Development of adolescent self-report measures from the National Longitudinal Study of Adolescent Health.

PURPOSE: To present a set of multi-item indicators and associated reliability estimates derived from early research with survey data from adolescents participating in the National Longitudinal Study of Adolescent Health (Add Health). METHODS: Add Health provides information on the health and health-related behaviors of a nationally representative sample of U.S. adolescents, as well as on individual-level and contextual factors that either promote young peoples' health or increase their health risk. Specifically, the 135-page in-home adolescent survey instrument includes multiple items intended to measure individual-level and social-environmental constructs relevant to adolescent health and well-being. This article details the development of a set of multi-item scales and indices from Add Health in-home adolescent survey data. These steps include identification of inconsistent responders, use of a split-halves approach to measurement validation, and use of a deductive approach in the development of scales and item composites. RESULTS: Estimates of internal consistency reliability suggest that many of the multi-item measures have acceptable levels of internal consistency across grade, gender, and race/ethnic groups included in this nationally representative sample of adolescents. In addition, moderate to high bivariate correlations between selected measures provide initial evidence of underlying latent constructs. CONCLUSIONS: This article provides adolescent health researchers with a set of methodologic procedures and measures developed in early research on the Add Health core adolescent data set.

The effects of race/ethnicity, income, and family structure on adolescent risk behaviors.

OBJECTIVES: The study examined the unique and combined contributions of race/ethnicity, income, and family structure to adolescent cigarette smoking, alcohol use, involvement with violence, suicidal thoughts or attempts, and sexual intercourse. METHODS: Analyses were based on the National Longitudinal Study of Adolescent Health. A nationally representative sample of 7th to 12th graders participated in in-home interviews, as did a resident parent for 85.6% of the adolescent subjects. The final sample included 10,803 White, Black, and Hispanic 7th to 12th graders. RESULTS: White adolescents were more likely to smoke cigarettes, drink alcohol, and attempt suicide in the younger years than were Black and Hispanic youths. Black youths were more likely to have had sexual intercourse; both Black and Hispanic youths were more likely than White teens to engage in violence. Controlling for gender, race/ethnicity, income, and family structure together explained no more than 10% of the variance in each of the 5 risk behaviors among younger adolescents and no more than 7% among older youths. CONCLUSIONS: Findings suggest that when taken together, race/ethnicity, income, and family structure provide only limited understanding of adolescent risk behaviors.

Adolescent use of alternative and complementary therapies. A framework for research.

Increasing numbers of U.S. adolescents are using alternative and complementary therapies, seemingly mirroring the trend among adults. Patterns of use among adolescents may be different from those of adults, however, due to the unique biological, psychological, and social factors affecting this population. Although there is a growing body of literature on utilization and efficacy of alternative and complementary therapies, few studies have included or focused on adolescents. Such research is needed. Social learning theory provides an appropriate theoretical framework to address the complex web of factors underlying health-care-seeking behavior of adolescents, allowing for consideration of the critical factor of individual expectations in their health care choices. Research on adolescents' utilization of alternative and complementary therapies is important for providers and policy makers concerned with the present and future health of youth.

Sexual intercourse, abuse and pregnancy among adolescent women: does sexual orientation make a difference?

CONTEXT: Although a limited amount of research has retrospectively explored the childhood and adolescent heterosexual experiences of lesbians, little is known about the prevalence of heterosexual behavior and related risk factors or about pregnancy histories among lesbian and bisexual teenagers. METHODS: A secondary analysis was conducted using responses from a subsample of 3,816 students who completed the 1987 Minnesota Adolescent Health Survey. Behaviors, risk factors and pregnancy histories were compared among adolescents who identified themselves as lesbian or bisexual, as unsure of their sexual orientation and as heterosexual. RESULTS: Overall, bisexual or lesbian respondents were about as likely as heterosexual women ever to have had intercourse (33% and 29%, respectively), but they had a significantly higher prevalence of pregnancy (12%) and physical or sexual abuse (19-22%) than heterosexual or unsure adolescents. Among sexually experienced respondents, bisexual or lesbian and heterosexual women reported greater use of ineffective contraceptives (12-15% of those who used a method) than unsure adolescents (9%); bisexual or lesbian respondents were the most likely to have frequent intercourse (22%, compared with 15-17% of the other groups). In the sample overall, among those who were sexually experienced and among those who had ever been pregnant, bisexual or lesbian women were the most likely to have engaged in prostitution during the previous year. CONCLUSIONS: Providers of reproductive health care and family planning services should not assume that pregnant teenagers are heterosexual or that adolescents who say they are bisexual, lesbian or unsure of their sexual orientation are not in need of family planning counseling. Further research should explore the interactions between adolescent sexual identity development and sexual risk behaviors.

