
ones. These are included in the first group. In addition, factors describing community
disorganization cannot easily be changed by organizations that focus primarily on
reproductive health. However, sometimes collaborative efforts with multiple community
or state agencies may be able to produce improvement in these areas. Other factors that
are difficult to address are those relating to family structure (e.g., number of parents in
the home, family education, and income), past events (e.g., the teen mother’s age at first
birth or prior sexual abuse), and parents’ sexual behavior. (However, some agencies may
be able to address the consequences of some of these factors.)
In the second group are those factors that cannot be easily changed by most pregnancy
and STD prevention organizations, but can be changed with intensive youth development
programs or other special services. Examples include:
· Educational and counseling programs for parents that help them monitor their
teen children more appropriately, teach them to discourage their teens from
having romantic involvements with much older partners, or urge parents to
emphasize the importance of doing well in school.
· Intensive counseling programs for families to improve the quality of family
interactions, to increase communication, and in general, to enhance
connectedness.
· Intensive counseling programs for youth with emotional distress that reduce
their stress, depression or suicide risk.
· Effective alcohol and drug abuse prevention programs for teens and/or their
parents.
24
· Programs for parents about teen sexuality that help them communicate to their
children their values about sexual behaviors and decision-making.
· Career education programs for youth that help them set educational and career
goals, and pursue them.
· Tutoring programs for teens that increase attachment toschool, improve school
performance and encourage pursuit of higher education.
· Intensive entrepreneurship programs that improve school performance for
youth.
· Intensive arts and creative expression programs that increase school
performance and connectedness to school.
· Intensive service learning programs that bolster connectedness to school,
improve school performance, and have other positive effects.
· Mentoring programs that increase attachment to parents, other adults and school,
and decrease alcohol and drug use.
· Sports programs for girls that increase their participation in athletics.
· Other school-sponsored programs that encourage youth to become actively
involved in school activities.
· Faith-based programs that encourage youth to be more involved in their faith
communities and to learn the values of those communities, especially about
sexuality.
· Comprehensive community-based programs that address multiple risk and
protective factors.
Most of these examples do have research-based evidence that they can actually affect the
risk and protective factors mentioned. However, such initiatives are not always effective.
Each of them has various characteristics that may be important to implement 10.
Furthermore, for some of the examples above, it should be remembered that it may not be
the exact activities that are critical; what may be critical is that youth are actively and
intensely involved over a lengthy period of time and form close connections with adults.
The third group of factors includes those that can be most easily changed by teen
pregnancy and STD prevention organizations. They include the proximal sexual factors
(e.g., knowledge, values, perception of peer norms, motivation and self-efficacy) of the
teens themselves, their partners, or their peers.
Studies have demonstrated that some sex and HIV education programs can change these
proximal sexual factors and delay the initiation of sex, reduce the frequency of sex,
reduce the number of sexual partners, and/or increase condom or contraceptive use11.
Logically then, some of these programs also reduce pregnancy and sexually transmitted
disease. Positive behavioral effects have been observed in a variety of program settings,
10 Kirby D et al. Preventing Teen Pregnancy: Youth Development and After-School Programs. Scotts
Valley, CA: ETR Associates, 2003.
11 Kirby D. Emerging Answers: Research Findings on Programs to Reduce Teen Pregnancy. Washington
DC: The National Campaign to Prevent Teen Pregnancy, 2001.
25
including schools during regular school hours and on the weekends, community health
centers, community detention centers, shelters for runaway youth, and residential drug
treatment programs.
Details of Important Proximal Sexual Factors
When organizations develop programs intended to target proximal sexual factors, they
can benefit from greater levels of detail about these factors than is provided in Tables 1 or
2. Accordingly, Table 3 provides specific content areas or items that have been included
in questionnaires measuring these factors or have been targeted by effective programs.
Summary and Conclusion
It is clear from this review that many factors affect teen sexual behavior, and their
relationships with behavior are complex. This report concludes by summarizing some of
the key points that will be most helpful to those working with and supporting teens.
· Risk and protective factors are rooted in states, communities, families, schools,
faith communities, friends and peers, romantic partners, and in the teens
themselves. Factors also involve teens’ relationships with these important
individuals or organizations in their environment. Some of these factors are risk
factors and some are protective factors. Some factors directly involve sexuality,
while others do not.
· The majority of factors fall into one of four groups or themes: 1) biological
factors suc h as age, physical maturity, and gender that cannot be changed; 2)
disadvantage, disorganization and dysfunction in the lives of the teens and their
families, peers, and communities; 3) sexual values and norms either verbally
expressed or modeled by the teens themselves or their families, romantic partners,
peers, faith communities, schools and/or communities; and 4) the teens’
connection to groups or institutions that discourage risky sexual behaviors and/or
encourage responsible behaviors.
· Many of these factors affect other factors and thereby affect behavior. For
example, community disorganization may affect teens’ expectations for future
careers and thereby affect motivation to avoid early childbearing and sexual
behavior; parent monitoring may affect teen norms about sex and opportunity to
have sex and thereby affect sexual behavior; and success in school may affect
motivation to avoid childbearing and thereby affect sexual behavior. Most factors
that do not inherently involve sexuality may nevertheless have an impact on the
proximal sexual factors and thereby change behavior.
· Because there are a large number of factors that affect teen sexual behavior, few
of them individually have a large impact on that behavior. Therefore, programs
26
or organizations working to change teen sexual behavior will probably need to
address (and change) multiple risk and protective factors.
· Some factors have a greater impact on sexual behavior than others. In general,
the proximal sexual factors such as values, attitudes and perceived norms about
sexual behavior have the greatest effect on teen sexual behavior. Nevertheless,
some important risk and protective factors do not directly involve sexuality and
characterize other parts of the teens’ environment.
· Because there are a variety of important risk and protective factors, diverse
organizations with varied missions can help reduce the rates of teen pregnancy
and STDs. While organizations that traditionally focus on teen sex and
reproductive health can most effectively address proximal sexual factors, those
with broader missions can select more distal non-sexual factors.
To assist organizations, programs and other interested individuals in synthesizing the
information contained in this report, the factors are diagrammed in the tables and figure
already presented. Table 1 includes the factors that are significantly related to sexual
behavior. All of these factors potentially can be used to identify those youth who are at
greatest risk of sex and unprotected sex. While all youth are potentially at risk and
therefore deserve the opportunity to participate in programs, it is particularly important to
involve these higher risk youth in programs. Table 2 highlights those factors that are
significantly related to behavior and can be affected with interventions. Thus, they are
the ones most worth focusing on. These factors can be used to design new programs and
to refine existing ones. Table 3 provides the greater detail that may be needed to
implement activities that most directly and efficiently address very specific proximal
sexual factors.
In sum, when programs and policies target those risk and protective factors that
ultimately have the greatest impact on behavior and that can be changed markedly, they
will maximize their chances for success in reducing teen pregnancy, childbearing and
sexually transmitted disease.
27
Table 1:
Potentially Important Risk and Protective Factors
That May Affect Adolescent Sexual Behavior,
Use of Condoms & Contraception, Pregnancy and STD12
Environmental Factors
Community
Foreign born
+ Higher percent foreign born
Community disorganization
- Greater community social disorganization (e.g., violence, hunger & substance use)
Family
Family Structure
+ Live with two biological parents (vs one parent or stepparents)
- Family disruption (e.g., divorce or change to single parent household)
Educational Level
+ Higher level of parental education
Substance abuse
- Household substance abuse (alcohol or drugs)
Positive family dynamics and attachment
+ Higher quality family interactions, connectedness & relationship satisfaction
+ Greater parental supervision and monitoring
- Physical abuse and general maltreatment
Family attitudes about and modeling of sexual risk-taking and early childbearing
- Mother’s early age at first birth
- Older sibling’s early sexual behavior and early age of first birth
+ Parental disapproval of premarital sex or teen sex
+ Parental acceptance and support of contraceptive use if sexually active
Communication about sex and contraception
+ Greater parent/child communication about sex and
condoms or contraception especially before youth
initiates sex
12 This table identifies risk and protective factors with strong and consistent evidence. Table 2
identifies the factors in this table that can be potentially changed by individuals or interventions.
“+” denotes a protective factor; “-” denotes a risk factor; “+/-“ denotes a factor that was a protective
factor for one or more behaviors and also a risk factor for one or more other behaviors.
28
Peer
Age
- Older age of peer group and close friends
Peer attitudes and behavior
- Peers’ alcohol use, drug use and deviant behavior
- Peers’ pro-childbearing attitudes or behavior
- Peers’ permissive values about sex
- Sexually active peers
+ Positive peer norms or support for condom or contraceptive use
+ Peer use of condoms
Romantic Partner
Partner characteristics
- Having a romantic or sexual partner who is older
+ Partner support for condom and contraceptive use
Teen Individual Factors
Biological factors
+/- Being male
+/- Older age
+ Older age of physical maturity or menarche
Race/Ethnicity
- Being Black (vs white)
- Being Hispanic (vs non-Hispanic white)
Attachment to and success in school
+ Greater connectedness to school
+ Higher academic performance
- Being behind in school or having school problems
+ High educational aspirations and plans for the future
Attachment to faith communities
+ Having a religious affiliation
+ More frequent religious attendance
Problem or risk-taking behaviors
- Alcohol use
- Drug use
- Being part of a gang
- Physical fighting and carrying weapons
- Other problem behaviors or delinquency
Other behaviors
- Working for pay more than 20 hours per week
+ Involvement in sports (females only)
29
Cognitive and personality traits
+ Higher level of cognitive development
+ Greater internal locus of control
Emotional well-being and distress
- Thoughts of suicide
Sexual beliefs, attitudes and skills
- More permissive attitudes toward premarital sex
- Perceiving more personal and social benefits (than
costs) of having sex
+ Greater feelings of guilt about possibly having sex
+ Taking a virginity pledge
+ Greater perceived male responsibility for
pregnancy prevention
+ Stronger beliefs that condoms do not reduce
sexual pleasure
+ Greater value of partner appreciation of condom
use
+ More positive attitudes towards condoms
and other forms of contraception
+ More perceived benefits and/or fewer costs and
barriers to using condoms
+ Greater self-efficacy to demand condom use
+ Greater self-efficacy to use condoms or other
forms of contraception
+ Greater motivation to use condoms or other
forms of contraception
+ Greater intention to use condoms
+ Greater perceived negative consequences of
pregnancy
+ Greater motivation to avoid pregnancy, HIV and
other STD
Relationships with romantic partners and previous sexual behaviors
- Dating more frequently
- Going steady, having a close relationship
- Ever kissed or necked
+ Older age of first voluntary sex
- Greater frequency of sex
- Having a new sexual relationship
- Greater number of sexual partners
+ Discussing sexual risks with partner
+ Discussing pregnancy and STD prevention with
partner
+ Previous effective use of condoms or contraception
- Previous pregnancy or impregnation
- History of STD
- History of prior sexual coercion or abuse
- Same-sex attraction or behavior
- Being married
30
Table 2:
Feasibility of Markedly Changing Risk and Protective
Factors13
Risk and Protective
Factors
Feasibility
of
Changing14
Comments on Feasibility of Possible
Programs To Change Them
Environmental Factors
Community
Foreign born
+ High percent foreign born * In general, pregnancy and STD prevention
programs cannot affect the percent foreign born in
a community.
Community disorganization
- Greater community social
disorganization (e.g., violence,
hunger & substance use)
* In general, pregnancy and STD prevention
programs, themselves, do not have the resources or
capability of markedly changing community-wide
social disorganization such as violence, hunger or
substance use. However, pregnancy and STD
prevention programs can work collaboratively with
other organizations to address these larger issues in
some communities.
Family
Family structure
+ Live with two parents (vs one
parent or stepparents)
*
- Family disruption (e.g., divorce
or change to single parent
household)
*
In general, pregnancy and STD prevention
programs cannot affect marital status, divorce risk
and living arrangements of families. However, if
their agencies have marriage or family counseling
departments, then these departments may be able
to help parents stay together.
2This table specifies which items can be most easily changed by different types of organizations. Thus, it
can provide a guide to organizations by suggesting which factors they should focus upon given their goals,
capabilities and resources.
14 * = Extremely difficult for most pregnancy and STD prevention agencies to change directly themselves,
although they may have a long term effect by working with other agencies to change policies.
** = Difficult for most pregnancy and STD prevention agencies to change unless they have special
programs or capabilities.
*** = Most amenable to change directly by pregnancy and STD prevention agencies. These are italicized.
31
Educational level
+ High level of parental
education
* In general, pregnancy and STD prevention
programs cannot affect the parents’ educational
level. However, in some communities, programs
with a holistic approach may be able to provide
guidance and counseling to parents and encourage
and facilitate their obtaining a higher education.
Substance abuse
- Household substance abuse
(alcohol or drugs)
** In general, pregnancy and STD prevention
programs can have little effect on whether parents
of teens abuse alcohol or drugs. However, some
agencies may be able to provide alcohol and drug
abuse prevention programs and thereby reduce
parental abuse.
Positive family dynamics and
attachment
+ High quality family
interactions, connectedness &
relationship satisfaction
** In general, pregnancy and STD prevention
programs can have little effect on family
interactions and connectedness. However, some
agencies may be able to provide intensive family
guidance and counseling and may be able to have
an impact on these family interactions.
+ Greater parental
supervision and monitoring
** Some more holistic programs may be able to
implement programs for parents that encourage
them to supervise and monitor their teen children
appropriately.
- Physical abuse and general
maltreatment
** In general, pregnancy and STD prevention
programs can have little effect on physical abuse
and maltreatment within the family. However,
some agencies may be able to provide intensive
family guidance and counseling and may be able to
have an impact on these behaviors.
Family attitudes about and
modeling of sexual risktaking
and early childbearing
- Mother’s early age at first sex
and first birth
* Programs cannot affect the teens’ mothers’ prior
behavior. However, programs can prevent current
teens from becoming teen mothers, and thereby
help the next generation.
- Older sibling’s early sexual
behavior and early age of first
birth
**
In general, pregnancy and STD prevention
programs cannot affect the previous behavior of
older siblings. However, they can, of course, affect
the behavior of current teens who may have
younger siblings.
