Every year, approximately 21 million girls aged 15 to 19 living in low- and middle-income countries (LMICs) become pregnant and over 12 million of these girls give birth. Complications from pregnancy are the leading cause of death for girls aged 15 to 19 in LMICs and adolescent mothers face an elevated risk of life-long morbidities due to pregnancy and childbirth. The risk of early childbearing and its associated consequences vary significantly depending on age, socioeconomic status, and place of residence. Adolescents affected by conflict or natural disasters are often recognized as one of the most vulnerable groups in this regard; among the countries with the highest adolescent birth rates globally, most are affected by conflict or fragility. This dissertation aimed to fill a critical gap in the literature on adolescent pregnancy in humanitarian settings. The three studies in this dissertation utilize qualitative and quantitative research to better understand the myriad drivers of adolescent pregnancy and, in the context of protracted conflict in Democratic Republic of the Congo (DRC), how exposure to armed conflict may or may not modify certain risk and protective factors. The findings of this dissertation confirm that risk and protective factors for adolescent pregnancy are numerous, interrelated, and complex; preventing early and unintended pregnancy requires multi-level interventions that build the protective assets of adolescents while also engaging with male partners, parents and caregivers, and community members. The research deepens this understanding by demonstrating the extent to which long-standing and deeply rooted sociocultural norms influence adolescents’ individual and inter-personal behaviors in diverse contexts, including settings affected by armed conflict. Thus, instead of considering how standalone risk and protective factors for adolescents differ depending on the context, the research highlights the importance of understanding linkages between environmental, inter-personal, and individual factors and the pathways through which these linkages influence reproductive health decision-making among adolescents. This dissertation also provides new evidence as to how the presence of armed conflict does not uniformly influence risk and protective factors for adolescent pregnancy. Instead, it finds that, in the case of DRC, underlying social norms and differences in social, demographic, and economic characteristics outweigh the effect of armed conflict on incidence of adolescent pregnancy. This finding does not mean that armed conflict does not have any impact on adolescent pregnancy; rather, it confirms the need for continued research in different humanitarian contexts and informs how to apply best practices from development settings to improve sexual and reproductive health (SRH) outcomes among adolescents affected by humanitarian crises. Meeting the SRH needs of adolescents requires going beyond service provision and understanding the numerous, interrelated risk and protective factors that exist at the individual, inter-personal, and community levels. Situations of conflict and displacement may present additional complexities for understanding and meeting the SRH needs of adolescents. However, this dissertation shows the feasibility of conducting research and utilizing existing data to understand some of the root causes of adolescent pregnancy in a conflict-affected setting. Moreover, the studies highlight how more robust evidence can challenge some of our longstanding assumptions about adolescents affected by humanitarian crises. Continued rigorous research and taking the time to listen to adolescents and their communities can lead to more responsive adolescent SRH programs and services that contribute to adolescents’ healthy transitions to adulthood.

