Critical Dialogue and Capacity-Building Projects Reduced Alcohol and Substance Use in a Randomized Clinical Trial Among Formerly Incarcerated Men.

Background: Rates of alcohol and/or substance use (ASU) among residents of predominantly Black and marginalized communities are similar to ASU rates in White communities. Yet ASU has worse consequences in predominantly Black and marginalized communities (e.g., higher incarceration). Objective: We randomized participants to one of 16 intervention conditions using a 24 full factorial design to optimize a multilevel intervention reducing ASU among 602 formerly incarcerated men with substance-use-disorders (SUD). Candidate intervention components included (1) critical dialogue (CD; six weekly 2-hour-long group sessions vs. no CD sessions), (2) Quality of Life Wheel (QLW; six weekly 1-hour-long group sessions vs. no QLW sessions), (3) capacity building projects (CBP; six weekly 1-hour-long group sessions vs. no CBP sessions), and (4) delivery by a trained peer versus licensed facilitators. Outcome was percentage of days in which participants used alcohol, cocaine, opioid, and/or cannabis in previous 30 days. Results: Intent-to-treat analysis did not meet a priori component selection criteria due to low intervention attendance. After controlling for intervention group attendance (percentage of sessions attended), peer-delivered CD and CBP produced statistically and clinically significant main and interaction effects in ASU over 5 months. Per the multiphase optimization strategy framework, we selected peer-delivered CD and CBP for inclusion as the optimized version of the intervention with a cost of US$1,380 per 10 individuals. No adverse intervention effects occurred. Conclusion: CD and CBP were identified as the only potentially effective intervention components. Future research will examine strategies to improve attendance and test the optimized intervention against standard of care in a randomized-controlled-trial.

Designing a childhood obesity preventive intervention using the multiphase optimization strategy: The Healthy Bodies Project.

BACKGROUND/AIMS: Preventing the development of childhood obesity requires multilevel, multicomponent, comprehensive approaches. Study designs often do not allow for systematic evaluation of the efficacy of individual intervention components before the intervention is fully tested. As such, childhood obesity prevention programs may contain a mix of effective and ineffective components. This article describes the design and rationale of a childhood obesity preventive intervention developed using the multiphase optimization strategy, an engineering-inspired framework for optimizing behavioral interventions. Using a series of randomized experiments, the objective of the study was to systematically test, select, and refine candidate components to build an optimized childhood obesity preventive intervention to be evaluated in a subsequent randomized controlled trial. METHODS: A 24 full factorial design was used to test the individual and combined effects of four candidate intervention components intended to reduce the risk for childhood obesity. These components were designed with a focus on (a) improving children's healthy eating behaviors and nutrition knowledge, (b) increasing physical activity and reducing sedentary activity in the childcare setting, (c) improving children's behavioral self-regulation, and (d) providing parental web-based education to address child target outcomes. The components were tested with approximately 1400 preschool children, ages 3-5 years in center-based childcare programs in Pennsylvania, the majority of which served predominantly Head-Start eligible households. Primary child outcomes included healthy eating knowledge, physical and sedentary activity, and behavioral self-regulation. Secondary outcomes included children's body mass index and appetitive traits related to appetite regulation. RESULTS: Four intervention components were developed, including three classroom curricula designed to increase preschool children's nutrition knowledge, physical activity, and behavioral, emotional, and eating regulation. A web-based parent education component included 18 lessons designed to improve parenting practices and home environments that would bolster the effects of the classroom curricula. A plan for analyzing the specific contribution of each component to a larger intervention was developed and is described. The efficacy of the four components can be evaluated to determine the extent to which they, individually and in combination, produce detectable changes in childhood obesity risk factors. The resulting optimized intervention should later be evaluated in a randomized controlled trial, which may provide new information on promising targets for obesity prevention in young children. CONCLUSION: This research project highlights the ways in which an innovative approach to the design and initial evaluation of preventive interventions may increase the likelihood of long-term success. The lessons from this research project have implications for childhood obesity research as well as other preventive interventions that include multiple components, each targeting unique contributors to a multifaceted problem.

Development and Psychometric Properties of the Sleep Parenting Scale for Infants.