32
+ Parental disapproval of
premarital sex or teen sex
** Pregnancy and STD prevention programs can
provide parents with accurate information about
teen sexual behavior and its consequences. Some
programs, especially church-based programs, may
emphasize conservative religious values about
premarital sex and teen sex. Many programs may
encourage parents to encourage their teens to be
abstinent.
+ Parental acceptance and
support of contraceptive use
if sexually active
** Pregnancy and STD prevention programs can
provide parents with accurate information about
teen sexual behavior, its consequences, and the
effectiveness of condoms and contraception. Some
programs may be willing to encourage parents to
encourage their teens to use contraception if they
do have sex.
Communication about sex
and contraception
+ Greater parent/child
communication about
sex and condoms or
contraception especially
before youth initiate sex
*** Pregnancy and STD prevention programs can
increase parent-child communication about sex,
condoms and contraception through school
homework assignments, special programs for
parents, college courses for parents, and other
approaches.
Peer
Age
- Older age of peer group and
close friends
** In general, pregnancy and STD prevention
programs cannot easily affect the age of youths’
peers. However, some programs may be able to
implement programs that provide activities for
young people to interact with people their own age
or to encourage same-age friends in other ways.
Peer attitudes and behavior
- Peers’ alcohol use, drug use
and deviant behavior
** If friends can be reached by programs, then some
pregnancy and STD prevention programs with a
youth development emphasis may be able to
implement effective alcohol and drug abuse
prevention programs and other effective youth
development programs that reduce non-normative
behavior.
- Peers’ pro-childbearing
attitudes or behavior
*** If peers can be reached by programs, then agencies
can implement effective sex education programs
that reduce pro-childbearing attitudes and behavior.
If peers cannot be reached in the program, then
programs can implement activities in small or large
group settings that demonstrate peer support for
avoiding pregnancy.
33
- Permissive values about sex *** If friends can be reached by programs, then
agencies can implement effective abstinence-only or
effective sex and HIV education programs that
change permissive values about sexual behavior and
delay the initiation of sex. If peers cannot be
reached in the program, then programs can
implement activities in small or large group settings
that demonstrate peer support for delaying sex.
- Sexually active peers *** If friends can be reached by programs, then
agencies can implement effective abstinence-only or
effective sex and HIV education programs that
change permissive values about sexual behavior and
delay the initiation of sex. If friends cannot be
reached, then programs can implement activities
demonstrating that perceptions of peer sexual
activity are typically exaggerated.
+ Positive peer norms or support
for condom or contraceptive
use
*** If friends can be reached by programs, then
agencies can implement effective sex and HIV
education programs or effective clinic protocols that
increase support for condom and contraceptive use
and actually increase condom and contraceptive
use. If peers cannot be reached, then programs
can implement activities in small or large group
settings that demonstrate peer support for condom
and contraceptive use if sexually active.
+ Peer use of condoms *** If peers can be reached by programs, then agencies
can implement sex and HIV education programs
that increase condom use. If peers cannot be
reached in the program, then programs can
implement activities in small or large group settings
that demonstrate peer support for condom use.
Romantic Partner
Partner characteristics
- Having a romantic partner who
is older
** Pregnancy and STD prevention programs can
encourage youth to date people their own age and
not older. However, such efforts have not yet been
evaluated.
+ Partner support for condom
and contraceptive use
** If partners can be reached by programs, then
effective sex and HIV education programs can be
implemented that improve attitudes toward condom
and contraceptive use. If partners cannot be
reached in the program, then programs can
implement activities in small or large group settings
that demonstrate peer support for condom use.
34
Teen Individual Factors
Biological factors
+/- Being male *
+/- Older age *
+ Greater physical maturity *
Within reason, it is not possible to change these
biological factors.
Race/Ethnicity
- Being Black (vs white) *
- Being Hispanic (vs
non-Hispanic white)
*
Programs can not affect the race or ethnicity of
people. However, sometimes in collaboration with
other groups, they can help reduce minority poverty
or minority cultural values that may contribute to
sexual risks.
Attachment to and success in
school
+ Greater connectedness to
school
**
+ Higher academic performance **
- Being behind in school or
having school problems
**
+ High educational aspirations
and plans for the future
**
Some pregnancy and STD prevention programs with
a youth development emphasis may be able to
implement tutoring programs, mentoring programs,
job shadowing, intensive arts programs, sports, or
service learning or other programs that may help
keep youth in school, keep them involved, improve
their grades and improve their future aspirations.
Attachment to faith
communities
+ Having a religious affiliation **
+ More frequent religious
attendance
**
Most pregnancy and STD prevention programs
cannot strive to increase involvement in religious
organizations. However, faith communities can
implement youth programs or initiatives that may
increase youths’ involvement and faith communities
can implement programs to help youth better
understand their religions’ values about sexuality.
Problem or risk-taking
behaviors
- Alcohol use **
- Drug use **
Some pregnancy and STD prevention programs with
a youth development emphasis may be able to
implement effective alcohol and drug prevention
programs and other effective youth development
programs that reduce alcohol use or drug use.
- Being part of a gang ** Some pregnancy and STD prevention programs with
a youth development emphasis may be able to
implement programs that reduce gang membership.
- Physical fighting and carrying
weapons
**
- Other problem behaviors or
delinquency
**
Some pregnancy and STD prevention programs with
a youth development emphasis may be able to
implement programs that reduce fighting, violence,
other problem behaviors.
35
Other behaviors
- Working for pay more than 20
hours per week
** Most pregnancy and STD prevention programs will
not wish to discourage youth from working and
having the greater autonomy that accompanies
work. However, some may be willing to discourage
youth from working more than 20 hours per week.
+ Involvement in sports (females
only)
** Some pregnancy and STD prevention programs with
a youth development emphasis may be able to
implement sports programs for girls.
Cognitive and personality
traits
+ Higher level of cognitive
development
** Most pregnancy and STD prevention programs are
not designed to increase level of cognitive
development. However, some with a youth
development emphasis may be able to implement
programs that slightly increase level of cognitive
development.
+ Greater internal locus of
control
** Internal locus of control is difficult to change.
However, some programs with an intensive youth
development focus may be able to improve locus of
control.
Emotional well-being and
distress
- Thoughts of suicide ** Most pregnancy and STD prevention programs are
not equipped to address serious depression or
thoughts of suicide. However, some programs may
be able to refer youth to other agencies to obtain
needed help or may provide these services in
house.
36
Sexual beliefs, attitudes and
skills
- More permissive attitudes
toward premarital sex
***
- Perceiving more personal and
social benefits (than costs) of
having sex
***
+ Greater feelings of guilt about
possibly having sex
***
+ Taking a virginity pledge ***
+ Greater perceived male
responsibility for pregnancy
prevention
***
+ Stronger beliefs that condoms
do not reduce sexual pleasure
***
+ Greater value of partner
appreciation of condom use
***
+ More positive attitudes
towards condoms and other
forms of contraception
***
+ More perceived benefits
and/or fewer costs and
barriers to using condoms
***
+ Greater self-efficacy to
demand condom use
***
+ Greater self-efficacy to use
condoms or other forms of
contraception
***
+ Greater motivation to use
condoms or other forms of
contraception
***
+ Greater intention to use
condoms
***
+ Greater perceived negative
consequences of pregnancy
***
+ Greater motivation to avoid
pregnancy, HIV and other STD
***
Pregnancy and STD prevention programs can
implement effective abstinence-only education
programs, sex and HIV education programs, and
clinic protocols that target these factors and have
been demonstrated to delay the initiation of sex,
reduce the frequency of sex and the number of
partners, and increase condom or contraceptive
use.
37
Relationships with romantic
partners and previous sexual
behavior
- Dating more frequently **
- Going steady, having a close
relationship
**
- Ever kissed or necked **
Pregnancy and STD prevention programs can
encourage parents to appropriately monitor and
supervise dating and going steady. Programs can
also encourage youth to delay dating and going
steady and to participate in group activities rather
than one-on-one dates. Such efforts have not been
evaluated, however.
+ Older age of first voluntary sex *** Pregnancy and STD prevention programs can
implement effective abstinence-only education
programs and sex and HIV education programs that
target these factors and have been demonstrated to
delay the initiation of sex.
- Greater frequency of sex ***
- Having a new sexual
relationship
***
- Greater number of sexual
partners
***
Some effective sex and HIV education programs
and clinic protocols can reduce the frequency of sex
and the number of sexual partners (and hence also
the number of new sexual relationships). Others
can encourage young people in new sexual
relationships to begin using contraception earlier in
their relationship.
+ Discussing sexual risks with
partner
***
+ Discussing pregnancy and
STD prevention with partner
***
Pregnancy and STD prevention programs can
implement effective sex and HIV education
programs and clinic protocols that increase
communication about sexual risks and pregnancy
and STD prevention.
+ Previous effective use of
condoms or contraception
***
- Previous pregnancy or
impregnation
***
- History of recent STD ***
Pregnancy and STD prevention programs can
implement effective sex and HIV education
programs, and clinic protocols that target and
increase condom and contraceptive use, and
thereby reduce risk of pregnancy and STD.
- History of prior sexual coercion
or abuse
* Logically, pregnancy and STD prevention programs
cannot prevent events that happened in the past
and typically they are not equipped to prevent
subsequent abuse or to properly address the
consequences of past sexual abuse. However, they
can refer sexually abused youth to intensive and
skilled counseling services for sexually abused
youth, if they exist, and some agencies may be
equipped to implement support groups for victims.
- Same-sex attraction or
behavior
** Pregnancy and STD prevention programs cannot
affect whether youth are gay or lesbian, but some
programs designed for gay, lesbian and questioning
youth may be able to reduce their sexual risktaking.
- Being married ** Most programs do not include delaying marriage in
their mission. However, some programs, especially
those with counseling components, may be able to
get some young people to think seriously about the
implications of early marriage.
38
Table 3:
Examples of Items That Have Been Used to Measure Selected Factors
and That Can Be Used to Create Specific Activities or Programs to
Address Them15
Attitudes favoring abstinence until marriage
+ It is wrong to have sex before marriage.16
+ Having sex before marriage is against my religious beliefs.
+ Abstaining from sex until marriage is important to me.
+ Teens would be better off if they said “no” to sex.
- It is okay for people my age to have sex.
- It is okay for people my age to have sex if they are in love.
- It is okay for people my age to have sex with someone they like, but don’t know very
well.
Perceived costs of having sex and benefits of abstaining from sex
+ I would not have sex now because I’m not ready to have sex.
+ I would not have sex now because it is against my beliefs.
+ I would not have sex now because it is against my parents’ values and they would be
terribly upset if they believed I was having sex.
+ I would not have sex now because I do not want to get pregnant.
+ I would not have sex now because I don’t want to get AIDS or some other STD.
+ I would not have sex now because I don’t want to get a bad reputation.
+ If I had sex with a boyfriend or girlfriend, my friends might gossip about me.
+ I would not have sex now because I’m waiting for the right person.
+ I would not have sex now because my friends think it is better to wait to have sex.
- If I want to be popular, I need to go farther than kissing.
- If I had sex with a boyfriend or girlfriend, it would prove that I love him or her.
- I would have sex now if someone I cared about pressured me to have sex.
- I would have sex now to satisfy strong sexual desires.
- I would have sex now because I want to have a baby.
Perceived parental values about having sex
+ My parents think having sex before marriage is wrong.
+ My parents think people my age should wait until they are older to have sex.
+ My parents think I should abstain from sex.
+ My parents would be terribly upset if they believed that I was having sex.
15 Most of these items are based on actual questions used to measure factors in previous research. These
items specify more precisely some of the factors that are related to behavior and can therefore be helpful
when designing programs to address the proximal sexual factors. They can also be used to create items for
questionnaires in survey research.
16 “+” denotes a protective factor; “-” denotes a risk factor; “+/-“ denotes a factor that was a protective
factor for one or more behaviors and also a risk factor for one or more other behaviors.
39
Perceived peer norms about having sex
+ Most of my friends have not had sex.
+ Most of my friends think people my age should wait until they are older before they
have sex.
+ Most of my best friends think I should wait to have sex.
- Most of my friends believe it’s okay for people my age to have sex.
- Most of my friends think it is okay to have sex with a steady boyfriend or girlfriend.
- Most of my friends think it is okay to have sex with a couple of different people each
month.
Perceived susceptibility to pregnancy or STD/HIV
- If I have sex without contraception, I would probably get pregnant (or get someone
pregnant).
- If I have sex without using a condom every time, I might get an STD.
- If I have sex without using a condom every time, I might get HIV.
Perceived consequences of pregnancy and childbearing
+ I am not emotionally ready to be a parent.
+ I am not financially ready to be a parent.
+ Being a teen parent would make it more difficult to finish school.
+ Being a teen parent would keep me from doing many things I like to do.
+ Being a teen parent would really mess up my life.
+ If I got pregnant (or got someone pregnant), I would be very embarrassed.
+ Getting pregnant at this time in my life is one of the worst things that could happen to
me.
- Having a baby to take care of would make me feel loved and needed.
- If I had a baby, for the first time, I would have something that is really mine.
- If I had a baby, I would never be lonely.
- If I had a baby, my boyfriend would be more committed to me.
- If I had a baby, I would feel more like an adult.
- If I had a baby, I would feel I had done something meaningful in life.
- My family would help me raise a baby.
Perceived consequences of sexually transmitted disease and HIV/AIDS
+ If I got an STD, I would be very embarrassed.
+ If I got an STD, I would hate to have to tell my partner.
+ If I got an incurable STD, it would mess up my life.
+ If I got an incurable STD, I might need to deal with it the rest of my life.
+ If I got an incurable STD, I would worry about infecting others.
+ Getting AIDS would really mess up my life.
+ Getting AIDS might mean that I would have to take lots of pills the rest of my life.
+ Getting AIDS would prevent me from doing many things I want to do.
Motivation to avoid contracting an STD
+ I really want to avoid getting an STD.
+ Not getting an STD is important to me.
+ Getting an STD is not a big deal.
40
Motivation to avoid pre gnancy and childbearing
+ Getting pregnant (or getting someone pregnant) would really mess up my life.