Background. In the United States, adolescents are the age group least likely to be aware of their HIV infection and linked to care in a timely manner, contributing to disproportionately low rates of viral suppression and increased risk of transmitting HIV to others. A major barrier to health care for adolescents relates to confidentiality concerns, such as fears that parent/guardian consent will be required or that parents, guardians, or others will be informed of test results. This suggests that state laws related to confidentiality in sexual and reproductive health services could influence their HIV testing practices. Guided by Andersen’s Behavioral Model of Health Services Use, this dissertation utilizes a large, representative sample of sexually active high school students from the 2019 state-level Youth Risk Behavior Surveillance System (YRBSS) to investigate the potential impact of five state-level confidentiality-relevant laws on U.S. adolescents’ HIV testing practices. Methods. Data on HIV testing and individual characteristics (i.e., potential individual-level confounders/covariates) were aggregated from 25 states that participated in the 2019 state-level YRBSS. Data on contextual characteristics (i.e., potential state-level confounders/covariates) were obtained from the United States Census Bureau and the Behavior Risk Factor Surveillance System. Information about state-level confidentiality-relevant laws was compiled from the Guttmacher Institute and the Center for HIV Law and Policy to create five variables indicating whether state laws were confidentiality-promoting at the time of the 2019 state-level YRBSS. Multilevel logistic regression was used to test the following hypotheses: 1. After adjusting for individual and contextual characteristics, confidentiality-promoting state laws will be positively associated with HIV testing among sexually active U.S. high school students, such that odds of self-reported lifetime HIV testing will be significantly higher when states (a) explicitly allow minors to consent to HIV testing, (b) do not have age of consent requirements, (c) do not permit parental/guardian notification, (d) protect the confidentiality of minors insured as dependents, and (e) do not have HIV-specific criminal laws that require disclosure to sexual and/or needle-sharing partners, as compared to states with non-confidentiality-promoting laws. 2. After adjusting for individual and contextual characteristics, sex will moderate the relationship between state-level confidentiality-relevant laws and HIV testing among sexually active U.S. high school students, such that associations between confidentiality-promoting state laws and self-reported lifetime HIV testing will significantly differ between males and females. 3. After adjusting for individual and contextual characteristics, young men who have sex with men (YMSM) status will moderate the relationship between state-level confidentiality-relevant laws and HIV testing among sexually active male high school students, such that associations between confidentiality-promoting state laws and lifetime HIV testing will be significantly stronger among males who report same-sex sexual contact than among males who report opposite-sex sexual contact only. Results. Findings supported the first hypothesis that parental notification not being permitted would be positively associated with HIV testing among sexually active U.S. high school students. After adjusting for individual (i.e., sex, grade level, race/ethnicity, sexual identity) and contextual (i.e., percentage of the state population aged 25 and older with a high school diploma or higher, median household income, lifetime HIV testing among adults) characteristics, odds of self-reported lifetime HIV testing were significantly higher in states that do not permit parent/guardian notification (adjusted odds ratio [aOR]: 1.07; 95% confidence interval [CI]: 1.04-1.11; p<.001) than in states that allow health care providers to inform parents or guardians that their child is seeking or receiving STI services. However, results did not support the hypothesis that the other confidentiality-promoting state laws would be positively associated with HIV testing among sexually active U.S. high school students; as compared to states with non-confidentiality-promoting laws, odds of self-reported lifetime HIV testing were significantly lower in states that explicitly allow minors to consent to HIV testing, do not have age requirements to consent to HIV testing, and do not have HIV-specific criminal laws that require disclosure. Results supported the second hypothesis that sex would moderate the relationship between state-level confidentiality-relevant laws and HIV testing among sexually active U.S. high school students, as associations between confidentiality-promoting state laws and lifetime HIV testing differed significantly between males and females. After adjusting for individual and contextual characteristics, the effects of living in a state without age requirements or HIV-specific criminal laws with disclosure requirements on lifetime HIV testing for females were 1.53 (CI: 1.07-2.20; p=.020) and 1.56 (CI: 1.16-2.10; p=.003) times those of males, respectively. Meanwhile, the effects of state laws that explicitly allow minors to consent to HIV testing, do not permit parental notification, and protect the confidentiality of minors insured as dependents on lifetime HIV testing for females were 0.73 (CI: 0.55-0.96; p=.025), 0.72 (CI: 0.52-0.99; p=.043), and 0.66 (CI: 0.48-0.90; p=.008) times those of males, respectively. Analyses with these data failed to reject the null hypothesis for the third [alternative] hypothesis that associations between confidentiality-promoting state laws and self-reported lifetime HIV testing would be significantly stronger among sexually active males who report same-sex sexual contact than among males who report opposite-sex sexual contact only. Conclusions. Findings provide evidence that parental notification not being permitted is associated with significantly increased odds of lifetime HIV testing among sexually active U.S. adolescents, and that sex differentially affects associations between state-level confidentiality-relevant laws and sexually active U.S. adolescents’ HIV testing practices. Parental/guardian notification not being permitted may increase access to and utilization of HIV testing among sexually active U.S. adolescents. Furthermore, confidentiality-promoting laws – particularly those that explicitly include HIV testing in the package of STI services to which minors may consent, do not permit health care providers to notify parents/guardians that their child is seeking or receiving STI services, and protect the confidentiality of minors insured as dependents – may facilitate access to and utilization of HIV testing for sexually active male adolescents. Altogether, this dissertation provides compelling preliminary evidence for efforts to better understand and address structural determinants of HIV and HIV prevention among sexually active U.S. adolescents. Results underscore the need for a comprehensive, multi-level approach to adolescent HIV prevention that goes beyond a focus on reducing individual-level risk factors to increase protective factors at the structural level (e.g., confidentiality-promoting state laws). To address HIV-related health inequities among young people in the United States, advocates must fight for the passage of state laws that protect adolescents’ right to confidential sexual and reproductive health care.