Although infants' sleep behaviors are shaped by their interactions with parents at bedtime, few tools exist to capture parents' sleep parenting practices. This study developed a Sleep Parenting Scale for Infants (SPS-I) and aimed to (1) explore and validate its factorial structure, (2) examine its measurement invariance across mothers and fathers, and (3) investigate its reliability and concurrent and convergent validity. SPS-I was developed via a combination of items modified from existing scales and the development of novel items. Participants included 188 mothers and 152 mother-father dyads resulting in 340 mothers and 152 fathers; about half were non-Hispanic white. Mothers and fathers completed a 14-item SPS-I for their 12-month-old infant. Exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) were used to explore and validate SPS-I's underlying structure. Multigroup CFA was used to examine measurement invariance across mothers and fathers. Reliability was examined using Cronbach's alpha. Concurrent validity was assessed using linear regressions examining associations between SPS-I factors and parent-reported infants nighttime sleep duration. Convergent validity was assessed using paired-sample t-tests to test whether the SPS-I subscale scores were similar between mothers and fathers in the same household. EFA and CFA confirmed a 3-factor, 12-item model: sleep routines, sleep autonomy, and screen media in the sleep environment. SPS-I was invariant across mothers and fathers and was reliable. Concurrent and convergent validity were established. SPS-I has good psychometric properties, supporting its use for characterizing sleep routines, sleep autonomy, and screen media in the sleep environment by mothers and fathers.Supplemental data for this article is available online at https://doi.org/10.1080/08964289.2021.2002799 .

itMatters: Optimization of an online intervention to prevent sexually transmitted infections in college students.

ObjectiveTo describe an iterative approach to developing an online intervention targeting the intersection of alcohol use and sexual behaviors among first year college students. Methods and Participants: Using the multiphase optimization strategy (MOST), we conducted two iterative optimization trials to: (1) identify candidate intervention components (i.e., descriptive norms, injunctive norms, outcome expectancies, perceived benefits of protective behavioral strategies, and self-efficacy to use strategies); (2) revise components; and (3) identify the optimized intervention. Participants were first year college students at six geographically diverse universities (optimization trial 1 N = 5,880; optimization trial 2 N = 3,551) Results: For both optimization trials, the results indicated that only descriptive and injunctive norms produced a significant effect (p<.05). Conclusions: The iterative process of MOST allowed us to develop an optimized intervention which is an essential tool to maximize intervention effectiveness and efficiency to improve uptake, sustainability, and public health impact.

First-year college students' alcohol and hookup behaviours: sexual scripting and implications for sexual health promotion.

This study used a sexual scripting framework to analyse data from the Online College Social Life Survey to examine the role of individual, (e.g. gender, race and alcohol use), relational (partner type, condom use behaviours), and contextual factors (sex ratios and fraternity/sorority affiliation) influencing 4,292 first-year college students' hookup experiences. Results suggest that hookups are relatively "safe", with the the majority involving non-penetrative sexual behaviour, condom use, and familiar partners. However, alcohol use affected hookup behaviours and lower levels of condom use were associated with heavy alcohol use, even with less well known partners. Findings point to the importance of interventions that reinforce first-year students' positive behaviours and present them with protective behavioural strategies to use in the context of alcohol, and with repeat or well-known partners to reduce risk and have enjoyable, consensual sexual experiences.

Sexual sensation seeking, hookups, and alcohol consumption among first-year college students.

OBJECTIVE: To explore sexual sensation seeking (SSS) among an ethnically-diverse sample of first-year college students and their hookup behaviors. PARTICIPANTS: 1,480 first-year college students who hooked up in the last 30 days were recruited from four universities in 2016. METHODS: Students completed an online survey before completing an online STI and alcohol prevention intervention. RESULTS: Male and sexual minority students had significantly higher SSS scores compared to female and heterosexual students respectively. Students with higher SSS scores were less likely to report condom use at last vaginal and anal hookup, more likely to hookup under the influence of alcohol and participate in a wide range of sexual behaviors. There were no significant mean differences in SSS scores by level of intoxication during their last hookup. CONCLUSION: These findings highlight the role of SSS in predicting sexual risk behaviors of first-year college students and the overall low SSS scores among this sample.

Testing the efficacy of motivational strategies, empathic reflections, and lifelike features in a computerized intervention for alcohol use: A factorial trial.