PIP: The influence of sexual orientation on adolescents' sexual behaviors and pregnancy histories was investigated in a subsample of 3816 female adolescents, 12-19 years old, who completed the 1987 Minnesota (US) Adolescent Health Survey. 182 identified themselves as bisexual or lesbian, 1753 were unsure of their sexual orientation, and 1881 were heterosexual. Bisexual/lesbian respondents were about as likely as heterosexual respondents ever to have had intercourse (33.0% and 29.3%, respectively), but they had a significantly higher prevalence of childhood physical abuse (19.3% vs. 11.9%) and sexual abuse (22.1% vs. 15.3%) than their heterosexual counterparts. Among sexually experienced respondents, 29.8% of bisexual/lesbian adolescents, 43.5% of those unsure about their identity, and 23.1% of heterosexuals used no contraception and 12.3%, 8.5%, and 14.5%, respectively, of those who used contraception used an ineffective method. 12.3% of bisexual/lesbian women, 6.1% of those unsure about their sexual orientation, and 5.3% of heterosexual adolescents had experienced a pregnancy; 2 or more pregnancies were reported by 23.5%, 15.1%, and 9.8%, respectively, of ever-pregnant teens. Finally, 9.7% of bisexual/lesbian women had engaged in prostitution in the year preceding the survey, compared with 1.9% of heterosexuals and 3.4% of those unsure about their orientation. These findings suggest that adolescents who identify themselves as lesbian or bisexual are at high risk of pregnancy and poor contraceptive practices. Providers of reproductive health care and family planning services should not assume that their pregnant adolescent patients are heterosexual or that lesbian clients or those unsure of their sexual orientation are not in need of contraception.

Fulfilling regional needs for specialty nurses through limited-cohort graduate education.

The University of Minnesota has developed a limited-cohort distance education graduate program to overcome geographic barriers and address the shortage of master's-prepared specialty nurses in rural areas of the upper Midwest. Such a program offers graduate nursing education in various specialty areas to distance sites for a predetermined, relatively short period.

New challenges, new answers: pediatric nurse practitioners and the care of adolescents.

INTRODUCTION: Since the 1950s, patterns of morbidity and mortality among adolescents have shifted to social and environmental causes. This study examines pediatric nurse practitioners' (PNPs') self-assessed competencies in addressing the common health concerns of adolescents. METHOD: The analysis used a sample of 257 PNPs drawn from a larger national data set of 637 nurses randomly sampled from 3 nursing organizations. Factors associated with self-perceived knowledge or skill and interest in training for 28 common health concerns of adolescents were analyzed using Chi square, t test, and Pearson's correlation. Barriers and attractions to working with adolescents were also investigated. RESULTS: The greatest deficits in self-perceived knowledge or skill, as well as low interest in training and low perceived relevance to practice, were around issues of gangs, gay/lesbian/bisexual/transgender youth, HIV/AIDS, and counseling about a positive pregnancy test. Also, PNPs identified the lack of resources appropriate for adolescent referrals as the greatest barrier to working with this population. DISCUSSION: PNPs assessed their lowest competencies in some of the areas that present the greatest threats to adolescents' health and well-being. These deficits suggest needed curricular shifts in entry-level and advanced-level preparation of PNPs, as well as new priorities for continuing education.

Demographics of sexual orientation among American-Indian adolescents.