The Republic of Kiribati is one of the last countries to face the HIV/AIDS epidemic in the Pacific. First appearing in the region in 1982, HIV/AIDS was recognized as a national concern during the late 90s. Partnering with the National AIDS Committee, research was conducted using qualitative and quantitative methods which included focus groups, surveys, personal interviews and quasi experiments. These methods were used to explore population and individual perceptions and behaviors related to HIV/AIDS. Once perceptions and behaviors were understood, HIV/AIDS was placed in a broader historical and social context. Placing the illness in these contexts, I examined how history and social environments influenced the spread of the virus. Focusing on youth, research exposed complex social structures which produced opportunities for varying levels of stigma, economic development, migration, education and modernity, all contributing to a systematic promotion and prevention of the spread of HI V/AIDS. Conclusions showed that gender roles, modernity, educational and economic opportunity, overpopulation, religious beliefs and limited resources contributed to greater amounts of high risk behaviors taken by individuals. Conversely, gender roles, religious beliefs, and modernity also assisted in the prevention of transmission. / Graduation date: 2006

Uganda has experienced the largest decline of HIV prevalence of any country in the world, from a peak of 15% in 1991 to 5% today. In cooperation with community-based and faith-based organizations, the Ugandan government has pursued an AIDS prevention strategy centered on urging people to Abstain from sex, Be faithful to one partner, or use Condoms (the so-called ABC model). It is believed that the large drop in AIDS prevalence has been due to behavior change, especially reduction of number of sexual partners among adults and abstinence and delayed sexual debut among youth. The purpose of this study was to conduct a qualitative investigation of Ugandan adolescent's attitudes and values towards relationships and sexuality, and the ways in which their social environment sends messages and creates perceived norms which shape sexual behavior, especially the behavior of abstinence. Focus groups were conducted with youth between the ages of 13 and 16 years in the districts of Soroti and Masaka. Youth discussed reasons for having relationships, both platonic and sexual; the benefits and risks of relationships; the proper age for boys and girls to initiate sexual relationships; messages they have received regarding sexuality and perceptions of family, peer, and community norms; and values regarding ideal sexual behavior. Youth expressed that the right age to begin having sex is 18 years and above, so that sex does not interfere with education and cause other adverse consequences such as early pregnancy, family strife, and infection with HIV/AIDS. / Graduation date: 2005

published_or_final_version / Medical Sciences / Master / Master of Medical Sciences

Sexual and reproductive health care have become key priorities both within developing and developed nations. Young people have been identified as particularly vulnerable to negative health outcomes. South Africa is one such example of a country that presently faces significant challenges in addressing the unmet sexual and reproductive health needs of young people. With the enormous burden of reproductive health problems and the accelerating HIV epidemic, the provision of sexual and reproductive health services remains a challenge. Though various studies highlight the importance of comprehensive services targeted at youth, there is a lack of adequate research in evaluating the extent to which health services are addressing the health needs of clients. This study aimed to address this gap by examining a health care facility for students at one of the largest tertiary institutions in KwaZulu-Natal. The core objective was to determine the extent to which the health services are responding to the sexual and reproductive needs of young people by, exploring the experiences and perspectives of service providers and young men and women in relation to comprehensive, youth-friendly sexual and reproductive health care. This was assessed using a revised version of the Bruce-Jain quality of care framework. Information for this study was obtained using quantitative and qualitative data collection methods including: an inventory of the facility and services, in-depth interviews with staff and exit interviews with 200 clients aged 18 to 24 years. The findings of the study reveal that logistical constraints hindered effective implementation of comprehensive, youth-friendly services by providers. Providers missed opportunities to provide clients with much needed information and services due to staff shortage, client overload, lack of infrastructure, and poor continuity mechanisms. HIV, STIs and unwanted pregnancies were some of the most important health issues among young people visiting the health facility. Very few young men utilised the services. Some of the key findings were that clients continue to experience barriers in interpersonal relations while many expressed the need for more information from providers. In addition, many young women still have an unmet need for contraception. Policy makers need to incorporate the needs of young clients within sexual and reproductive health initiatives. Ideally young people should be involved in the design and implementation process of comprehensive, youth-friendly health initiatives. This would form a platform for addressing the barriers that hinder health service provision. / Thesis (M.A.)-University of KwaZulu-Natal, Durban, 2011.