Although computer delivered brief interventions (CDBIs) have been effective in reducing alcohol use, few studies have examined which components of CDBIs are most associated with drinking reductions. The current factorial trial deconstructed a brief alcohol intervention into component parts to identify main and interaction effects on drinking outcomes. Participants (N = 352) were randomly assigned to 1 of 16 possible combinations of four dichotomous (present vs. absent) CDBI components for which theoretical and empirical support was available: empathic reflections, motivational strategies, a spoken voice, and an animated narrator. We measured main and interaction effects of these components on the primary outcome of self-reported mean drinks per day at 1- and 3-month follow-up, as well as on secondary outcomes, including binge drinking, intentions to reduce drinking, and alcohol consequences. Participants reduced drinking across all alcohol use indices over the 3-month assessment period. These effects were stronger for participants who were exposed to motivational strategies, F = 7.7, p < .001. Empathic reflections, use of a spoken voice, and use of an animated narrator were not associated with reductions in alcohol use, either as main effects or in interaction with other factors. Results suggest that CDBIs using motivational strategies are effective in reducing alcohol use. However, empathic reflections and lifelike characteristics (e.g., narrator, voice) may operate differently in CDBIs than they do in person-delivered interventions. More research is needed to better understand how these (or other factors) may influence efficacy. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Examining the Effects of an Adolescent Pregnancy Prevention Program by Risk Profiles: A More Nuanced Approach to Program Evaluation.

PURPOSE: The objective of the study was to examine whether latent class analysis (LCA) could (1) identify distinct subgroups of youth characterized by multiple risk and protective factors for early sexual initiation and (2) allow for a more nuanced assessment of the effects of a middle school program to prevent teen pregnancy/HIV/sexually transmitted infection. METHODS: LCA was applied to data from the baseline (seventh grade) sample of 1,693 sexually inexperienced students participating in a randomized controlled trial of It's Your Game…Keep It Real in Harris County, Texas. Multilevel analysis was applied within subgroups defined by the latent classes to assess for potential differential program effects. RESULTS: LCA identified 3 distinct profiles of youth: family disruption, other language household, and frequent religious attendance. Multilevel analyses found differential effects of the program across these profiles with a significant and substantial reduction (30%) in initiation of vaginal sex by ninth grade for students in the family disruption profile only. CONCLUSIONS: Application of LCA may hold promise for conducting more nuanced evaluations and refinements of behavior change interventions for youth.

The effect of substantiated and unsubstantiated investigations of child maltreatment and subsequent adolescent health.

Children with substantiated child maltreatment (CM) experience adverse health outcomes. However, it is unclear whether substantiation vs. an investigation not resulting in substantiation has a greater impact on subsequent adolescent health. Propensity scores were used to examine the effect of investigated reports on the subsequent health of 503 adolescent females. CM was categorized into three levels: 1) investigated and substantiated, 2) investigated but unsubstantiated, and 3) no investigation. Models using inverse propensity score weights estimated the effect of an investigation on subsequent teen motherhood, HIV-risk behaviors, drug use, and depressive symptoms. Females with any investigation, regardless of substantiation status, were more likely to become teen mothers, engage in HIV-risk behaviors, and use drugs compared to females with no investigated report. Substantiated CM was associated with depressive symptoms. Findings underscore the importance of maintaining case records, regardless of substantiation, to better serve adolescents at risk for deleterious outcomes. Prospective methods and propensity scores bolster causal inference and highlight how interventions implemented following investigation are an important prevention opportunity.

Optimizing a community-engaged multi-level group intervention to reduce substance use: an application of the multiphase optimization strategy.