Self-report of sexual orientation and sexual behavior was compared for 12,978 reservation-based American-Indian and 11,356 rural Anglo-American adolescents. Findings included a significantly higher prevalence of homosexual, bisexual, and unsure responses among American Indians. However, a larger nonresponse rate for American-Indian adolescents raises questions about the cultural relevance of the survey method, and underscores the need for development of more culturally sensitive research tools and methods.

Sexual orientation, sexual behaviors, and pregnancy among American Indian adolescents.

PURPOSE: A recent study found a disproportionate number of pregnancies among Euro-American lesbian and bisexual adolescents compared to heterosexual peers. American Indian adolescents have reported higher prevalence of gay/lesbian/bisexual orientations than Euro-Americans; do they also report higher prevalence of pregnancy? METHODS: The study assessed prevalence of teen pregnancy and related factors by sexual orientation among sexually experienced, reservation-based American Indian adolescent males (n = 2056) and females (n = 1693) who participated in a national school-based survey in 1991. Self-reported orientation was classified as heterosexual, gay/lesbian/bisexual, and "unsure" of orientation. RESULTS: Gay/bisexual males were more likely than other males to report early heterosexual intercourse (<14 years), more consistent contraception, and a higher prevalence of abuse and running away (p < 0.05 to p < 0.0001). Likewise, lesbian/bisexual females were more likely to report early onset of heterosexual intercourse, more frequent intercourse, and running away. Sexual or physical abuse did not vary by orientation for females. Prevalence of pregnancy also did not vary by orientation (males, 18.6% gay/bisexual vs. 10.4% "unsure" vs. 11.8% heterosexual; females, 25.0% lesbian/bisexual vs. 22.1% "unsure" vs. 21.9% heterosexual). For lesbian/bisexual females, no variables were significantly associated with pregnancy history; for "unsure" females, pregnancy was associated with contraceptive frequency and early onset of heterosexual activity. For heterosexual females, age, intercourse frequency, and physical abuse were associated. For gay/bisexual males, intercourse frequency, ineffective contraception, and physical abuse were associated with involvement in a pregnancy; for "unsure" and heterosexual males, most items except ineffective contraception were related to pregnancy involvement history. CONCLUSIONS: Although prevalence of pregnancy is similar, findings show group differences in associated risk factors by sexual orientation. Interventions to reduce pregnancy among American Indian adolescents should include assessment of sexual orientation and behavioral risk factors.

Gender differences in health and risk behaviors among bisexual and homosexual adolescents.

OBJECTIVE: This study explored gender differences in the health and risk behaviors of 394 self-identified bisexual and homosexual adolescents who participated in an anonymous, school-based survey. METHODS: Respondents included 182 girls and 212 boys; girls were significantly younger than boys (p < 0.001), so respondents were further grouped as younger (< or =14 years) and older (> or =15 years) for analysis. Chi-square was used to test for gender differences in health perceptions and risk behaviors. Items included general health perceptions and health care access, body image and disordered eating behaviors, sexual behaviors, alcohol use, and emotional health measures including mood, life satisfaction, and suicidal ideation and attempts. RESULTS: Both younger and older girls were significantly more likely than their male age mates to report a history of sexual abuse, dissatisfaction with weight, a negative body image, more frequent dieting, and an earlier age at onset of sexual intercourse. Both younger and older boys were significantly more likely than girls to have a positive body image, to rate themselves as healthier than peers, to report no regular source of health care, to be sexually experienced, and to drink alcohol more often and in greater quantity; a significantly greater proportion of older boys than older girls reported alcohol use before school (19.0% vs. 3.9%; p < 0.05). No significant gender differences were found for measures of emotional health, including suicidal ideation and attempts; however, nearly 1 of 3 older boys and girls reported at least one suicide attempt. CONCLUSIONS: Gender is a substantive source of variation in health and risk behaviors among bisexual and homosexual adolescents. Health care providers should incorporate gender-specific approaches to health promotion and risk reduction with young people who self-identify as gay, lesbian, or bisexual.

Dimensions of risk behaviors among American Indian youth.