+ I really don’t want to get pregnant (or get someone pregnant).
+ I am really not ready to be a parent.
+ If I get pregnant (or get someone pregnant), it is not a big deal.
+ Sometimes I think I’d like to be pregnant (or get someone pregnant).
- I’d like to be a mother (or father).
Self-efficacy to abstain from sex
+ I have the ability to abstain from sex until married.
+ I can abstain from sex until I’m finished with high school.
+ My boy/girlfriend cannot pressure me into having sex.
+ My friends will not pressure me into having sex.
+ If someone I liked a lot wanted me to have sex, I am sure I could say “no.”
+ If someone I liked a lot wanted me to have sex, I am sure I could say “no” without
hurting his/her feelings.
+ If someone I liked a lot wanted me to have sex and threatened to break up with me
unless I had sex, I am sure I could say “no.”
+ If someone I liked a lot wanted me to have sex and I had been drinking alcohol, I am
sure I could say “no.”
Intention to have sex
+ I intend to abstain from sex until I am older.
+ I intend to abstain from sex until I am married.
Perceived effectiveness of condoms and contraception
+ If used correctly and consistently, condoms are effective at preventing pregnancy.
+ If used correctly and consistently, contraception is effective at preventing pregnancy.
+ If used correctly and consistently, condoms are quite effective at preventing some
STDs.
+ If used correctly and consistently, condoms are effective at preventing AIDS.
Personal values and attitudes about condoms & contraception
+ I believe condoms should always be used if a person my age is sexually active.
+ I believe contraception should always be used if a person my age is sexually active.
+ I believe that condoms should always be used if a person my age has sex, even if the
two people know each other very well.
+ I believe that condoms should always be used if a person my age has sex, even if they
are going together.
+ I believe that condoms should always be used if a person my age has sex, even if the
girl uses contraception.
+ I believe that another form of contraception should always be used, even if the guy
uses a condom.
41
Perceived costs & barriers to using condoms
- Using condoms is a hassle.
- Using condoms disrupts the mood.
- Condoms reduce pleasure of sex.
- Condoms reduce sensation during sex.
- I would be embarrassed to buy birth control in a store.
- When I’m all excited, I don’t want to think about using condoms.
- Condoms are messy.
- I would be afraid my partner would be angry if I asked him/her to use a condom.
- I am afraid that my sex partner would think I am infected with and STD if I asked
him/her to use a condom.
- Condoms create distrust during relationship.
- Condoms are embarrassing to use.
+ Condoms are comfortable to use.
+ Using condoms can be sexy.
+ Using condoms makes me feel more secure that I will not cause a pregnancy or get an
STD.
Perceived embarrassment using condoms
- It would be embarrassing to buy a condom.
- It would be embarrassing to ask my partner to use a condom.
- It would be embarrassing to put on a condom.
Perceived peer norms about condom or contraceptive use
+ Most of my friends believe condoms should always be used if a person my age has
sex.
+ Most of my friends believe condoms should always be used if a person my age has
sex, even if the girl uses birth control pills.
+ Most of my friends believe condoms should always be used if a person my age has
sex, even if the two people know each other very well.
- Women who carry condoms are looking for sex.
- If you tell your partner you want to use a condom, your partner will think you’re
having sex with other people.
+ Most young people use contraception when they have sex.
- Very few young people are doing anything to protect themselves against sexually
transmitted disease.
Perceived self-efficacy in using condoms or contraception
+ It would not be too hard for me to buy condoms.
+ It would not be too hard for me to carry a condom and have it with me if I needed it.
+ If I decided to have sex with someone, I am sure that I could talk to my partner about
using condoms.
+ If I decided to have sex with someone, I am sure that I could get my partner to agree
to use condoms.
+ If I decided to have sex with someone but did not have a condom, I am sure that I
could stop myself from having sex until I got a condom.
+ If my partner refused to use condoms, I could refuse to have sex.
42
+ If I decided to have sex with someone but did not have any form of contraception, I
am sure that I could stop myself from having sex until one of us could get an effective
method of contraception.
+ I am sure that I could use a condom correctly.
+ I am sure that I could use a condom correctly even when highly aroused.
+ I am sure that I could use a condom correctly every time I have sex.
+ I am sure that I could use a condom every time even with my girl/boyfriend.
+ I am sure that I could use a condom even if I had drunk alcohol or used drugs.
+ I am sure that I could take contraception consistently and correctly.
Intention to use condoms or contraception
+ If I have sexual intercourse in the next year, I am sure that I will always use a
condom.
+ If I have sexual intercourse in the next year, I am sure that I will always use an
effective method of contraception.
43
Appendix:
Matrix 1:
Risk and Protective Factors That Affect
One or More Sexual Behaviors or Outcomes,
by Domain
44
Introduction
This document is designed both as a stand-alone matrix and as the appendix to the
following paper: “Sexual Risk and Protective Factors” by the same authors. The full
paper summarizes the content of this matrix, discusses causal relationships among these
factors, and indicates which factors can most readily be changed17.
Goals
The overall goal of this matrix is to specify and summarize research studies measuring
the relationships between a wide variety of risk and protective factors and their respective
sexual behaviors. Accordingly, this matrix:
1. Identifies in the columns of the matrix eight important sexual behaviors and their
consequences: initiation of sex, frequency of sex (which includes return to
abstinence), number of sexual partners, use of condoms, use of other forms of
contraception, pregnancy, childbearing and sexually transmitted disease.
2. Specifies in the rows of the matrix the risk and protective factors found in
research studies that may ultimately have a causal impact on one or more of the
sexual behaviors in the columns.
3. Specifies in the cells of the matrix the particular studies that have measured the
relationship between each risk and protective factor and each behavior.
4. Specifies in the rows of the matrix whether each study found the factor to be a
risk factor or a protective factor or to be non-significantly related to each of the
sexual behaviors.
Criteria for Inclusion of Studies
As noted in the full article, to be included in this matrix, studies must have:
1. Been conducted in the United States18
2. Examined the impact of factors on one or more of the eight sexual behaviors
specified above
3. Been based on a sample of teenagers, roughly 18 years of age or younger
4. Included a sample of at least 100 for significant results and a sample of at least
200 for non-significant results19
5. Met scientific criteria required for publication in professional peer-reviewed
research journals or other publications
6. Been published between 1990 and 2004 inclusive
7. Included multivariate analyses20
17 Readers in search of information on a particular risk or protective factor should consider using the find
function (simultaneously pressing the “control” and “f” buttons on your keyboard) to search for a particular
word describing that factor, e.g., “income,” “attachment,” “self-esteem,” or “attitudes.”
18 A second matrix by Kristin Mmari and Bob Blum will soon be available on risk and protective factors in
the developing world (www.teenpregnancy.org).
19 A few studies with sample sizes less than 100 were included if they were good studies involving
significant results for new and interesting factors not found in other studies.
20 A few studies without multivariate analyses were included if they involved new and interesting factors
not found in other multivariate studies.
45
Criteria for Inclusion of Results within Studies
Some studies presented multiple results for the same factor. For example, they may have
included results for multiple measures of a particular behavior (e.g., condom use at first
sex, condom use at last sex, and frequency of condom use) or results for different groups
(e.g., both sexes, different racial and ethnic groups, or different age groups). If the results
within a study were consistent for a particular factor, then, of course, those results were
incorporated once in the matrix. If the results for a particular factor were inconsistent
across different measures or groups, then all the different results were included in the
matrix. Thus, hypothetically, the results presented in the matrix would show that a
specific factor was a protective factor for a particular behavior, a risk factor for that
behavior, and not significantly related to that behavior, if these were the findings for three
different groups in the study.
Many studies presented results for different statistical models that controlled for different
potentially confounding variables. When different models were presented, typically the
results from the model with the most variables were included.21
How to Use the Matrix
Readers can use this matrix in different ways:
· To gain an understanding of the wide range of risk and protective factors that affect
any of the sexual behaviors and their outcomes, readers can visually examine the
different domains and sub-domains of risk and protective factors.
· To determine whether a potential factor has been found to be a risk or protective
factor for any of the eight sexual behaviors and their outcomes, readers can:
1. Visually review the risk and protective factors in the appropriate domain.
2. Use the “find” option (“control f”) to search for a particular word describ ing that
factor, e.g., “income,” “attachment,” “self-esteem,” or “attitudes.” Be sure to
search for all uses of the word, for it may appear multiple times in different
domains. For example, “income” may be in a factor describing average
community income and also in a factor describing family income.
· To identify findings from a particular study, readers can search for the study in the
references and then use the “find” option to find the reference number in the matrix.
· To assess which factors are most likely to be important for their own target
populations, readers can identify those factors that 1) have many studies
demonstrating they are significant factors and 2) have multiple studies that
21 Results from models were included if they statistically controlled for those variables that might be
confounding (they might co-vary with both the factor and the behavior), but sometimes results from models
were excluded if the models included variables that were in the causal pathway to the behavior. For
example, when examining the impact of parent-child communication about sex on initiation of sex,
presented results did control for family income because family income may be correlated with both parentchild
communication and initiation of sex and might therefore add to (or subtract from) the actual causal
relationship between parent-child communication and initiation of sex, but results did not control for
intention to have sex, because parent-child communication may affect intention to have sex which in turn
affects actual initiation of sex.
46
consistently demonstrate the factors are risk factors (or a protective factors). Readers
should then read the relevant studies to be certain that the factors were significant in
populations similar to their own target populations.
Some Cautions about Drawing Conclusions from the Matrix
While this matrix should be used to reach tentative conclusions about the impact of
different risk and protective factors on sexual behaviors and their outcomes, readers
should not simply count the number of studies with significant findings for particular
factors and then conclude that those factors with more significant findings necessarily
have a stronger causal impact than factors with fewer significant findings. Similarly,
readers should not simply calculate the ratio of significant findings to non-significant
findings and then conc lude that those factors with the largest ratios necessarily have the
largest causal impact. Rather, it is important for readers to actually read many of the
referenced studies about relevant risk and protective factors and then make appropriate
assessments. Why is this important? There are several reasons: 1) Some factors are far
more commonly measured in studies, even though they do not necessarily have a greater
causal impact; 2) some studies were far more rigorous in assessing causal impact than
others; 3) some studies may have found that a factor was significant for many groups but
not quite significant for one group, yet both the significant and non-significant results
were entered in the matrix once; 4) requiring multivariate analyses might have excluded a
few potentially important factors; and 5) some statistical problems (such as
multicolinearity and causality) are difficult to resolve in many studies. Thus, factors with
multiple studies consistently demonstrating a significant impact do have relatively strong
evidence that they have a causal impact on the specified behaviors, but actually reading
some of the studies, particularly the more rigorous studies, will enhance understanding of
the role of those factors.
Future Plans
Each year we hope to search data bases for new studies and add those studies to this
matrix as appropriate. Thus, this matrix is an on-going work in progress. We, the
authors, encourage you to send us articles that you believe meet our criteria and should be
included in subsequent versions. We also welcome ideas on methods of improving this
matrix’s utility.
Until then, we hope this is useful to you.
Matrix:
Risk and Protective Factors That Affect One or More Sexual Behaviors or Outcomes, by Domain
Risk and Protective Factors Protective
Factor,
Risk Factor
or Not
Significant
Initiation
of sex
Frequency of
sex/ Sex
during
specified time
# of
Partners
Use of
condoms
Use of
contraception
Pregnancy /
Impregnation
Childbearing
STD
Environment/ Context
Season:
Early summertime months Risk [217]
December (holiday season) Risk [217]
Region:
Northeastern Protective [357]
North Central Risk [13]
South Risk [162] [54] [13]
West Risk [54] [294] [13] [370]
Region measured was not found to be significant NS [54] [162] [54] [294] [54] [68, 110] [163] [299] [361]
State:
Higher education level Protective [221] [270]
Higher levels of female labor force participation Risk [270]
Higher crime rate Risk [270]
Higher minimum legal drinking age Protective [159]
Higher tax on beer Protective [159]
Coordinated programs and policies for
addressing teen pregnancy
Protective [270]
Higher level of state funding for family planning Protective [270] [401]
Greater social capital Protective [97]
Greater income inequality NS [97]
Higher incidence AIDS NS [207] [207] [207]
Risk [233, 234] Restrictive laws regarding contraceptive
licensing, advertising, or selling NS [234]
Protective [7] Parental involvement legislation for abortion
Risk [370]
Restricted public funding for abortion Risk [270] [370]
Risk and Protective Factors Protective
Factor,
Risk Factor
or Not
Significant
Initiation
of sex
Frequency of
sex/ Sex
during
specified time
# of
Partners
Use of
condoms
Use of
contraception
Pregnancy /
Impregnation
Childbearing
STD
Community:
Protective [14] [255] [255] [255]
[353]
[174] [353] [163] [185] [13]
Risk [134, 162,
174, 210]
[324] [395]
[207] [134] [163]
[353]
[361] [174]
Living in an urban area (vs rural)
NS [21] [54]
[103] [126]
[162] [167]
[277] [324]
[357] [395]
[106] [126] [205]
[353]
[126]
[205]
[332]
[353]
[54] [294] [54] [68, 110]
[126] [167]
[205] [242]
[311] [353]
[32] [163] [167]
[205] [353]
[13] [21]
[167] [185]
[205] [238]
[370]
[90]
Risk [35] [205] Higher ratio of men to women
NS [35] [205] [205] [205] [205]
Higher percent of women aged 15-25 never
married
Protective [199]
Higher percent white Protective [199] [370]
Protective [35, 53] [353]
Risk [103] [353] [221]
Higher percent black
NS [103] [205] [353] [205]
[353]
[353] [53] [205] [353] [205] [353] [205]
Protective [374] [205] [104]
Risk [205] [353]
Higher percent Hispanic
NS [205] [353] [353] [353] [353] [205] [353] [205]
Protective [35, 53] [61] Higher percent foreign born
NS [61] [53]
Stronger ties to countries of origin Protective [104]
Risk [53] [35] [377] Higher residential mobility
NS [61] [377] [53] [377]
Higher percent of families headed by married
couples
Protective [370]
Higher proportion female-headed households NS [205] [78] [205] [205] [205] [205]
Risk [53] [53] Higher divorce rates
NS [35]
Risk [35] [88] Higher school dropout rate
NS [35]
Protective [53] [199] [370] Higher education levels
NS [53]
More community opportunities Protective [34]
Protective [53] Greater female labor force opportunities
NS [53]
Risk and Protective Factors Protective
Factor,
Risk Factor
or Not
Significant
Initiation
of sex
Frequency of
sex/ Sex
during
specified time
# of
Partners
Use of
condoms
Use of
contraception
Pregnancy /
Impregnation
Childbearing
STD
Risk [35] [52] [199] Higher percent of females employed
NS [35]
Higher percent of males employed Risk [199]
Risk [377] [255] [353] [353] [353] [34] [205] [377] Higher unemployment rate
NS [52] [205] [353] [205]
[353]
[353] [205] [353] [205] [353] [370] [377]
Lower average job wage Risk [34]
More high-status workers Protective [88]
Higer population of working class NS [128]
Protective [61] [205] [57, 221]
[199]
Risk [205] [353] [205] [370]
Higher income level / socio-economic status
NS [35] [272]
[352]
[353] [205]
[353]
[353] [272] [353] [353] [34] [205]
[369] [370]
[128]
Risk [272] [273] Higher proportion on welfare
NS [273] [205] [205] [205] [205] [205]
Protective [370] [401] Greater religiosity
NS [35, 53] [53] [242]
Protective [61] [214] [21] [245] [99]
Risk [264]
Better neighborhood quality
NS [21] [264] [264] [21] [264] [245] [369]
Protective [61] [350] Greater neighborhood monitoring by adults in
community NS [273] [273]
Greater youth participation in a stable community Protective [34]
Protective [210] Greater community social disorganization
(violence, hunger, substance abuse) Risk [209] [211]
[374]
[213] [35, 104]
Higher levels of community stress Risk [270]
Higher crime rate / arrest rate Risk [35] [211]
Media exposure to AIDS information NS [166]
Protective [37] [53] Greater number of clinics
NS [53]
Clinic provides contraceptive guidance Protective [280]
Clinic provides advance emergency
contraception
Risk [305]
Greater clinician-client rapport (time,
confidentiality, trust, etc.)