BACKGROUND: Rates of alcohol and illicit drug use (AIDU) are consistently similar across racial groups (Windsor and Negi, J Addict Dis 28:258-68, 2009; Keyes et al. Soc Sci Med 124:132-41, 2015). Yet AIDU has significantly higher consequences for residents in distressed communities with concentrations of African Americans (DCAA - i.e., localities with high rates of poverty and crime) who also have considerably less access to effective treatment of substance use disorders (SUD). This project is optimizing Community Wise, an innovative multi-level behavioral-health intervention created in partnership with service providers and residents of distressed communities with histories of SUD and incarceration, to reduce health inequalities related to AIDU. METHODS: Grounded in critical consciousness theory, community-based participatory research principles (CBPR), and the multiphase optimization strategy (MOST), this study employs a 2 × 2 × 2 × 2 factorial design to engineer the most efficient, effective, and scalable version of Community Wise that can be delivered for US$250 per person or less. This study is fully powered to detect change in AIDU in a sample of 528 men with a histories of SUD and incarceration, residing in Newark, NJ in the United States. A community collaborative board oversees recruitment using a variety of strategies including indigenous field worker sampling, facility-based sampling, community advertisement through fliers, and street outreach. Participants are randomly assigned to one of 16 conditions that include a combination of the following candidate intervention components: peer or licensed facilitator, group dialogue, personal goal development, and community organizing. All participants receive a core critical-thinking component. Data are collected at baseline plus five post-baseline monthly follow ups. Once the optimized Community Wise intervention is identified, it will be evaluated against an existing standard of care in a future randomized clinical trial. DISCUSSION: This paper describes the protocol of the first ever study using CBPR and MOST to optimize a substance use intervention targeting a marginalized population. Data from this study will culminate in an optimized Community Wise manual; enhanced methodological strategies to develop multi-component scalable interventions using MOST and CBPR; and a better understanding of the application of critical consciousness theory to the field of health inequalities related to AIDU. TRIAL REGISTRATION: ClinicalTrials.gov, NCT02951455 . Registered on 1 November 2016.

Linking Patterns of Substance Use With Sexual Risk-Taking Among Female Adolescents With and Without Histories of Maltreatment.

PURPOSE: This study aimed to determine the associations between patterns of substance use and sexual risk-taking among female adolescents with and without histories of maltreatment. METHODS: Data are from a prospective cohort study examining the impact of maltreatment on subsequent female adolescent sexual health (N = 504). Participants averaged 18.24 years in age (SD = 1.12), and approximately 63% had substantiated incidences of maltreatment filed with Child Protective Services prior to age 18. The present study used latent class analysis to examine patterns in adolescent substance use, and negative binomial regression models to examine the links between patterns of substance use and sexual risk-taking and to determine whether these associations were moderated by adolescents' maltreatment status. RESULTS: Six classes emerged from latent class analysis labeled as follows: abstainers (25% of sample); polysubstance users-early initiators (13%); polysubstance users-late initiators (23%); alcohol and cannabis users-late initiators (9%); alcohol users-late initiators (18%); and tobacco users (12%). Patterns of adolescent polysubstance use were associated with the highest levels of sexual risk-taking, and patterns of late-initiated polysubstance use, late-initiated alcohol use, and tobacco use were more strongly related to sexual risk-taking for female adolescents with histories of maltreatment. CONCLUSIONS: This study is the first to determine the specific patterns of substance use that are more strongly related to sexual risk-taking for maltreated female adolescents. By doing so, this study demonstrates how a person-centered approach can facilitate our understanding of how to best leverage sexual risk-taking prevention efforts.

Long-term consequences of early sexual initiation on young adult health: A causal inference approach.

Although early sexual initiation has been linked to negative outcomes, it is unknown whether these effects are causal. In this study, we use propensity score methods to estimate the causal effect of early sexual initiation on young adult sexual risk behaviors and health outcomes using data from the National Longitudinal Study of Adolescent to Adult Health. We found that early sexual initiation predicted having 2 or more partners (for both males and females) and having a sexually transmitted infection in the past year (females only) but did not predict depressive symptoms in the past week (for either gender). These results underscore the importance of continued programmatic efforts to delay age of sexual initiation, particularly for females.

Applying and advancing behavior change theories and techniques in the context of a digital health revolution: proposals for more effectively realizing untapped potential.

As more behavioral health interventions move from traditional to digital platforms, the application of evidence-based theories and techniques may be doubly advantageous. First, it can expedite digital health intervention development, improving efficacy, and increasing reach. Second, moving behavioral health interventions to digital platforms presents researchers with novel (potentially paradigm shifting) opportunities for advancing theories and techniques. In particular, the potential for technology to revolutionize theory refinement is made possible by leveraging the proliferation of "real-time" objective measurement and "big data" commonly generated and stored by digital platforms. Much more could be done to realize this potential. This paper offers proposals for better leveraging the potential advantages of digital health platforms, and reviews three of the cutting edge methods for doing so: optimization designs, dynamic systems modeling, and social network analysis.

Development of a theory-based questionnaire to assess structure and control in parent feeding (SCPF).