OBJECTIVE: To explore the covariation of risk behaviors in a national sample of American Indian reservation-based youth using listwise principal components factor analysis and to determine how these risk behaviors may vary by age and sex. DESIGN: Analysis of data from the National Indian Adolescent Health Survey, a validated anonymous self-report questionnaire of 162 items addressing various health domains. SETTING: The survey was administered nationally in more than 200 reservation-based schools. PARTICIPANTS: Thirteen thousand nine hundred twenty-three reservation-based American Indian or Alaska Native students in grade 7 through 12 representing more than 50 tribes. The listwise factor analysis sample included 7687 respondents with complete data. MAIN OUTCOME MEASURES: Item loading and factor correlations by age and sex for 30 risk behaviors across various health domains. RESULTS: Three risk behavior factors were fairly stable across sex and age: (1) the use of alcohol, tobacco, and other drugs; (2) risky sexual behavior, and (3) suicidal behaviors. Correlations between these and other factors suggested different strengths of relationships by sex and age. Other factors, including violence, truancy, and delinquency, showed differences in item loading on factors and correlations between factors. The use of tobacco, alcohol, and other drugs was most frequently associated with other risk behavior factors, and suicidal behaviors showed the next highest frequency of intercorrelations. CONCLUSIONS: There are sex and age differences in the covariation of risk behaviors, and suicidal behaviors should be further investigated to determine of our findings are unique to American Indian youth. Health interventions that focus categorically on 1 risk dimension should also emphasize substance use prevention and intervention. To prevent substance abuse among American Indian youth, research efforts need to focus on effective strategies for coping with social and psychological stressors.

The validity of self-reported condom use among adolescents.

BACKGROUND: Research and public health interventions designed to reduce the risk of sexually transmitted diseases (STDs) often are based on self-reported condom use. Yet, validation of self-reported condom use, in particular with adolescents, has rarely been described in the literature. METHODS: Baseline data were obtained from 540 adolescents, 13-21 years of age, enrolled in a 1-year longitudinal study of health beliefs, sexual behaviors, and STD acquisition. Of the 445 participants reporting to be sexually active, 404 (90.8%) agreed to a complete physical examination, including a genital examination, with STD screening after completing the self-administered written questionnaire. Participants' written self-report of condom use was compared to histories obtained by clinicians and laboratory diagnosis of acute STDs to assess validity of written self-report. RESULTS: Complete data were available for 321 females and 77 males of whom 52 females and 5 males had laboratory evidence of 63 infections. Although three individuals who had STDs reported to be consistent users of condoms, a significant association (P < 0.05) was found between those who reported more frequent condom use with the last two partners and the absence of STDs. CONCLUSION: In this group of adolescents, self-report of condom use with the last two partners was associated with the absence of an acute STD. This finding suggests that self-reported condom use is a valid indicator of risk for STDs, with implication for those working with adolescents clinically and in research contexts.

PIP: Although most research on sexually transmitted disease (STD) risk behavior surveillance and prevention is based on self-reports of condom use, there have been few attempts to assess the extent to which self-reports accurately reflect true behavior. To validate this methodology, baseline data were obtained from 540 US male and female adolescents 13-21 years of age enrolled in a 1-year longitudinal study of sexual behaviors and STDs. Of the 445 participants who reported they were sexually active, 398 underwent genital examination and STD screening. 52 females and 5 males had laboratory evidence of acute STDs. 15.2% of females and 32.3% of males reported consistent condom use with their most recent sexual partner. Although 3 young people with STDs had reported they were consistent condom users, a significant (p 0.05) inverse association was found between consistency of reported condom use with the last 2 sexual partners and the occurrence of an acute STD. This finding suggests that, even among adolescents, self-reported condom use is a valid indicator of STD risk.

Protecting adolescents from harm. Findings from the National Longitudinal Study on Adolescent Health.