NS [280]
Higher STD rate NS [182]
Higher percent of females 15-19 using family
planning services
Risk [35]
Risk [53] Higher teen non-marital birth rate
NS [53]
Risk and Protective Factors Protective
Factor,
Risk Factor
or Not
Significant
Initiation
of sex
Frequency of
sex/ Sex
during
specified time
# of
Partners
Use of
condoms
Use of
contraception
Pregnancy /
Impregnation
Childbearing
STD
School:
Risk [343] [149] Urban school community
NS [149] [149]
Protective [312] [238] [238] [409] Private religious school (e.g. Catholic vs public)
NS [204] [377] [204] [204] [312] [377]
Protective [377] [377] Private non-religious school
NS [377]
College prep program (vs. vocational or general) Protective [409]
Protective [154] School for students with cognitive disabilities
NS [154]
Learning-focused school setting Protective [190]
Conflictual school seting NS [190]
Students grouped by ability (at the class level) NS [238]
Higher average number of students per public
secondary school
Risk [34]
Higher student to teacher ratio NS [34]
Higher student to school counselor ratio NS [34]
Higher percent of students with single mothers NS [238] [271]
Risk [324] [238] [409] Higher percent of minority students
NS [324] [238] [271]
Risk [238] Higher percent of students receiving free lunch
NS [238] [271]
Higher per capita funding for schools (federal,
state, or local)
NS [34]
Risk Higher school dropout rates
NS [324] [205] [205] [205] [205] [34] [205]
Risk [73] [271] Higher rates of school crime / lower levels of
safety NS [271]
Protective [242]
Risk [204] [286] [286] [238] [271]
Sex education in school
NS [23] [204]
[264] [286]
[264] [264] [229] [204]
[264] [341]
[229] [204]
[311]
[23] [286] [239] [156] [238]
[241] [271]
Protective [204] [203] [149] [149] HIV / STD education in school
NS [37] [204]
[308]
[207] [11] [207]
[308]
[404]
[11] [166]
[204] [207]
[308] [404]
[240] [204]
[308]
[308] [149]
Protective [228] [35] [149] [246] [242, 246] [308]
Risk [204] [204]
Contraception instruction in school
NS [53] [204]
[308]
[203] [228] [207]
[308]
[207] [308] [240] [228]
[246] [308]
[149]
Risk and Protective Factors Protective
Factor,
Risk Factor
or Not
Significant
Initiation
of sex
Frequency of
sex/ Sex
during
specified time
# of
Partners
Use of
condoms
Use of
contraception
Pregnancy /
Impregnation
Childbearing
STD
Protective [39] [39] [264] [264] [39]
Risk [39]
Condom distribution at school
NS [264] [39] [91] [264] [39]
Family:
Protective [24] [102]
[154, 162,
167, 210,
226] [61]
[74] [82]
[214] [227]
[230] [5, 22,
44, 52, 54,
257] [259]
[260] [261]
[273]
[203, 205, 213]
[363] [35]
[2] [78]
[205]
[181] [240] [87] [242]
[239]
[62] [99] [181]
[205] [221]
[234] [18, 73,
238, 408] [273]
[314]
[13] [185]
[205] [238]
[271] [241,
364, 409]
[349] Live with two parents
NS [24] [30]
[36] [76]
[102] [162]
[252] [261]
[324] [377]
[395]
[205] [54] [229] [53] [54] [62]
[240] [87] [205]
[229] [242]
[272] [372]
[239]
[23] [62] [163]
[205] [234]
[314] [351]
[364]
[21] [205]
[238] [361]
[369] [408]
[377]
Protective [102]
Risk [134] [203]
Parents cohabiting (unmarried)
NS [102] [273]
[377]
[102] [273] [377]
Risk [24] [167]
[230] [256]
[314] [376]
[395] [377]
[242] [298] [409] [377] Live with parent and stepparent (vs. both parent)
NS [24] [36]
[230] [403]
[229] [167] [229] [167] [167] [377]
Risk [403] Live with mother only / female-headed household
NS [204] [256]
[314] [403]
[353] [353] [278] [294] [204] [353] [298] [353] [409]
Risk [403] [409] Live with father only
NS [403]
Protective [307] [167] [409] Live with one parent (vs. no parent)
NS [307] [167] [167] [167]
Protective [307] [377]
Risk [395] [361]
Other family structure / living situation
NS [307] [62] [62] [377]
Risk and Protective Factors Protective
Factor,
Risk Factor
or Not
Significant
Initiation
of sex
Frequency of
sex/ Sex
during
specified time
# of
Partners
Use of
condoms
Use of
contraception
Pregnancy /
Impregnation
Childbearing
STD
Risk [238] Not living with biological mother
NS [238]
Protective [184] [377] Presence of mother in the home
NS [203] [90] [377]
Protective [84] [129]
[103] [403]
[377]
[129] Presence of father in the home
NS [84] [103]
[403]
[90] [377]
Risk [167] Parents not together at time of teen’s birth
NS [403] [167] [167] [167]
Risk [261] [272]
[65] [21]
[134] [403]
[21] [134] [402] Family disruption (divorce, change to singleparent
household or re-marriage)
NS [260] [261] [21] [99] [241] [369]
Presence of a grandparent in the home Protective [13]
Protective [126] [204] [131]
Risk [30] [324] [234] [13] [146]
[238]
Larger family size/greater number of siblings
NS [23] [61]
[126] [204]
[257] [277]
[324]
[126] [126] [204] [126] [204] [23] [99] [234]
[299]
[238] [361]
Risk and Protective Factors Protective
Factor,
Risk Factor
or Not
Significant
Initiation
of sex
Frequency of
sex/ Sex
during
specified time
# of
Partners
Use of
condoms
Use of
contraception
Pregnancy /
Impregnation
Childbearing
STD
Protective [2, 21, 42,
140] [52]
[82] [184]
[145] [154]
[162] [67]
[103] [230]
[252, 254,
261] [258]
[259] [256]
[272] [327,
334, 337,
350] [357]
[35, 53] [54]
[377]
[2, 21, 78] [174] [54,
278] [246]
[334]
[126] [167]
[242] [246]
[311] [388] [54]
[32, 118, 163,
167] [99] [234]
[298] [314] [73,
323, 408] [405]
[167] [185]
[241] [369]
[57, 409]
[377]
Risk [145] [140]
[243]
Higher parental education
NS [21] [35]
[36, 42] [76]
[84] [103]
[126] [154]
[41] [161]
[162] [230]
[204] [252]
[254] [257]
[261] [256]
[272] [273]
[277] [333]
[324] [376]
[21] [126] [203]
[288] [334]
[78] [334]
[353]
[229] [204]
[334] [353]
[53] [62] [240]
[68, 110] [126,
186] [229] [204]
[242] [245]
[272] [334]
[353] [239]
[32] [62] [234]
[351] [353]
[21] [271]
[273] [361]
[408]
[182]
[192]
[377]
Higher parental job status NS [76] [377] [405] [377]
Risk and Protective Factors Protective
Factor,
Risk Factor
or Not
Significant
Initiation
of sex
Frequency of
sex/ Sex
during
specified time
# of
Partners
Use of
condoms
Use of
contraception
Pregnancy /
Impregnation
Childbearing
STD
Protective [24] [5, 35,
44] [134,
140, 210]
[214] [257]
[317]
[21] [397] [87] [176] [31, 134] [99]
[205] [18, 176,
238, 314] [330]
[13] [21]
[238] [271]
[57, 409]
[361]
Risk [140] [226] [205] [207] [353,
363]
[205]
[207]
[353]
[255] [353] [238]
Higher income level / socio-economic status
NS [21] [24]
[52] [65,
334] [61]
[76] [230]
[260] [262]
[256] [264]
[272] [273]
[277] [314]
[376]
[21] [213] [262]
[264] [330] [334]
[78] [262]
[264]
[334]
[353]
[229] [207]
[264] [294]
[334] [353]
[341]
[68, 110] [62]
[87] [229] [205]
[311] [334]
[353] [372]
[62] [273]
[306] [330]
[353] [405]
[205] [238]
[271] [364]
[66] [365]
Family owns home NS [21] [21] [21] [369]
Protective [145] [167] [167] [211,
408]
Risk [145] [167]
[204] [277]
[35]
[255] [255] [167] [185]
Mother employed
NS [162] [204]
[260] [277]
[204] [167] [204]
[311]
[234] [299] [167] [185]
[241] [408]
Parents unemployed Risk [349]
Protective [93]
Risk [21] [126] [55] [4] [21] [406,
409]
Receipt of welfare (AFDC, TANF)
NS [126] [228]
[260] [273]
[352]
[126, 205] [207]
[228]
[126]
[205]
[207]
[207] [278] [126] [205]
[228] [311]
[93] [205] [273]
[351] [406]
[205] [349]
Intergenerational receipt of welfare NS [272]
Protective [22] [22] Private health insurance
NS [23]
Public health insurance NS [23] [311]
Protective [333] [234] Foreign language spoken at home
NS [183] [204] [204] [339] [204]
Lived outside the US NS [243]
Risk and Protective Factors Protective
Factor,
Risk Factor
or Not
Significant
Initiation
of sex
Frequency of
sex/ Sex
during
specified time
# of
Partners
Use of
condoms
Use of
contraception
Pregnancy /
Impregnation
Childbearing
STD
Risk [183] First or second generaton US resident
NS [23] [61]
[374]
[23]
Protective [377] Foreign-born
NS [377]
Protective [167]
Risk [167] [357] [21] [99] [167]
Residential mobility
NS [21] [21]
Protective [21] [327]
[35, 357]
[207] Greater family religiosity
NS [42] [252]
[256]
[21]
Risk [103] More conservative family attitudes towards
women NS [103]
Protective [119] [75] [369] Greater family social support
NS [75] [277] [75] [119]
Family problem solving NS [119] [405]
Risk [165] [8] Mother abused
NS [165]
Risk [248] [247] [119] Exposure to family conflict
NS [119] [369]
Parental antisocial behavior NS [65]
Incarcerated family member Risk [165] [165]
Risk [165] [165] Household mental illness / depression
NS [369]
Risk [312] Recent family suicide attempts
NS [312]
Protective [156] [369] Higher parental educational / college
expectations for teen NS [405] [156] [238]
[271]
Parental tobacco use Risk [395]
Protective [193]
Risk [72] [165] [236] [283] [165]
[236]
[283]
[72]
Household substance abuse (alcohol or drugs)
NS [260] [395]
Parental lack of seatbelt use NS [395]
Parental deviant behaviors as adolescents NS [277]
Mother’s age at first sex was older Protective [277] [185]
Risk and Protective Factors Protective
Factor,
Risk Factor
or Not
Significant
Initiation
of sex
Frequency of
sex/ Sex
during
specified time
# of
Partners
Use of
condoms
Use of
contraception
Pregnancy /
Impregnation
Childbearing
STD
Protective [2, 140] [84,
204] [272]
[394]
[207] [353] [2] [207]
[353]
[255] [353] [211] [353] [369] [185,
241]
Mother’s age at first birth was older
NS [353] [353] [204] [353] [204] [353] [353] [406] [406]
Single mothers’ dating behaviors Risk [393]
An older sibling who had sex Risk [125, 394]
Risk [126] [123]
[124]
[123, 146] [146]
An older sister who gave birth as an adolescent /
Greater number of parentlng sisters
NS [55] [126] [126] [126]
Protective [174] [29]
[24] [42]
[102, 350]
[43, 116,
117, 154,
178, 226,
252, 312,
318, 393,
394]
[29, 116, 117,
178, 263] [177]
[263,
264]
[117] [90] Parental disapproval of teen or pre-marital sex
NS [29] [24]
[82] [252]
[264] [263]
[256]
[264] [102] [264] [263] [116] [117]
[177] [186]
[177] [312] [90] [192]
Parents would punish if discovered teens’ sexual
activity
Protective [116] [183]
Protective [187] [397] [186] [177]
[229]
Risk [312] [177] [312]
Parental acceptance and support of
contraception
NS [183] [218] [229]
[341]
[177]
Parental disapproval of early parenthood NS [183]
Protective [154] Pregnancy would not embarrass family
NS [154] [116]
Risk [117] [117] Mother’s perception that adolescent is in a steady
relationship / is sexually active NS [117]
Mother uncomfortable discussing sex NS [42] [252]
Risk [102] Mother frequently discusses sex w/teen
NS [42] [102]
Mother recommends spec ific birth control NS [42] [252]
Risk and Protective Factors Protective
Factor,
Risk Factor
or Not
Significant
Initiation
of sex
Frequency of
sex/ Sex
during
specified time
# of
Partners
Use of
condoms
Use of
contraception
Pregnancy /
Impregnation
Childbearing
STD
Peer:
Risk [23] [70]
[84] [82]
Older age of peer group and close friends
NS [70] [261]
Protective [23] Close friends’ closeness to parents
NS [23]
Risk [70] Greater number of friends / larger peer group
NS [70]
Risk [70] More peers of the opposite sex
NS [70] [261]
[277]
Risk [23] Peers with poor grades and high non-normative
behavior NS [23] [190]
Protective [23] [70] [22, 190] Friends with good grades and little non-normative
behavior NS [70] [273] [273]
Risk [254] Peers with lower achievement orientation
NS [254] [156]
Peers with positive attitudes about preventive
health
Protective [50] [50]
Peers who use tobacco Risk [237]
Risk [198, 201]
[43]
[201] [201] Peers who drink alcohol
NS [76] [119]
Risk [53] [75]
[76] [395]
[75] Peers who use drugs
NS [75] [75] [119] [63]
Peers who sell drugs Risk [63]
Risk [264] [61]
[23]
[264] [336] Peers who engage in deviant behaviors
NS [52] [65]
[76] [86]
[198]
[264] [119] [264] [268] [351] [66]
Peers with permissive attitudes about sex Risk [226, 312]
[243] [318]
[67, 226,
357, 368]