M.A. (Psychology) / Please refer to full text to view abstract

Created to give the secondary school teacher a bibliography for use in health educatioin instruction and to recommend a procedure for accumulating teaching materials. / Typescript. / "August, 1950." / "Submitted to the Graduate Council of Florida State University in partial fulfillment of the requirements for the degree of Master of Science." / Includes bibliographical references.

The purpose of this study was to investigate the relationship among different levels of acculturation on the childbearing beliefs and practices of pregnant Mexican American adolescents living in Southwest border regions. A descriptive correlational design was used in this study. Three instruments were used to collect data. A total of 73 pregnant Mexican American adolescents participated in the study. The Laredo sample and the Tucson sample were identified as true bicultural samples. The El Paso group was identified as a Mexican-oriented bicultural sample. All geographical areas had an equal acceptance of traditional Mexican medicine and biomedical beliefs. Laredo and Tucson adolesents' beliefs in the traditional Mexican childbearing culture was directly related to their acculturation level. For the El Paso group, there was a low negative correlation which indicated that being more or less acculturated did not necessarily affect the adolescents' beliefs in the traditional Mexican childbearing culture.

Adolescence is a time of great exploration and change. During this time, youth are transitioning both biologically and sexually into adults. Adolescents are also testing the boundaries of self-reliance and making choices about their personal relationships. Not surprisingly, aggressive urges are often driven by peers in pursuit of some form of identity (Masten 2004). Peers can have both positive and negative effects on the wellbeing on youth. Peer groups can provide emotional, physical, and social support to youth during a time of immense change (Parker and Asher 1987; Gest, Graham-Berman, and Hartup 2001). Peers can also model delinquent and risk-taking behaviors that have lasting health, social, and economic consequences throughout the life course. In an effort to understand the role of friendships in adolescent health, social scientists have increasingly focused on adolescent network structures within schools and the role various positions and peer group formations influence behaviors such as alcohol and cigarette use, violent and serious delinquency, and sexual risk-taking. While informative, peer networks studies have yet to adequately address how peer network structures based on immigrant generation and types of marginalized social positions influence health risk behavior engagement among adolescents. In three studies, I address the dearth of research in these areas, using data from the National Longitudinal Study of Adolescent to Adult Health (Add Health). The first study investigates the influence of generational peers on alcohol misuse among immigrant youth. Testing hypotheses derived from sociological theories of generations regarding race/ethnicity, gender, and immigrant generation, findings from this study demonstrate generational ties are inversely related to alcohol misuse for immigrants and these effects depend partly on race/ethnicity and gender. The second study investigates the effects of specific network forms of social isolation on heavy episodic drinking and cigarette use among adolescents. The central finding from this study is that different network-based forms of social isolation had varying effects on alcohol and cigarette use when compared to sociable youth. The final study examines the relationship between types of social isolation and violent delinquency when compared to sociable youth. Deriving hypotheses from general strain theory, I test whether the isolation-violence relationship varies across isolation types when compared to sociable youth. I also test whether other negative experiences and circumstances (strains) tied to adolescence moderate the relationship between isolation types and violent delinquency. Finally, studies indicate a consistent gender gap in criminality. Therefore, I test whether the isolation-violence relationship differs by gender. Findings demonstrate that socially disinterested youth show a greater capacity for violent behavior, but other types of marginalized youth showed no difference in violence when compared to sociable youth. Results also suggest that some types of strain moderate the isolation-violence relationship and that these patterns are gendered.