CONTEXT: The main threats to adolescents' health are the risk behaviors they choose. How their social context shapes their behaviors is poorly understood. OBJECTIVE: To identify risk and protective factors at the family, school, and individual levels as they relate to 4 domains of adolescent health and morbidity: emotional health, violence, substance use, and sexuality. DESIGN: Cross-sectional analysis of interview data from the National Longitudinal Study of Adolescent Health. PARTICIPANTS: A total of 12118 adolescents in grades 7 through 12 drawn from an initial national school survey of 90118 adolescents from 80 high schools plus their feeder middle schools. SETTING: The interview was completed in the subject's home. MAIN OUTCOME MEASURES: Eight areas were assessed: emotional distress; suicidal thoughts and behaviors; violence; use of 3 substances (cigarettes, alcohol, marijuana); and 2 types of sexual behaviors (age of sexual debut and pregnancy history). Independent variables included measures of family context, school context, and individual characteristics. RESULTS: Parent-family connectedness and perceived school connectedness were protective against every health risk behavior measure except history of pregnancy. Conversely, ease of access to guns at home was associated with suicidality (grades 9-12: P<.001) and violence (grades 7-8: P<.001; grades 9-12: P<.001). Access to substances in the home was associated with use of cigarettes (P<.001), alcohol (P<.001), and marijuana (P<.001) among all students. Working 20 or more hours a week was associated with emotional distress of high school students (P<.01), cigarette use (P<.001), alcohol use (P<.001), and marijuana use (P<.001). Appearing "older than most" in class was associated with emotional distress and suicidal thoughts and behaviors among high school students (P<.001); it was also associated with substance use and an earlier age of sexual debut among both junior and senior high students. Repeating a grade in school was associated with emotional distress among students in junior high (P<.001) and high school (P<.01) and with tobacco use among junior high students (P<.001). On the other hand, parental expectations regarding school achievement were associated with lower levels of health risk behaviors; parental disapproval of early sexual debut was associated with a later age of onset of intercourse (P<.001). CONCLUSIONS: Family and school contexts as well as individual characteristics are associated with health and risky behaviors in adolescents. The results should assist health and social service providers, educators, and others in taking the first steps to diminish risk factors and enhance protective factors for our young people.

The utility of locus of control for predicting adolescent substance use.

Structural equation modelling (SEM) was used to examine the utility of locus of control (LOC) for predicting adolescent substance use. As part of a larger three-wave cohort-sequential study (1983-1989), 155 secondary school-based adolescents completed questionnaires on substance use, personality characteristics, family/peer influences, and health behaviors. Latent variable indicators were developed from the Nowicki-Strickland Personal Reaction Survey and substance use survey items. LOC was a weak predictor of substance use. In two instances were relationships significant: (a) 7th grade LOC predicted 11th grade alcohol use; and, (b) 9th grade LOC correlated with 11th grade cannabis use. Small samples precluded analysis of gender and social class effects. SEM with panel data offers a methodological approach for examining the explanatory capability of LOC.

Patterns of consultation among adolescent minors obtaining an abortion.

Interviews with 184 adolescents revealed that all had consulted at least one individual before obtaining an abortion, although one-quarter, primarily the older adolescents, did not consult an adult prior to pregnancy counseling. At both the time of the abortion and one year later, the adolescents perceived their mother and their male partner as the two most important and helpful people in reaching a decision.

PIP: Minors seeking abortion in Minnesota must either provide written evidence to the health care provider that both parents have been notified of the intent to abort the fetus or obtain court affirmation that they are sufficiently mature to provide informed consent for their own abortion. The authors invited all females under age 18 who used any of a total of six clinics for abortion in Minnesota and Wisconsin to participate in this study. Participation entailed completing written questionnaires and a face-to-face interview while waiting for the abortion, together with a follow-up telephone interview one year later. 148 Minnesotans and 37 females from Wisconsin agreed to participate for a Wisconsin participation rate of 62% and a Minnesota participation rate of 83%. The women were first interviewed during a three-month period in 1984. 6% were 13-14 years old, 17% were aged 15, 37% aged 16, and 40% aged 17. 91.6% were Caucasian and 6% African-American, with 38% employed at the time of the interviews. 18% were of the highest levels of socioeconomic status (SES), 71% among the middle levels, and 11% of the lowest SES. 50% indicated an history of pregnancy in at least one family member under age 18, and 4% indicated that their pregnancy was the result of sexual assault. It was found through the interviews that all of the young women had consulted at least one person before obtaining an abortion. 25%, however, mainly the older girls, did not consult an adult before pregnancy counseling. At abortion and one year later, the subjects perceived their mother and their male partner to be the two most important and helpful people in reaching a decision. Study findings cast doubt upon the need for the existence of broad legislation mandating adult involvement in abortion decision-making.