Risk and Protective Factors Protective
Factor,
Risk Factor
or Not
Significant
Initiation
of sex
Frequency of
sex/ Sex
during
specified time
# of
Partners
Use of
condoms
Use of
contraception
Pregnancy /
Impregnation
Childbearing
STD
Peers who believe it is better to initiate sex when
older
Protective [368]
Peers who believe it is okay to have sex with
multiple partners
Risk [20]
Risk [21] [228]
[368]
[21] [21] Peers with pro-childbearing attitudes/behavior
NS [358] [228] [358] [228]
Protective [198] Boys gain respect if sexually active
Risk [198]
Peers with later sexual debut Protective [390] [390]
Risk [38] [124]
[198, 226]
[227] [228]
[261, 304,
318] [321]
[357, 358]
[243, 319,
390] [359]
[29, 228] [390] [75] [75] Sexually active peers
NS [75] [75] [358] [359] [228]
Risk [264] [264] Greater peer sexual risk-taking
NS [264] [264]
Peer norms opposing acquisition of an STD Protective [326]
Protective [96] [107,
109] [321]
[339, 390]
[20] [187]
Positive peer norms and support for condom use
NS [127]
Protective [358] [91] [304]
[358] [390]
Greater peer use of condoms
NS [358] [60] [396]
Positive peer norms and support for
contraceptive use
NS [186]
Risk [147] Good friend(s) who have been pregnant/gotten
someone pregnant NS [358]
Good friend(s) who are teen mothers Risk [168]
Partner:
Having a partner the same age (vs. no partner) Risk [243]
Protective [408] Partner has a higher level of education at first
intercourse NS [408]
Protective [139]
Risk [408]
Partner different race/ethnicity
NS [206] [138] [242] [408] [137]
Risk and Protective Factors Protective
Factor,
Risk Factor
or Not
Significant
Initiation
of sex
Frequency of
sex/ Sex
during
specified time
# of
Partners
Use of
condoms
Use of
contraception
Pregnancy /
Impregnation
Childbearing
STD
Protective [408] Partner same religion
NS [408]
Partner is very religious NS [408] [408]
Protective [139] Partner lives in different neighborhood
NS [138] [137]
Protective [255] Greater percentage of year living with partner
Risk [255]
Partner goes to different school Risk [139] [138] [137]
Protective [204] [204]
Risk [184] [243] [386] [113] [138]
[242] [206]
[34, 100, 242,
388] [239]
[2] [93] [216]
[100, 408]
[2, 204] [48] [89]
[137]
[365] [2]
[26]
Having an older romantic or sexual partner
NS [200] [297,
365] [389]
[240] [242]
[239]
[323] [408] [241] [408] [63]
Partner use / abuse of alcohol / illegal
substances
NS [196] [182]
Risk [206] Higher risk status of partner
NS [206] [235]
Risk [276] Partner has STD
NS [365]
Protective [187, 212]
[235] [291,
294] [325]
[278, 291,
389]
[325] Greater partner support for condom use
NS [325]
Protective [278, 389] [394] Greater partner support for contraceptive use
NS [186] [388]
Protective [206]
Risk [206]
Partner used contraception at first intercourse
NS [206]
Risk [204, 206] Greater partner sexual experience
NS [206]
Risk [276] Partner has multiple sex partners
NS [365] [158] [365]
Risk and Protective Factors Protective
Factor,
Risk Factor
or Not
Significant
Initiation
of sex
Frequency of
sex/ Sex
during
specified time
# of
Partners
Use of
condoms
Use of
contraception
Pregnancy /
Impregnation
Childbearing
STD
Individual
Biological:
Protective [309] [343] [177] [302] [11] [60,
109, 197,
344] [229]
[341]
[117] [192]
[137]
[326]
[366]
[377]
Risk [44, 117]
[37] [214]
[198, 219]
[333] [307,
321] [368]
[394] [30,
176] [377]
[75, 106] [2, 21]
[11, 171,
262]
[138] [344] [138] [177]
[229]
[2]
Being male (vs female)
NS [21] [24]
[44] [82]
[382]
[21] [309] [316] [382] [239]
Higher testosterone levels in both genders Risk [155]
Protective [30, 65,
117, 135]
[61] [74]
Older pubertal development and timing
NS [117]
Risk and Protective Factors Protective
Factor,
Risk Factor
or Not
Significant
Initiation
of sex
Frequency of
sex/ Sex
during
specified time
# of
Partners
Use of
condoms
Use of
contraception
Pregnancy /
Impregnation
Childbearing
STD
Protective [36, 134] [173]
[335]
[10] [206]
[397]
[117] [177] [75,
186] [245] [176,
311, 334]
[220]
Risk [2, 36, 117,
140, 154]
[74] [82]
[37] [126]
[75] [145]
[52] [230]
[219, 228,
261] [309]
[257] [258]
[262] [256]
[272, 273]
[307, 314,
321] [343]
[357, 358,
368] [394]
[35, 53]
[23, 54,
176, 227,
334] [24]
[324]
[75] [106] [126]
[177] [203, 207]
[205] [228] [262]
[289][302] [330]
[213] [288] [334]
[2] [11]
[149]
[180]
[205]
[207]
[262]
[309]
[302]
[315]
[171, 263,
332] [379]
[11] [109]
[149, 166]
[207] [275,
278] [294]
[291, 302,
310, 315]
[344] [356]
[335] [334]
[87] [99] [163] [4]
[205] [330]
[355] [408] [23,
100, 151, 176]
[100, 146,
380] [205]
[49] [326]
[365]
[375]
[377]
Older age / higher grade level
NS [24] [52]
[53] [230]
[145] [188]
[243] [252]
[261] [256]
[35] [126] [288]
[334]
[126]
[180]
[188]
[309]
[302]
[334]
[335]
[379]
[108] [138]
[229]
[206] [207]
[245] [315]
[316] [334]
[345] [378]
[53] [55] [62]
[87] [126] [138]
[229] [205]
[228]
[62] [117]
[177] [306]
[330]
[21] [180] [49] [90]
[192]
[149]
[377]
Risk and Protective Factors Protective
Factor,
Risk Factor
or Not
Significant
Initiation
of sex
Frequency of
sex/ Sex
during
specified time
# of
Partners
Use of
condoms
Use of
contraception
Pregnancy /
Impregnation
Childbearing
STD
Protective [36, 134]
[272, 314]
[327] [35]
[54, 261]
[324]
[35] [134] [185]
Risk [4]
Older age of menarche
NS [243] [273]
[277] [324]
[54] [54] [234] [273]
[323]
[241]
Risk [45, 135,
154] [117]
[254] [65,
312]
[177] [117] Greater physical maturity (appears older than
most)
NS [117] [177] [45] [177] [312]
Risk [154] [261] Physically attractive
NS [154] [261]
Physically disabled (minimally) Risk [74]
Physically disbled (severely) NS [74]
Race/Ethnicity:
Protective [228] [303]
[334]
[207] [207] [11] [166] [137]
Risk [11] [275] [341]
Non-Hispanic white
NS [382] [334] [78] [334] [207] [334]
[345]
[62] [228] [334]
[382]
[62]
Protective [74]
Risk [74] [90]
Ethnic minority (vs. white)
NS [23] [74]
[82] [161]
[106] [171] [108] [23]
Risk and Protective Factors Protective
Factor,
Risk Factor
or Not
Significant
Initiation
of sex
Frequency of
sex/ Sex
during
specified time
# of
Partners
Use of
condoms
Use of
contraception
Pregnancy /
Impregnation
Childbearing
STD
Protective [9, 149]
[229]
[245] [278]
[294] [335]
[245] [246]
Risk [2, 102] [37]
[184] [145]
[167] [198]
[214] [219]
[257] [252,
262] [277]
[333] [343]
[357, 368,
376] [44,
334, 394]
[324] [377]
[205, 207] [213]
[262]
[11] [78]
[102]
[173]
[149]
[205]
[207]
[262]
[171, 332,
344] [335]
[107] [204] [167] [204]
[242]
[99] [167] [205]
[306] [23, 176,
408] [323]
[330]
[21, 167]
[146] [205]
[241] [271]
[369] [409]
[57, 241]
[49, 128]
[192]
[137]
[220]
[276]
[366]
[375]
[377]
Black (vs. White)
NS [21] [145]
[230] [252]
[256] [272]
[277] [382]
[21] [203] [213]
[330]
[21] [78]
[332]
[9] [138]
[206] [207]
[246] [335]
[316]
[55] [229] [240]
[138] [205]
[311] [382]
[239]
[62] [314]
[330]
[149]
Risk [2] Black vs. Hispanic
NS [328]
Protective [102, 154]
[352] [377]
[13] [377]
Risk [102] [11] [149]
[332]
[335]
[11] [138]
[278] [206,
316]
[240] [87] [139]
[167] [242]
[246] [176]
[239]
[62] [99] [167]
[314] [408]
[176] [323]
[167] [271]
[369]
[137]
[276]
Hispanic (vs. white)
NS [24] [44,
126] [167]
[230] [243]
[252] [256]
[277] [343]
[376]
[126] [205] [207] [78] [173]
[126]
[171]
[205]
[207]
[335]
[332]
[149] [229]
[206] [207]
[245] [246]
[294] [335]
[55] [229] [240]
[126] [205]
[245] [239]
[205] [306] [205] [241]
[409]
[192]
[149]
[375]
[377]
Risk and Protective Factors Protective
Factor,
Risk Factor
or Not
Significant
Initiation
of sex
Frequency of
sex/ Sex
during
specified time
# of
Partners
Use of
condoms
Use of
contraception
Pregnancy /
Impregnation
Childbearing
STD
Protective [24] [172]
[256] [377]
[377]
Risk [172] [375]
Asian/Pacific Islander (vs. white)
NS [154] [309]
[376]
[149]
[172]
[309]
[149] [172] [55] [240] [306] [409] [149]
[220]
[377]
Protective [335] [240]
Risk [149]
[335]
[239] [205] [205]
Mixed / other ethnicity (vs. white)
NS [230] [256]
[343] [377]
[205] [205]
[335]
[149] [246]
[294] [335]
[240] [205]
[246]
[306] [192]
[149]
[377]
Protective [243]
Risk [138] [188] [138, 188] [188]
Greater acculturation by Hispanics
NS [138] [243] [138]
Relationship with Family:
Protective [238]
Risk [162, 319,
394]
Being a younger (rather than older) sibling
NS [204] [272] [204] [204] [238]
Risk [204] [204] Being a middle sibling
NS [204] [204]
Higher quality of relationship with siblings NS [123]
Protective [42, 102]
[61] [244,
261] [262]
[312] [23,
178, 189,
327, 350,
352]
[330] [29, 106,
178, 213] [262]
[262] [244] [178] [244] [18, 23]
[336]
[369] Having higher quality of family interactions,
support of parents, connectedness
NS [24] [102]
[244] [261]
[374]
[29] [213] [363] [102] [91] [244]
[339]
[244] [312]
[330] [351]
[267] [364]
[369]
[192]
Greater amount of time spent with one or both
parents
NS [86] [29]
Risk and Protective Factors Protective
Factor,
Risk Factor
or Not
Significant
Initiation
of sex
Frequency of
sex/ Sex
during
specified time
# of
Partners
Use of
condoms
Use of
contraception
Pregnancy /
Impregnation
Childbearing
STD
Protective [102] [312] Greater parental-adolescent activities
NS [102] [312] [102] [119]
Protective [238] Greater parent involvement in adolescent’s
education NS [259] [238] [271]
[409]
Greater general parental expectations NS [210]
Greater parent influence Risk [140]
Protective [102] [116]
[117] [252]
[273]
[116] [177] [78] [102] [116] [117]
[177]
[117] [177]
Risk [174]
Greater quality and level of mother-child
interaction / relationship satisfaction
NS [42] [252] [102] [62] [62] [273]
Protective [86] [388] Greater parental influence on personal decisions
NS [76] [86]
Protective [86] Greater compatibility between parent and peer
expectations of adolescent NS [86]
Protective [204] [80]
[82] [272,
304, 322]
[327, 350,
352] [392]
[395]
[181] [75] [263]
[29, 263]
[120]
[181]
[263, 264]
[47] [263]
[359]
[255] [33] [80]
[95] [396]
Risk [140] [119]
Greater parental monitoring / strictness (curfew in
place)
NS [21, 47] [65]
[61] [75]
[123] [204]
[254] [263]
[264] [272]
[352] [359]
[395]
[21] [29] [47]
[75] [264]
[21] [47] [119]
[204] [264]
[322]
[204] [93] [185] [47] [66]
[80]
Protective [42] [252] Greater parental contact with teen’s friends /
their parents NS [252] [21] [21] [271]
Positive perception of parent monitoring Protective [112] [112] [17, 112] [112]
Protective [47]
Risk [47] [47]
Negotiated unsupervised time
NS [47] [47]
Protective [47] [47] Perceived parental trust
NS [47] [47] [47] [47]
Greater conflict with parents Risk [38]
Risk [352] [211] General maltreatment by family
NS [58] [352] [58, 351]
Risk and Protective Factors Protective
Factor,
Risk Factor
or Not
Significant
Initiation
of sex
Frequency of
sex/ Sex
during
specified time
# of
Partners
Use of
condoms
Use of
contraception
Pregnancy /
Impregnation
Childbearing
STD
Verbal abuse Risk [165] [165]
Risk [134] [165,
348, 350]
[363] [165]
[348]
[348] [8, 73, 134,
193, 348]
Physical abuse
NS [58] [348] [348] [58] [323] [369]
Risk [164] Living away from parents
NS [10]
Risk [9] [15] [150] [6] Homelessness
NS [9]
Risk [201] [201] Running away from home
NS [55] [364]
Residing in shelter Risk [150]
Protective [174, 189]
[317] [359]
[264] [263] [263] [174] [359] [382] [156] Greater general communication (between teen
and parent/s)
NS [263] [264]
[382]
[264] [263] [264] [271]
Protective [123] [390] [175] [264] [390] [110, 174]
[218] [322]
[390]
[68, 110] [228]
[272] [311]
[4] [185] [241]
Risk [77, 178]
[75] [263]
[394]
[75, 223] [263] [77] [77]
Greater parent/child communication about
sex and birth control (and/or pregnancy)
NS [153] [228]
[252] [263]
[264] [322]
[29] [178] [228]
[263]
[175]
[263]
[264]
[77] [265]
[264] [391]
[390]
[178] [228] [153] [185] [241] [174]
[396]
Protective [77, 174] [77] [174, 265] [77]
Risk [77]