BACKGROUND: Parents shape children's eating environments and act as powerful socialization agents, impacting young children's behavioral controls of food intake. Most feeding measures assess parents' use of control to manage children's intake of energy dense foods. The Structure and Control in Parent Feeding (SCPF) questionnaire was developed to assess more positive aspects of feeding practices with their young children -setting limits, providing routines-that promote self-regulation, as well as controlling feeding practices. METHODS: A mixed method approach was used to develop the SCPF. In 2013, cognitive interviews informed the modification, deletion and/or replacement of items. In 2014, the survey was distributed statewide to mothers of toddlers aged 12 to 36 months participating in the Women, Infants, and Children program. In 2016, exploratory factor analyses was conducted to test our theoretical parenting model and content validity and criterion validity were assessed (n = 334). RESULTS: Exploratory factor analysis (EFA) and second-order EFA revealed a 2-factor, 22-item Structure model and a 2-factor, 12-item Control model. Internal consistencies for all factors exceeded 0.70. As predicted, the Structure superfactor was positivity associated with responsiveness, whereas the Control superfactor was positively associated with demandingness on the Caregiver's Feeding Styles Questionnaire. The Structure subscales were also positively associated with mealtime behaviors and Control subscales were positively associated with control-oriented feeding measures from the Control in Parent Feeding Practices questionnaire. CONCLUSION: The SCPF questionnaire is a reliable tool that can be used to assess aspects of structure- and control-based feeding practices to better understand how parents feed their toddlers.

Increasing the public health impact of evidence-based interventions in behavioral medicine: new approaches and future directions.

The dissemination and implementation of evidence-based behavioral medicine interventions into real world practice has been limited. The purpose of this paper is to discuss specific limitations of current behavioral medicine research within the context of the RE-AIM framework, and potential opportunities to increase public health impact by applying novel intervention designs and data collection approaches. The MOST framework has recently emerged as an alternative approach to development and evaluation that aims to optimize multicomponent behavioral and bio-behavioral interventions. SMART designs, imbedded within the MOST framework, are an approach to optimize adaptive interventions. In addition to innovative design strategies, novel data collection approaches that have the potential to improve the public-health dissemination include mHealth approaches and considering environment as a potential data source. Finally, becoming involved in advocacy via policy related work may help to improve the impact of evidence-based behavioral interventions. Innovative methods, if increasingly implemented, may have the ability to increase the public health impact of evidence-based behavioral interventions to prevent disease.

Application of the multiphase optimization strategy to a pilot study: an empirical example targeting obesity among children of low-income mothers.

BACKGROUND: Emerging approaches to building more efficient and effective behavioral interventions are becoming more widely available. The current paper provides an empirical example of the use of the engineering-inspired multiphase optimization strategy (MOST) to build a remotely delivered responsive parenting intervention to prevent obesity among children of low-income mothers with and without depressive symptoms. METHODS: Participants were 107 mothers with (n = 45) and without (n = 62) depressive symptoms who had a child aged 12 to 42 months participating in the Women, Infants and Children program. Participants were randomized to one of sixteen experimental conditions using a factorial design that included a combination of the following eight remotely delivered intervention components: responsive feeding curriculum (given to all participants), parenting curriculum, portion size guidance, obesogenic risk assessment, personalized feedback on mealtime routines, feeding curriculum counseling, goal setting, mobile messaging, and social support. This design enabled efficient identification of components with low feasibility and acceptability. RESULTS: Completion rates were high (85%) and did not statistically differ by depressive symptoms. However, mothers with depressive symptoms who received obesogenic risk assessment and personalized feedback on mealtime routines components had lower completion rates than mothers without depressive symptoms. All intervention components were feasible to implement except the social support component. Regardless of experimental condition, most participants reported that the program increased their awareness of what, when, and how to feed their children. CONCLUSIONS: MOST provided an efficient way to assess the feasibility of components prior to testing them with a fully powered experiment. This framework helped identify potentially challenging combinations of remotely delivered intervention components. Consideration of how these results can inform future studies focused on the optimization phase of MOST is discussed.

Timing of First Sexual Intercourse and Young Adult Health Outcomes.