Interdisciplinary education in adolescent health.

To date, evidence suggests that, across disciplines, the educational preparation of health professionals has not kept pace. Those involved in the education of clinicians, researchers, and educators in adolescent health are currently faced with the need to rethink traditional educational strategies. Concurrent with a shift in the primary causes of morbidity and mortality in adolescence, from infectious to social aetiologies, is an emerging clarity about the success of integrated comprehensive service settings in addressing adolescents' health needs. One approach for better preparing health providers to work in multiservice settings is to provide training in interdisciplinary programmes. Various models for interdisciplinary education in adolescent health exist; characteristics common to all are delineated. Whereas obstacles to the creation and implementation of interdisciplinary programmes, including institutional, financial, and educational barriers, are great, the need to overcome them is critical if we are to keep pace with the changing needs of the adolescent population.

Nursing competence in adolescent health: anticipating the future needs of youth.

The health problems of youth have dramatically shifted in the last 30 years from biological to social causes of morbidity and mortality. To assess the adequacy of nurses' knowledge and skills in adolescent health, a national survey of 445 nurses, including members of the American Public Health Association, the American School Health Association, and the National Association of Pediatric Nurse Associates and Practitioners, was undertaken in 1985. Results indicated that even among nurses who work with young people the most, areas of greatest knowledge and skill deficiencies included common social morbidities of adolescents. In addition to self-assessed inadequacies in knowledge and skills, nurses identified excessive time demands as a primary obstacle to the provision of health services to adolescents. To assure adequate preparation of nurses, it is recommended that accreditation criteria for baccalaureate and graduate programs specify essential adolescent health content for curricula compared to current accreditation criteria that generalizes "across the life span." Focusing on the enhancement of educational opportunities in adolescent health, nurses identified strategies for further education that would bridge the gap between the health needs of youth and nurse's self-perceived competencies in providing these services.

Knowledge and attitudes of health professionals toward adolescent health care.

The rising concern over the competency of health care professionals in the United States to meet the health needs of adolescents was the impetus for a national survey of 3066 physicians, nurses, social workers, nutritionists, and psychologists. The survey explored perceptions of training and competency regarding 16 dimensions of adolescent health care. Major deficits were noted for each discipline. For physicians, self-perceived limitations were in the areas of eating disorders, learning disabilities, chronic illness, and delinquent behavior. The same limitations were also mentioned by nurses. Over half of the psychologists reported deficits related to the psychological sequelae of sexual concerns, sexual orientation conflict, eating disorders, and chronic illness. Many of the same concerns reflected the perceived competencies of social workers. Nearly half of all nutritionists surveyed acknowledged deficits in almost all adolescent food-related concerns. The impact of these low levels of perceived competency is discussed in terms of implications for clinical service.

Study group report on the impact of television on adolescent views of sexuality.

PIP: There is not much research done on US television's portrayal of sex and its relation to teenage attitudes and sex behavior. What has been done is on marital fidelity, gender roles, and rape myths. Sexuality taboos have created research problems. Future research should include longitudinal studies. These should use sex behavior as a dependent variable and focus on correlational and causal questions. Blacks, Hispanics, and Native Americans should be included in future research. Research should address the decision-making process within the television industry. A "consortium" of researchers from different disciplines should be used. Health professionals and the television industry should talk. Key people in professional organizations should have this dialog with the television industry. Press releases should be sent to key industry publications. The study group recommends a 6-12 month "sabbatical" wherein television and health professionals could work in each others' settings. There is a restriction on the advertising of contraceptive in the networks. Condoms can be promoted for disease protection, but not for birth control. Prescription products can't be advertised. Generic contraceptive advertisement should be created. Products could be advertised in magazines, too. Guidelines should be set up for television advertising. It is not possible to predict which hours adolescents will be watching television anymore. Critical viewing skills should be taught in "media literacy" curricula for "early and middle" adolescents.^ieng