Greater parent/child communication about sex
prior to sex
NS [390] [390] [397] [174]
Protective [175] [171] [98] Greater parent/child communication about STD
and AIDS prevention NS [175] [391]
Greater belief that children should follow parents’
rules about sexual behavior
NS [29]
Greater congruity of parent/child sexual values NS [223]
Relationship with Community and Community
Adults:
Protective [382] [27] Having a mentor
NS [382]
Protective [94] [249] [94] Involvement in community
NS [382] [94] [119] [94] [382]
Teen perceives that adults care about him/her Protective [90]
Witnessed community violence NS [91]
Risk and Protective Factors Protective
Factor,
Risk Factor
or Not
Significant
Initiation
of sex
Frequency of
sex/ Sex
during
specified time
# of
Partners
Use of
condoms
Use of
contraception
Pregnancy /
Impregnation
Childbearing
STD
Protective [9] Received condom from outreach worker last
month NS [9]
People important to you (parents, other adults, or
peers) approve of contraception / condoms
Protective [187, 212]
Risk [404] Discussed HIV/AIDS with health service provider
NS [404]
Attachment to and Success in School:
Protective [54, 314] [100] [238] [238] [241] Enrolled in school (vs dropped out of school)
NS [10] [54] [314] [238] [365]
Expelled NS [242]
Changed schools multiple times Risk [271]
Protective [312]
Risk [188] [188]
Greater school attendance
NS [30] [188] [312]
Protective [160] [213] [409] [271] Greater participation/involvement in school
NS [86] [29] [213] [288] [271]
Protective [154] [262] [262] [330] [262] [271] [409] Greater participation in extracurricular activities
(i.e., music, drama, clubs) or school sports NS [24] [154]
[262] [382]
[262] [330] [262] [119] [382] [330] [271]
Protective [24] Greater popularity in school
NS [24]
Greater educational investment NS [238]
Protective [21] [24]
[249] [312]
[350]
Greater connectedness to school
NS [24] [251] [21] [21] [312] [369]
Greater perception that teachers are supportive Protective [251]
Protective [213] [298] [299] Positive attitude toward school
NS [259] [277] [213]
Risk and Protective Factors Protective
Factor,
Risk Factor
or Not
Significant
Initiation
of sex
Frequency of
sex/ Sex
during
specified time
# of
Partners
Use of
condoms
Use of
contraception
Pregnancy /
Impregnation
Childbearing
STD
Protective [24] [30]
[52] [45,
102, 140]
[70] [86]
[82] [2, 154]
[75, 210,
243] [214]
[273] [333]
[35, 259,
307, 312]
[203] [106, 363]
[288]
[2, 102] [119] [245]
[356]
[242, 245] [168, 238]
[336] [351]
[13] [238]
[271] [369]
[361] [364,
409]
Better educational performance
NS [65] [61]
[86] [70]
[243] [307]
[352]
[223] [288] [119] [23] [45] [190]
[273] [312]
[156] [271]
[364]
Protective [140]
Risk [204] [35,
53] [300]
[255] [205] [228] [53] [205, 364]
[406]
[238] [271]
Behind in school/problems in school
NS [228] [205] [207] [228]
[353]
[205]
[207]
[353]
[204] [207]
[353]
[55] [204] [228]
[353]
[353] [205] [238]
[406]
Either very high or very low intelligence scores Protective [154]
Protective [21] [75] [75] Greater importance of academic achievement
NS [75] [86] [75] [21]
Protective [199, 211]
[324] [337,
352]
[213, 223] [211] [298]
[238] [351]
[156] [271]
[361]
Higher educational aspirations
NS [36] [161]
[243] [264]
[324] [352]
[21] [213] [264]
[363]
[21] [264] [264] [294] [190] [405] [271] [299]
[369]
Protective [43, 154] [238] [271] Plans for higher education
NS [259] [29] [288] [238]
Attachment to Faith Communities:
Spiritual interconnectedness Protective [169]
Protective [285] [395] [285] Greater importance of religion / frequency of
prayer NS [285] [285]
Protective [2, 45, 102]
[82] [204]
[23, 312]
[102] [207] [185, 241] Having a religious affiliation
NS [52] [207] [207] [229] [62] [229] [45] [62] [163]
[312]
[156] [185]
[238] [369]
[90]
Risk and Protective Factors Protective
Factor,
Risk Factor
or Not
Significant
Initiation
of sex
Frequency of
sex/ Sex
during
specified time
# of
Partners
Use of
condoms
Use of
contraception
Pregnancy /
Impregnation
Childbearing
STD
Protective [24] [21,
103] [157]
[162] [167]
[228] [249]
[257] [285]
[250, 253,
261] [256]
[314] [35,
154, 203,
210, 312]
[324] [382]
[21, 223] [228]
[106, 207, 363]
[360]
[2] [266]
[353]
[255] [353] [240] [167, 266] [285] [298] [241] [271]
Risk [203]
More frequent attendance /greater religiosity
NS [24] [30]
[36] [103]
[140] [162]
[204] [261]
[266] [264]
[277] [324]
[264] [353] [360] [264]
[353]
[204] [245]
[250] [264]
[294] [310]
[240] [186]
[204] [228]
[245] [285]
[311] [353]
[382]
[167] [234]
[299] [353]
[408]
[167] [241]
[408]
Attend same church as peers Protective [277]
Protective [387] [258] [207] Having a conservative religious affiliation
NS [266] [266] [294] [266]
Protective [68, 110]
Risk [408] [23]
Protestant
NS [30] [53]
[395]
[53]
Protective [395]
Risk [36] [54]
Catholic
NS [30] [53]
[324] [395]
[207] [207] [207] [53] [54] [68,
110] [272] [311]
[408] [408]
Risk [324] [234] Baptist
NS [53] [324] [53] [299] [408] [408]
Catholic, Protestant or Jewish (vs. other or none) Protective [54] [246] [246] [234] [298] [185]
NS [162] [204]
[257] [258]
[314]
[54] [204]
[246]
[54] [204] [246]
[372]
[23] [185]
Protective [207] Evangelicial
NS [207] [207]
Non-Christian NS [207] [207] [207]
Risk and Protective Factors Protective
Factor,
Risk Factor
or Not
Significant
Initiation
of sex
Frequency of
sex/ Sex
during
specified time
# of
Partners
Use of
condoms
Use of
contraception
Pregnancy /
Impregnation
Childbearing
STD
Relationships with Peers:
Risk [76] Greater importance of friends/more peer
influence on decisions NS [140] [350]
[358]
[358]
Having peer role models Protective [382] [382]
Protective [213] [249]
Risk [50] [213]
Greater peer support / bonding with peers / more
social activities with peers
NS [61] [70]
[76]
[50]
Protective [23] Not being part of a peer group
NS [339] [62] [62]
Protective [23]
Risk [85] [23] [271]
Being popular with peers
NS [154] [85] [271]
Risk [254] Greater importance of popularity
NS [254]
Difficulty talking with others NS [55]
Protective [308]
Risk [211] [383] [225]
[308]
[383]
[225] [225] [313]
[383]
[369] [225]
Membership in a gang / problems with gangs
NS [308] [308] [91] [308]
[383]
[55] [308] [308] [383]
Pressure from peers to engage in high-risk or
deviant behaviors
NS [363]
Risk [29] Perceive more peer pressure to engage in sexual
activity NS [358] [29] [358]
Protective [328] Discuss sexuality with friends
NS [153] [153]
Discuss contraception with friends NS [397]
Discussed HIV/AIDS with friends Protective [171] [166]
Relationships with Romantic Partners:
Dating alone Risk [254]
Risk [230] [256] [229] Currently dating
NS [229]
Risk [261] [357] Greater frequency of dating
NS [261]
Older age of onset of dating / having romantic
relationships
NS [410] [311]
Risk and Protective Factors Protective
Factor,
Risk Factor
or Not
Significant
Initiation
of sex
Frequency of
sex/ Sex
during
specified time
# of
Partners
Use of
condoms
Use of
contraception
Pregnancy /
Impregnation
Childbearing
STD
Protective [253] [363] [139] [240] [139]
[186] [242, 245]
Risk [24] [42, 84]
[70] [154,
226] [227]
[252] [318]
[337, 350]
[43]
[177] [235, 274]
[365]
[156]
Having a romantic relationship, going steady with
a boy/girlfriend, closeness of relationship with
partner, longterm relationship (>1 year)
NS [24] [84]
[70] [226]
[252] [318]
[141] [196]
[200]
[224] [245]
[294] [297]
[328] [389]
[28] [240] [177]
[186] [242]
[177] [241] [365]
Protective [23] [316] [356]
[397]
Risk [24] [108, 136]
[294] [397]
[62] [240] [292] [355] [23,
151]
[49, 63]
[137]
[192] [89]
[142]
[202]
[220,
276]
[287]
[326]
[365]
[375]
Having a greater number of romantic or sexual
partners
NS [19] [20]
[200] [206]
[235] [316]
[328] [389]
[404]
[158] [240]
[372]
[323] [406] [406] [63] [182]
[339]
[365]
[366]
[384]
Importance of present relationship Risk [152]
Risk [239] Social embeddedness of romantic relationship
NS [24] [239]
Risk [240] Met partner as a s tranger
NS [240]
Risk [242] [239] Just friends with partner / liked partner
NS [240] [239] [241]
Risk [63] New sexual partner (within past month)
NS [396]
Risk and Protective Factors Protective
Factor,
Risk Factor
or Not
Significant
Initiation
of sex
Frequency of
sex/ Sex
during
specified time
# of
Partners
Use of
condoms
Use of
contraception
Pregnancy /
Impregnation
Childbearing
STD
Protective [206, 224]
[297] [365]
[239]
Risk [139] [204] [139] [204]
[242] [239]
[276]
[396]
Newer relationship (<6 months)
NS [141] [206]
[224] [297]
[239] [306] [63] [89]
Protective [239] Time between start of relationship and first sex
NS [239]
Protective [136] [388] [192]
Risk
Monogamous relationship
NS [297]
Sex partner concurrency (self or partner) NS [182]
Risk [255] [255] [255] [255] Ever engaged
NS [204] [204] [242]
Protective [188]
[332]
Risk [206] [18, 32, 176] [176]
Being married
NS [188] [188] [384]
Protective [371] Greater emotional intimacy power in the
relationship NS [371]
Greater decision-making power in the
relationship
NS [371]
Discuss sex with partner NS [153] [91] [372] [153]
Protective [15] [19]
[96] [316,
391] [328]
Discuss sexual risk or history with partner
NS [63] [396]
Protective [107] [391] [228] Discuss STDs/AIDS with partner
NS [224]
Perceives partner to be HIV infected Risk [365]
Risk [93] Perceives (male) partner desires pregnancy
NS [407] [407] [407]
Protective [224] [389,
397]
[301, 372] Discuss contraception / STD prevention with
partner
NS [91] [297]
Risk and Protective Factors Protective
Factor,
Risk Factor
or Not
Significant
Initiation
of sex
Frequency of
sex/ Sex
during
specified time
# of
Partners
Use of
condoms
Use of
contraception
Pregnancy /
Impregnation
Childbearing
STD
Protective [239] Discuss contraception with partner before sex
NS [239]
Agree with partner about contraceptive method Protective [278] [55]
Risk [347] [347]
[404]
[347] [240] [347] Experienced physical abuse by partner
NS [404] [404] [240] [239]
Sexual Abuse and Violence:
Risk [31] [31] [31] Experienced violence
NS [31]
Experienced dating violence Risk [379] [400] [400] [400]
Experienced sexual coercion Risk [243] [284]
Risk [72, 102,
134, 165,
260] [64]
[272] [346,
348, 350]
[362] [51,
243, 308]
[375]
[346] [102]
[149, 165]
[64] [331]
[346]
[362]
[348]
[404]
[284]
[308]
[379]
[375]
[149] [331]
[346] [404]
[375]
[51, 362] [71]
[331]
[8] [72] [134]
[331] [292]
[346] [51, 362]
[308]
[64] [149]
[331]
[381]
[375]
Experienced sexual abuse / forced sex
NS [58] [64]
[346]
[363] [64] [256]
[348]
[346]
[404]
[64] [308]
[348]
[55] [308] [58] [64] [241] [256]
Greater severity of sexual abuse NS [323]
Risk [323] Relationship to perpetrator
NS [323]
Healthful Behaviors:
Protective [118] [208]
[262] [329]
[262] [329, 330] [208]
[262]
[315]
[329]
[143] [329] [208] [329] [409] [329] [329]
Risk [329]
Greater participation in sports / exercise
NS [208] [262]
[382]
[262] [208]
[262]
[315] [382] [118] [208]
[330]
Seat belt use Protective [143]
Healthier diet Protective [143]
Well-groomed NS [154]
Good dental hygiene Protective [143]
Risk and Protective Factors Protective
Factor,
Risk Factor
or Not
Significant
Initiation
of sex
Frequency of
sex/ Sex
during
specified time
# of
Partners
Use of
condoms
Use of
contraception
Pregnancy /
Impregnation
Childbearing
STD
Protective [132] [161] [131] [87] Greater involvement in other healthy behaviors
NS [290]
Problem or Risk-taking Behaviors:
Okay to break the law Risk [76]
Protective [154] [201]
Risk [109]
Greater impulsivity
NS [91]
Risk [82] [201] [315]
[378]
[315] [12, 87] [313, 355] [201] [338] Greater sensation seeking / reckless behavior /
risk-taking
NS [36] [70] [315]
[378]
[224] [315]
[341]
Greater general psychosocial conventionality Protective [76] [211] [87]
Risk [86, 140]
[324]