PURPOSE: To examine how age of onset of sexual intercourse is associated with past-year and lifetime sexually transmitted infections (STIs) and depression in young adulthood. METHODS: We examined how occurrence of a lifetime and past-year STI, lifetime diagnosis of depression, and past-week depressive symptoms differed as a function of age of onset of sexual intercourse using data from the National Longitudinal Study of Adolescent to Adult Health (Add Health; N = 8,938 individuals). Time-varying effect models were used to examine how age of onset, measured as continuous age, was associated with these outcomes in young adulthood, with all analyses stratified to examine gender differences. RESULTS: Individuals who engaged in first intercourse before age 16 reported higher than average rates of all outcomes studied; for example, an estimated 35% of women and 12% of men who initiated at age 14 years reported a lifetime STI, compared with about 5% of those who initiated at age 24 years. Timing of first intercourse past the mid-twenties was associated with lower than average rates of STIs and lifetime depression diagnoses but was associated with a somewhat higher level of past-year depressive symptoms. Patterns were similar by gender, although there was little difference in men's depression diagnoses by age of onset. CONCLUSIONS: Results suggest that sexual intercourse before age 16 years may be associated with higher rates of STIs and depression. Findings provide support for comprehensive programs that both promote delay of first intercourse and provide safe sex and psychological support for those who initiate early.

Latent Classes of Adolescent Sexual and Romantic Relationship Experiences: Implications for Adult Sexual Health and Relationship Outcomes.

Adolescents' sexual and romantic relationship experiences are multidimensional but often studied as single constructs. Thus, it is not clear how different patterns of sexual and relationship experience may interact to differentially predict later outcomes. In this study we used latent class analysis to model patterns (latent classes) of adolescent sexual and romantic experiences, and then examined how these classes were associated with young adult sexual health and relationship outcomes in data from the National Longitudinal Study of Adolescent to Adult Health (Add Health). We identified six adolescent relationship classes: No Relationship (33%), Waiting (22%), Intimate (38%), Private (3%), Low Involvement (3%), and Physical (2%). Adolescents in the Waiting and Intimate classes were more likely to have married by young adulthood than those in other classes, and those in the Physical class had a greater number of sexual partners and higher rates of sexually transmitted infections (STIs). Some gender differences were found; for example, women in the Low-Involvement and Physical classes in adolescence had average or high odds of marriage, whereas men in these classes had relatively low odds of marriage. Our findings identify more and less normative patterns of romantic and sexual experiences in late adolescence and elucidate associations between adolescent experiences and adult outcomes.

Optimization of Multicomponent Behavioral and Biobehavioral Interventions for the Prevention and Treatment of HIV/AIDS.

To move society toward an AIDS-free generation, behavioral interventions for prevention and treatment of HIV/AIDS must be not only effective, but also cost-effective, efficient, and readily scalable. The purpose of this article is to introduce to the HIV/AIDS research community the multiphase optimization strategy (MOST), a new methodological framework inspired by engineering principles and designed to develop behavioral interventions that have these important characteristics. Many behavioral interventions comprise multiple components. In MOST, randomized experimentation is conducted to assess the individual performance of each intervention component, and whether its presence/absence/setting has an impact on the performance of other components. This information is used to engineer an intervention that meets a specific optimization criterion, defined a priori in terms of effectiveness, cost, cost-effectiveness, and/or scalability. MOST will enable intervention science to develop a coherent knowledge base about what works and does not work. Ultimately this will improve behavioral interventions systematically and incrementally.

Patterns of adolescent sexual behavior predicting young adult sexually transmitted infections: a latent class analysis approach.

Adolescent sexual behavior is multidimensional, yet most studies of the topic use variable-oriented methods that reduce behaviors to a single dimension. In this study, we used a person-oriented approach to model adolescent sexual behavior comprehensively, using data from the National Longitudinal Study of Adolescent Health. We identified five latent classes of adolescent sexual behavior: Abstinent (39%), Oral Sex (10%), Low-Risk (25%), Multi-Partner Normative (12%), and Multi-Partner Early (13%). Membership in riskier classes of sexual behavior was predicted by substance use and depressive symptoms. Class membership was also associated with young adult STI outcomes although these associations differed by gender. Male adolescents' STI rates increased with membership in classes with more risky behaviors whereas females' rates were consistent among all sexually active classes. These findings demonstrate the advantages of examining adolescent sexuality in a way that emphasizes its complexity.