This study used an event-based approach to understand condom use in a probability sample of homeless youth recruited from service and street sites in Los Angeles County.
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Condom use was significantly more likely when the youth held positive condom attitudes or were concerned about pregnancy, the partners talked about condom use, and the partners met up by chance. This study extends previous work by simultaneously examining a broad range of individual, relationship, and contexual factors that may play a role in condom use. National data suggest that the sexual health of adolescents and young adults in the U.
Homeless youth are more likely than housed youth to be sexually active, as well as engage in sexual risk behaviors such as multiple partnerships and trading sex [ 23 T and d unprotected, which heighten their risk of HIV and other sexually transmitted T and d unprotected STIs.
Given the widespread use of alcohol and drugs among homeless youth [ 7 - 12 ], including substance use during sex [ 13 ], it might seem reasonable to conclude that substance use is an important determinant of unprotected sex among homeless youth through one or more of its cognitive, affective, and physiological effects on the individual [ 14 ]. However, studies of sexual risk behavior among homeless youth have not conducted the types of analyses that are necessary to better understand whether this is the case.
Over the past two decades, numerous studies have examined the association between substance use and unprotected sex using a variety of research designs and levels of analysis [ 15 ]. Among these studies, the most common approach has been to examine the global association between substance use and condom use.
Global association studies ask individuals to report on their substance use and condom use behaviors either in general or over a specific period of time e. These studies typically find that individuals who are more likely to engage in substance use are also more likely to engage in unprotected sex [ 1617 ].
A drawback of global T and d unprotected studies is T and d unprotected they cannot determine whether substance use tends to precede unprotected sex and thus establish the temporal pairing between these behaviors that is a necessary condition for inferring a causal link.
Event-level studies address this limitation by asking respondents to report on their substance use and condom use during a specific sexual event e. Although event-level studies cannot establish causality, investigating whether these behaviors tend to co-occur during a specific sexual event provides greater insight into whether substance use before sex decreases the likelihood that protected sex will occur.
A review of the event-level literature on youth substance use and sexual behavior indicates that drinking is strongly related to the decision to have sex and indiscriminate forms of risky behavior such as having multiple or casual sex partners.
The evidence linking substance use to unprotected sex is less consistent [ 1618 ], but most studies have been of school-based samples, particularly college undergraduates. The small number of event-level studies conducted with at-risk youth, although not entirely consistent, suggest that alcohol and drug T and d unprotected may be stronger predictors of condom use behavior among these youth than in the general population.
For example, a study of adolescents with substance use disorders found that both alcohol and drug use during the event predicted condom use; however, these associations weakened to nonsignificance after adjusting for partner type and other factors [ 19 ]. Another study of homeless youth indicated that marijuana use during the sexual event was associated with unprotected sex, whereas crack use was associated with protected sex alcohol use was unrelated to condom use ; crack use remained a significant predictor of condom use in multivariate analyses [ 20 ].
A third study of criminally involved adolescents, which focused exclusively on alcohol use, found that drinking at the event was associated with unprotected sex in both between- and within-subjects analyses [ 21 ].
A limitation of many existing event-level studies in this area is that they devote insufficient attention to a host of factors other than substance use that may contribute to unprotected sex. Accounting for these other factors is important both in terms of better understanding the effect of substance use on unprotected sex in different populations, as well as identifying additional risk and protective factors that may be important targets for intervention.
Event-based research by Tortu, McMahon and colleagues identifying the determinants of condom use in high-risk populations are exemplars in terms of collecting detailed information on: A recent event-based study of at-risk women living in temporary shelters took a similar approach, finding that condom use was more likely among women who consumed alcohol at the event, as well as for those who held more positive attitudes towards condoms, had sex with a casual or need-based partner, T and d unprotected condoms with the partner, T and d unprotected felt T and d unprotected sexually pressured by the partner during the event [ 24 ].
Not all studies taking this approach have T and d unprotected evidence for the importance of contextual factors in predicting condom use; for example, a study of gay and bisexual men found that condom use was more likely with casual partners and among HIV-negative men, but that T and d unprotected social setting and whether sex was expected did not matter [ 25 ].
Together, however, these studies demonstrate the potential usefulness of gathering rich information on specific sexual events to better understand the determinants of sexual risk behavior at multiple levels of influence and how they may differ across diverse populations. This study significantly extends the literature on whether youth substance use is a risk factor for unprotected sex in three important respects.
First, it examines these associations among homeless youth, a population that has been understudied in this context but has high rates of substance use and elevated risk for pregnancy and STIs. Second, it takes an event-based approach in examining the association between unprotected sex and multiple types of substance use alcohol, marijuana, hard drugs.
Finally, based on findings from prior event-level studies and our own T and d unprotected research with homeless youth, it takes into account characteristics of the youth e. Data come from a larger study of homeless youth in Los Angeles County examining the social context of substance use and HIV risk within this population. Youth were eligible for the study if they: Interviews were conducted between October and August Of the youth who initially screened eligible for the study, were interviewed.
Our analytic sample consists of the youth who reported being sexually active in the past 3 months see Table 1 for characteristics of this sample. After providing informed consent, computer-assisted face-to-face structured interviews were conducted by trained interviewers.