[264] [264] [143] Greater involvement in general unconventional
behavior
NS [86] [272]
[324]
[364] [66]
Greater perception of parental disapproval of
substance use
NS [86]
Protective [188]
Risk [50] [188]
[333] [324]
[352] [367]
[343]
[29] [188]
[367]
[367] [151, 355]
[336]
[369] [264]
[367]
Substance use (combined alcohol, tobacco,
marijuana)
NS [324] [29] [50] [365]
Protective [133, 134]
Risk [161] [210]
[219] [309]
[277] [307,
318] [317]
[395]
[302] [173]
[309]
[302]
[315]
[344]
[378]
[119] [302,
315] [404]
[186] [32] [292] [355] [220]
Tobacco use
NS [36] [76]
[161] [277]
[308] [318]
[309]
[308]
[119] [219]
[231] [308]
[302] [315]
[404]
[186] [242]
[308]
[308] [323]
Risk and Protective Factors Protective
Factor,
Risk Factor
or Not
Significant
Initiation
of sex
Frequency of
sex/ Sex
during
specified time
# of
Partners
Use of
condoms
Use of
contraception
Pregnancy /
Impregnation
Childbearing
STD
Protective
[308]
Risk [16, 161]
[41] [86,
281] [198,
201] [210]
[219, 264]
[309] [277]
[307] [314]
[350] [395]
[264] [302] [15] [16, 281]
[173]
[264]
[309]
[315]
[344]
[378]
[404]
[308]
[332]
[335]
[410]
[19, 166]
[290] [15,
315]
[143] [201] [268] [193] [93]
[355]
[201] [83]
[340]
Alcohol use / abuse
NS [76] [86]
[277] [308]
[122]
[308]
[404]
[108] [119]
[196] [219]
[231] [235]
[308] [302]
[316] [339]
[345] [404]
[335]
[308] [32] [268] [48] [49]
[63] [345]
Protective [351] Older age at first tobacco/alcohol/substance use
NS [103] [309] [309]
[344]
[344]
Drinking while driving Risk [355]
Protective [15] [308]
Risk [65] [281]
[201] [210]
[219, 226]
[264] [309]
[314] [308]
[343]
[264] [15, 106,
302]
[281]
[264]
[309]
[283, 302]
[308]
[332]
[344, 379]
[404]
[335]
[15, 19,
166] [196]
[197, 222]
[290, 302]
[315] [344]
[231, 404]
[335]
[143] [4, 133] [93]
[336] [355]
[308]
[48] [49,
164] [89]
[194,
222] [25]
Substance use / abuse
NS [86] [122]
[332]
[335]
[404]
[15] [108]
[119] [219]
[235] [264]
[302] [315]
[316] [339]
[345] [404]
[158] [308] [308] [364] [63] [182]
[164]
[345]
Risk and Protective Factors Protective
Factor,
Risk Factor
or Not
Significant
Initiation
of sex
Frequency of
sex/ Sex
during
specified time
# of
Partners
Use of
condoms
Use of
contraception
Pregnancy /
Impregnation
Childbearing
STD
Problems because of substance use Risk [201]
Sharing needles NS [19]
Risk [211] [123]
[82] [65,
105, 161,
195, 303,
324] [395]
[106, 363] [264] [264]
[315]
[60, 290] [190, 292] [93]
[336]
[156] [364] [89] Greater involvement in delinquent / problem
behaviors
NS [161] [261]
[264] [277]
[324]
[264] [195] [364]
Prior involvement in problem behaviors Risk [61]
Risk [81] [161]
[261] [308]
[343]
[173]
[379]
[308]
[93] [355] [308]
[313]
Physical fighting
NS [161] [198]
[261] [308]
Risk [81] [308]
[343]
[379]
[308]
[292] Carrying weapons
NS [308] [308] [308] [308]
Risk [85] [315]
[378]
[338] [267] [338] Hostility / aggression
NS [378] [315] [85] [268] [364]
Previous aggression (as a child) Risk [268]
Greater risk of unintentional injury Risk [313]
Multiple admissions to a detention facility NS [196]
Other Behaviors
Risk [45] [312,
314]
[205] [353] [205]
[353]
[255] [353] [205] [205] Paid work / employed more than 20 hours/week
NS [357] [353] [353] [353] [55] [186] [205]
[353]
[45] [312] [353] [409] [384]
Protective [103] [314]
[405]
[361] Higher work / occupational aspirations
NS [21] [183] [299] [21] [156]
Volunteer (unpaid work) Protective [201] [201]
Greater average wage Risk [255] [255]
Has a driver’s license NS [90]
TV / video game viewing NS [378]
Risk [59] [82] Viewing TV shows with sexual content (depicting
behaviors, discussion about sex or risks) NS [82]
Viewing x-rated movies Risk [398] [398] [398] [398]
Risk and Protective Factors Protective
Factor,
Risk Factor
or Not
Significant
Initiation
of sex
Frequency of
sex/ Sex
during
specified time
# of
Partners
Use of
condoms
Use of
contraception
Pregnancy /
Impregnation
Childbearing
STD
General Skills and Personality Traits:
Protective [132] [324] [62] [240] [170]
[239]
[62] [342] Higher level of cognitive development
NS [324] [290] [341] [240] [342]
Makes responsible choices NS [382] [382]
Greater problem-solving skills Protective [154] [131]
More sociable / outgoing / social ease Risk [61]
Protective [382] More future orientation
NS [123] [277] [382]
Greater egocentrism Protective [170]
Opinions more influenced by others NS [36]
Emotional Well-Being and Distress
Protective [103] [333]
[354] [385]
[264] [131] [170]
[353]
[32] [299] [201]
Risk [354] [255]
[353]
Higher self-esteem, self -image, self -concept
NS [24] [30]
[103] [183]
[145] [230]
[264] [350]
[223] [264] [353]
[363]
[264] [290] [294]
[345]
[62] [186] [353] [23] [32] [62]
[353]
[299] [369]
[361]
[164]
[345]
[396]
Greater general emotional well-being NS [82] [210]
[260] [277]
[290]
Greater life satisfaction NS [161]
Risk [399] Greater dissatisfaction with body image
NS [399] [399]
Bulimic Risk [282]
Greater feeling of failure Risk [201] [201]
Protective [255] [353] [255] [353]
[356]
[298] [405] [156] [201]
Risk [103]
Greater internal locus of control
NS [103] [353] [353] [294] [353] [353] [299] [361]
Protective [109] [356] Greater impulse control and self -control
NS [196]
Higher decision-making autonomy Risk [154]
Hyperactivity / ADHD NS [364]
Risk [45] [154]
[312]
Greater perceived risk of untimely death
NS [154] [45] [312]
Risk and Protective Factors Protective
Factor,
Risk Factor
or Not
Significant
Initiation
of sex
Frequency of
sex/ Sex
during
specified time
# of
Partners
Use of
condoms
Use of
contraception
Pregnancy /
Impregnation
Childbearing
STD
Protective [65] [85]
Risk [161]
Greater level of stress or anxiety
NS [154] [85] [164]
Concern about job prospects Risk [350]
Risk [320] Greater feelings of sadness / hopelessness
NS [173]
[320]
[320] [320] [320]
Protective [201] [283]
Risk [85] [230]
[201] [352]
[232] [320, 345] [201] [232] [201] [267] [320,
345]
Depression
NS [161] [254]
[352]
[320] [345] [55] [85] [320] [351] [364] [369] [164]
[345]
Protective [320] [308]
Risk [30] [210]
[308]
Suicide thoughts
NS [308] [308]
[320]
[308] [320] [308] [320] [320]
Suicide attempts Risk [292]
Receipt of help for emotional problems Risk [201] [201]
Protective More social support
NS [50] [50] [164]
Risk [46] Conduct disorder
NS [364]
Personality disorder Risk [215]
Beliefs and Attitudes about Gender Roles:
Protective [188] [255] [255] [255] [298]
Risk [145] [140] [295] [245] [295] [201] [245] [361]
More stereotypical gender roles
NS [188] [294] [188] [299]
Protective [224] [278]
[294, 295,
296]
[255] [353] Greater perceived male responsibility for
pregnancy prevention
NS [353] [353] [293] [353] [353]
Knowledge, Beliefs, Attitudes and Skills
Regarding Sex
Protective Greater sexual knowledge
NS [30] [180] [180] [180]
Risk and Protective Factors Protective
Factor,
Risk Factor
or Not
Significant
Initiation
of sex
Frequency of
sex/ Sex
during
specified time
# of
Partners
Use of
condoms
Use of
contraception
Pregnancy /
Impregnation
Childbearing
STD
Greater knowledge about fertility cycle Protective [311]
Protective [228] [368] [228] Older ideal age to initiate intercourse
NS [228]
Risk [116] [116] Believe is mature enough for sexual relationship
NS [116]
Protective [116] [116] Believe ought to be in love to have sex
NS [116]
Risk [140] [41]
[228, 258]
[368] [67,
227, 393]
[209]
[29] [180] [203]
[228]
[180]
[255]
[255] [4] More permissive attitudes toward premarital sex
NS [183] [228] [180]
Believe premarital sex is okay if plan to marry Protective [203]
Protective [41] [183] Teen sex / premarital sex is against personal
beliefs (waiting until married to have sex) NS [116] [116] [116]
Greater use of rationalizations for sexual
behavior
NS [29]
More perceived personal benefits of abstaining
from sex
Protective [115] [333]
Risk [115] [256]
[318]
[29] More perceived personal and social benefits
(than costs) of having sex
NS [115] [116] [116]
More positive perceived norms about sex Risk [115]
Belief that boys gain respect if they have sex Risk [198]
Belief that boys lose respect if they have sex Protective [198]
Belief that boy/girlfriend would lose respect if
have sex
NS [116] [116]
Protective [358] Desire to have friends believe respondent is a
virgin Risk [358]
Protective [116] [318,
358]
Greater feelings of guilt if sexually active
NS [183] [358] [116]
Regrets over previous sexual behavior NS [116] [90]
Protective [75, 191]
[318] [317]
[20] [115] Greater self-efficacy to refrain from sex
NS [67] [75]
[115] [358]
[75] [358]
Protective [204, 279] [207] [207] Greater resistance skills
NS [207]
Greater erotophilia Risk [92]
Greater enjoyment of sex (“sex feels good”) NS [92]
Risk and Protective Factors Protective
Factor,
Risk Factor
or Not
Significant
Initiation
of sex
Frequency of
sex/ Sex
during
specified time
# of
Partners
Use of
condoms
Use of
contraception
Pregnancy /
Impregnation
Childbearing
STD
Protective [274] Greater intention to have sex
Risk [198] [20]
Protective [45] [24,
312]
Risk [24] [239]
Pledge of virginity
NS [24] [239] [45] [312]
Beliefs and Attitudes about Number of Sexual
Partners
More conservative attitudes and norms toward
number of sexual partners
Protective [20, 69]
Perception that monogamy will not reduce STD
risk
Risk [49]
Beliefs and Attitudes about Condoms and
Contraception
Protective [108] [166] [63] Stronger belief that condoms are effective in
reducing STD/HIV/pregnancy NS [127] [235]
[278] [294]
[358]
Protective [92] [166] [278]
[293] [294,
295] [325]
[356]
Stronger belief that condoms do not reduce
pleasure
NS [358]
Protective [278] [293]
[294, 295]
Greater value of partner appreciation of condom
use
NS [294]
Greater perceived hassle of condom use Risk [291]
Protective [20, 197]
[196]
[235, 245]
[310]
[166]
[62] [170] [245]
[407] [388]
[407] More positive attitudes toward condoms and
other forms of contraception
NS [180] [180] [127] [212]
[290]
[180] [407] [49] [89]
Risk [166] [278]
[294]
Greater embarrassment to use condom
NS [41] [293] [294]
[295]
Risk and Protective Factors Protective
Factor,
Risk Factor
or Not
Significant
Initiation
of sex
Frequency of
sex/ Sex
during
specified time
# of
Partners
Use of
condoms
Use of
contraception
Pregnancy /
Impregnation
Childbearing
STD
Protective [228] [228] Greater embarrassment to buy birth control
NS [41] [228]
Protective [333] [96] [108]
[115]
[228] Lower perceived barriers or costs of using
condoms
NS [114]
[396]
Protective [333] [235] Greater perceived accessibility of condoms
NS [325]
Protective [50] [127]
[115, 310]
[152] [75]
[187, 191]
[229] [291]
[109] [341]
[358]
[229] [407]
Risk [192]
Greater perceived self -efficacy in using condoms
or contraception
NS [50] [75] [75] [310] [407] [407] [384]
[396]
Greater perceived skills for using condoms NS [187] [49]
Protective [109] [20]
[235]
Greater self-efficacy to demand condom use
NS [396]
Protective [20, 60]
[91]
[3] Greater intention to use condoms
NS [49]
Protective [9, 166]
[356]
Carry condoms
NS [9] [111] [111]
Protective [310, 397] [170]
Risk [228]
Greater knowledge about condoms /
contraception
NS [228] [187] [310] [228] [156] [384]
Perception of positive side effects of oral
contraceptives
Protective [388]
Perception of negative side effects of oral
contraceptives
NS [388]
Protective [228] Greater perceived effectiveness of oral
contraception NS [228] [228] [228]
Greater comfort and satisfaction with
contraceptive method
Protective [55]
Greater motivation to use condoms /
contraception
Protective [15, 278]
[341]
Risk and Protective Factors Protective
Factor,
Risk Factor
or Not
Significant
Initiation
of sex
Frequency of
sex/ Sex
during
specified time
# of
Partners
Use of
condoms
Use of
contraception
Pregnancy /
Impregnation
Childbearing
STD
Greater intention to use contraception Protective [318] [3]
Knowledge, Beliefs, and Attitudes about
Pregnancy, Abortion and Childbearing:
Protective
Risk [36]
Older ideal age for marriage
NS [123]
Greater desire for marriage NS [213]
Protective [255] [353]
Risk [255] [353] [353]
Belief that marriage is not an easy solution to
pregnancy
NS [353] [353] [353] [353] [353]
Protective [245] [278]
Risk [313]
Belief that causing a pregnancy was a sign of
manhood
NS [245] [293]
[295]
Greater embarrassment if pregnant Protective [154]
Greater knowledge about pregnancy avoidance NS [62] [62]
Protective [44] [118] [116] [255] [255] [255] [294]
[341]
[116] [255] [45, 179] [312] Greater perceived negative consequences of
pregnancy
NS [45] [116]
[312] [317]
[358]
[116] [212] [358] [62] [116] [62]
Greater ambivalence about pregnancy Risk [62] [62]
Greater perceived pregnancy risk if does not
contracept
NS [341]
Risk [101] [407] [407] Greater desire to get pregnant
NS [92] [101] [101] [93] [407]
Protective [212] [290] [388, 407] Greater importance of avoiding pregnancy
NS [183] [293] [397] [186]
Greater worry about pregnancy NS [41]
Protective [36] [228]
[368]
[228]
Risk [36]
Older ideal age for first birth
NS [123] [228] [228] [311]
Risk [228] [228] [406, 407] Greater desire to have a child or ambivalent
about having one NS [213] [228] [406]
Risk and Protective Factors Protective
Factor,
Risk Factor
or Not
Significant
Initiation
of sex
Frequency of
sex/ Sex
during
specified time
# of
Partners
Use of
condoms
Use of
contraception
Pregnancy /
Impregnation
Childbearing
STD
Support premarital childbearing (for self) NS [21] [123] [21] [21]
Belief that adolescents are not good parents NS [228] [228] [228]
Protective [245] Expect to have at least one child
NS [245]
Greater perceived ease of childbearing and
parenting
Risk [373] [373] [168]
Risk [317] More positive attitudes towards (teen)
childbearing NS [317] [358] [358] [62] [62]
More responsible paternity attitudes NS [245] [245]
Protective [255] [255] [255] Intention to have and support baby if became
pregnant Risk [203]
Protective [228] [228] [311] Intention to keep baby if became pregnant
NS [228]
Would consider adoption as a resolution for
unplanned pregnancy
NS [203]
More positive attitudes towards abortion Protective [407]
More permissive attitudes about abortion Risk [203]
NS [407] [407]
Beliefs and Attitudes about STD and
HIV/AIDS:
Protective [11, 171] [11, 207]
[339]
[114]
Risk [197] [196]
[275]
Greater knowledge about HIV/AIDS/STDs
NS [50] [264]
[321]
[207] [264] [122]
[207]
[264]
[108]
[264] [290]
[321]
[49] [164]
Protective [316] [166]
Risk [9]
Knowing someone with HIV/AIDS
NS [9]
Risk and Protective Factors Protective
Factor,
Risk Factor
or Not
Significant
Initiation
of sex
Frequency of
sex/ Sex
during
specified time
# of
Partners
Use of
condoms
Use of
contraception
Pregnancy /
Impregnation
Childbearing
STD
Protective [358] [264] [264] [127] [166]
[152] [278]
[310]
[12]
Risk [50] [333] [207] [9] [164]
[326]
[384]
Greater perceived risk or concern about
STDs/HIV
NS [41] [116]
[183] [264]
[358]
[116] [207] [130] [9] [10]
[19] [50]
[130] [127]
[207] [264]
[278] [293]
[294] [310]
[339] [341]
[358]
[116] [49] [192]
[396]
Risk [293] [294] Greater denial about/discounting risk of HIV/AIDS
NS [294]
Protective [358] Greater perception that mother would be upset if
respondent contracted an STD NS [358]
Protective [207] [278]
[294]
[283]
Risk [161] [207] [207]
Greater general worry about AIDS
NS [50] [161] [19] [50]
[224] [293]
[339] [341]
[396]
Protective [19] Greater worry about friends contracting
STD/AIDS NS
Protective
[207] [275]
[290] [358]
[326] Greater motivation to avoid STDs/AIDS
NS [207] [207] [212] [290]
Protective [50] [235] Greater self-efficacy for STD/AIDS prevention
NS [50] [122] [108] [339] [49]
Risk and Protective Factors Protective
Factor,
Risk Factor
or Not
Significant
Initiation
of sex
Frequency of
sex/ Sex
during
specified time
# of
Partners
Use of
condoms
Use of
contraception
Pregnancy /
Impregnation
Childbearing
STD
Discussed AIDS with their physician Protective [166]
Discussed AIDS with others Protective [166]
Risk [50] More negative attitudes toward people with AIDS
NS [50]
Belief that contracting HIV is one’s own fault NS [19]
Greater perception that peers do not support
STD/AIDS prevention
NS [49]
Sex-Related Behaviors:
Identifies as homosexual or bi-sexual (vs. hetero) NS [10]
Protective [312] [235]
Risk [40, 45,
269] [312]
[269] [40, 79,
102] [149]
[308]
[149] [40] [308] [149] [25]
Same-sex attraction or behavior (GLB)
NS [308] [102] [308] [308] [45] [312] [365]
[384]
Ever kissed or necked Risk [140] [44,
252]
Risk [288] [229] [305] Sexually active (currently or ever)
NS [229]
Protective [122]
[283]
[332, 344,
386, 404]
[152]
[246] [278]
[293] [294]
[206, 344,
404]
[131] [242]
[246] [272]
[303]
[193] [283]
[355] [23, 408]
[323] [351]
[185] [241]
[352, 369]
[361]
[174]
[202]
[384]
[375]
[377]
Risk [316] [240]
Older age at first sex
NS [92] [344] [108] [206]
[345] [341]
[404]
[239] [93] [406] [406] [63] [89]
[182]
[345]
[384]
[377]
Risk and Protective Factors Protective
Factor,
Risk Factor
or Not
Significant
Initiation
of sex
Frequency of
sex/ Sex
during
specified time
# of
Partners
Use of
condoms
Use of
contraception
Pregnancy /
Impregnation
Childbearing
STD
Protective [163]
Risk [344] [15] [344] [311] [45] [312] [365]
Greater number of years being sexually active
NS [312] [341] [62] [311] [372] [62] [163]
Protective [186]
Risk [141] [109]
[206, 389]
[147] [330]
[406]
[406] [202]
Greater frequency of sex
NS [206] [328] [186] [311]
[388]
[48]
Greater wantedness of first sex Protective [1]
Risk [114]
[396]
Unprotected intercourse
NS [114]
Unprotected intercourse with multiple partners Risk [114]
Greater sexual risk-taking in general NS [224] [323]
Protective Greater acceptance of own sexual behavior
NS [372]
Intention to avoid sex with strangers Protective
Risk [302]
[335]
[172, 302]
[341]
[114] Use of alcohol or drugs before sex
NS [404] [335] [404] [55] [63] [192]
[339]
[375]
Greater number of visits to a family planning
clinic
Protective [56]
Protective [141] [127]
[206] [325,
356]
[151, 163] [174]
[276]
[287]
[340]
[384]
Previous use of condoms
NS [206]
Protective [66] [114]
[142]
[287]
[339]
Regular use of condoms
NS [122] [63] [144]
[48] [384]
Protective [240] [245, 388] [18, 23, 168,
312]
Previous use of contraception
NS [240]
Risk and Protective Factors Protective
Factor,
Risk Factor
or Not
Significant
Initiation
of sex
Frequency of
sex/ Sex
during
specified time
# of
Partners
Use of
condoms
Use of
contraception
Pregnancy /
Impregnation
Childbearing
STD
Protective [62] [133]
[306]
[202]
[365]
Regular use of contraception
NS [92] [290] [63]
Protective [265] [341]
[356]
[45, 147] [163,
167] [292]
[312] [323]
[185]
Risk [192]
Effective contraception / condom use at first / last
sex
NS [312] [173] [341] [241] [192]
[366]
[384]
[375]
Use of contraception other than condom Risk [274]
Protective [163] [306] [276]
Risk [294] [328] [220]
Use of hormonal contraceptive
NS [91] [297]
[389]
[90]
Use of implant method of contraception Protective [158]
Risk Oral intercourse (ever had or age at first
experience) NS [49] [365]
Risk [164] Anal intercourse (ever had or age at first
experience) NS [49] [365]
Unprotected anal intercourse Risk [121]
Protective [10] [316]
Risk [9] [384]
Exchanged sex for money, drugs, needs/survival
sex (prostitution)
NS [9] [10]
[316]
[323]
Sex with intravenous drug user NS [316]
[365]
[49] [365]
Risk [365] Sex with HIV-positive partner
NS [365] [49]
Pregnancy and STD Status:
Previous pregnancy scare Protective [289]
Protective [148] [289]
Risk [92] [151] [10] [151]
[91] [245]
[397]
[87] [131] [245]
[55]
[62] [306] [49] [151]
[276]
Previous pregnancy / impregnation
NS [328] [62] [87] [158]
[311] [372]
[63] [164]
[89]
Prior miscarriage Risk
Risk and Protective Factors Protective
Factor,
Risk Factor
or Not
Significant
Initiation
of sex
Frequency of
sex/ Sex
during
specified time
# of
Partners
Use of
condoms
Use of
contraception
Pregnancy /
Impregnation
Childbearing
STD
Protective [388] Previous abortion
NS [311] [164]
Greater number of children Risk [384]
Older age at birth of first child (for respondent
who already has a child)
Protective [147]
Protective [10] Been tested for HIV
NS [10] [55]
Protective [328]
Risk [114] [33]
Any STD history
NS [91] [341]
[397]
[158] [306] [63] [114]
[89] [366]
Protective
Risk [151] [90] [142]
[287]
[384]
[396]
History of recent STD
NS [141] [55] [63] [144]
Protective [28] HIV positive
NS [10]
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About the Putting What Works to Work project:
Putting What Works to Work (PWWTW) is a project of the National Campaign to
Prevent Teen Pregnancy, funded, in part, by the Centers for Disease Control and
Prevention (CDC). Through PWWTW, the National Campaign is translating research on
teen pregnancy prevention and related issues into user friendly materials for practitioners,
policymakers, and advocates. Materials produced for the PWWTW project are supported
by Grant #U88/CCU322139-01 from the CDC. Contents of these materials are solely the
responsibility of the authors and do not necessarily represent the views of the CDC.
Acknowledgments
The National Campaign and author Douglas Kirby would like to thank the members of
the PWWTW Scientific Advisory Committee (listed below) for their helpful comments
on early drafts of this document. Their careful review and advice has made this a much
more useful document. In addition, the author would like to recognize valuable
guidance from Susan Philliber, Shanti Conly, Jim Jaccard, Jennifer Manlove, and
William Marsiglio as well as invaluable editorial assistance from Karen Troccoli of the
National Campaign.
Finally, the authors would especially like to thank both Bob Blum and Kristin Mmari.
Over many years, they have substantially contributed to both the conceptualization and
execution of this project during many domestic and international meetings and through
joint searches for relevant articles, reviews of thousands of abstracts, and their retrieval of
hundreds of articles, among many other things.
Putting What Works To Work Scientific Advisory Committee
Brent Miller (Co-Chair), Vice President for Research, Utah State University
Sharon Rodine (Co-Chair), Coordinator, Heart of OKC Project, Oklahoma Institute for
Child Advocacy
Suzan Boyd, Executive Director, South Carolina Campaign to Prevent Teen Pregnancy
Claire Brindis, Director, Center for Reproductive Health Policy Research, National
Adolescent Health Information Center, University of California, San Francisco
Ralph DiClemente, Charles Howard Candler Professor of Public Health and Associate
Director, Center for AIDS Research, Emory University
Jonathan Klein, Associate Professor of Pediatrics and of Preventive and Community
Medicine, University of Rochester School of Medicine
Brenda Miller, Executive Director, The DC Campaign to Prevent Teen Pregnancy
Nadine Peacock, Associate Profe ssor of Community Health Sciences, University of
Illinois At Chicago
(UIC) School of Public Health
Héctor Sánchez-Flores, Senior Research Associate, Institute for Health Policy Studies,
University of California, San Francisco
Freya Sonenstein, Director, Center for Adolescent Health, John Hopkins University
Ex-Officio:
Patricia Paluzzi, Executive Director, National Organization on Adolescent Pregnancy,
Parenting and Prevention (NOAPPP).
Laura Davis, Director of Adolescent Sexual and Reproductive Health Services Initiative,
Advocates for Youth
John Santelli, MD, MPH, Professor of Clinical Pediatrics and Clinical Population and
Family Health, Mailman School of Public Health, Columbia University