To obtain a representative sample of homeless youth from the greater Los Angeles area, we designed and implemented a probability sample of homeless T and d unprotected recruited from shelters, drop-in centers, and street venues in the study area. We developed two sampling frames of sites: The first sampling frame was developed using existing directories of services for homeless individuals.
Service sites were considered eligible if they were located in the study area and the majority of their clientele was ages 13 to 24 and English speaking. Service sites not limited to that age group were eligible if they had a specific program geared toward youth.
In addition, for short-term transitional housing programs the average length of stay had to be one year or less. Our final list of service sites consisted of 22 eligible sites: All the eligible service sites in the study area that agreed T and d unprotected participate in the study were selected with certainty and thus the sites can be considered strata. The second sampling frame, for street venues, was developed with the assistance of service providers and outreach agencies. We ultimately identified 19 street venues in the study area where homeless youth congregate.
All of these street sites were included in the study and thus can be considered as strata. Each of the 41 service and street sites were investigated intensively with the purpose of obtaining an estimate of the average number of youth served daily by the service sites and the average number of youth that congregate at the street venues in a given day.
This information was T and d unprotected to assign an overall complete quota to each site which was approximately proportional to the size of a site. The second stage of the adopted sampling design consisted of drawing a probability sample of homeless youth from the 41 study sites. Strategies specific to the type of sites were developed to select randomly the youths to be approached, screened and interviewed.
The proposed sampling design deviates from a proportionate-to-size stratified random sample where a constant proportion of the population is sampled from every site because of: This last factor means that some youth are more likely than others to be included in the sample for a given site.
We corrected departures from a proportionate-to-size stratified random sample with sampling weights. The outcome variable was whether a condom was properly used at the most recent sexual event. This event was defined as the most recent time the youth had vaginal T and d unprotected anal intercourse.
All reported events occurred within the past 3 months. Respondents were asked whether they used a condom at the event, whether the condom was taken off before they were done having intercourse, and whether a new condom was used if they had intercourse more than once during the event.
The event was coded as one where condoms were used if they couple used a condom, did not take it off until they were done having T and d unprotected, and if applicable used a new condom for each insertive act. A scale assessing condom use attitudes was comprised of four items asking whether condoms interfere with the enjoyment of sex, condoms can be used without ruining the mood, you can stop before sex to use a condom, and it would be okay if a partner suggested that a condom be used [ 2627 ].
We used two items to assess attitudes towards pregnancy, with slightly different wording for female and male respondents: Youth reported whether the event involved the first time that they had sex with this partner, how long they had known the partner converted to number of monthswhether it was a monogamous relationship at the time of the event, and for males whether it was a same-sex partnership. Finally, the relationship was classified T and d unprotected having a history of abuse if the respondent endorsed any of the following four items: Did they talk about using a condom just prior to having sex that time; was it a chance meeting or had they planned to meet up; was there something different or special about this event e.
These items were dichotomized due to their skewed distribution felt good and felt aroused: We derived measures that combined respondent use and partner use to avoid multicollinearity in our models due to significant overlap in these reports: We assessed alcohol use in terms of the maximum number of drinks consumed by either partner during the event with nondrinking couples receiving a score of 0.
We used two dummy-coded variables to assess drug use: Alcohol use was not considered in the derivation of the drug use variables. The use of a disproportionate random sampling technique T and d unprotected differential nonresponse rates require the use of design and nonresponse weights to represent the target population from the sample of respondents. All analyses incorporate these weights and account for the modest design effect that they induce, using the linearization method [ 29 ].
We conducted a series of logistic regression models, using the statistical package SAS 9. The base model included the three variables assessing alcohol T and d unprotected drug use T and d unprotected the event, as well as the four demographic characteristics. To this base model we then added each of three sets of variables attitudes about condoms and pregnancy; relationship characteristics; and context characteristics to examine how adjusting for each variable set affected the strength of associations between substance use and condom use.
Overall, the maximum number of drinks consumed by either partner averaged 2. Twenty-six percent of the events involved marijuana use only i. Of the 90 youth and 79 partners who used drugs at the event, marijuana was the drug most commonly used respondents: See Table 1 for characteristics of the sexual events.
Condom use was not significantly associated T and d unprotected marijuana use only or the maximum number of drinks consumed. Several of these contextual factors were associated with condom use in their own right: In addition, condom use was more likely if the youth held a more positive attitude about condoms, had greater concern about pregnancy, were with a casual partner, met up with the partner by chance, or talked about condoms prior to the event.
Given the significant association between hard drug use and unprotected sex, we examined whether youth who used T and d unprotected drugs, or had a partner who used hard drugs, believed that the drug use affected whether a condom was used during the event.
Among youth who used hard drugs, One explanation for the relatively low rate of protected sex among homeless youth is that the disinhibiting effects of substance use impair their inclination or ability to use condoms. This explanation might seem reasonable given that two-thirds of homeless youth are current drinkers or drug users [ 12 ]. However, demonstrating an event-level association between youth substance use and condom use has been surprisingly elusive in the literature, although few existing studies have focused on high-risk youth.
Similar to the results of Bailey and colleagues [ 20 ], substance use prior to sex was common in our sample, with one-third of events involving alcohol or drug use.
Most of the drug use events involved methamphetamine which, along with alcohol, has received considerable attention for its disinhibiting effect on sexual behavior [ 31 ]. A key finding from this study is that condom use was less likely when hard drug use and, to a lesser extent, heavier drinking occurred prior to sex.