Associations between Community Violence and Sexual Risk-Taking in Baltimore and Johannesburg: An Analysis of Two Sites of the Well-Being of Adolescents in Vulnerable Environments (WAVE) Study
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Background: Sexual health is one of the most important health concerns for adolescents worldwide as it has short and long term consequences for both morbidity and mortality. Early pregnancy and sexually transmitted infections contribute greatly to the burden of disease during this period of life. Poor adolescents in urban areas are more likely to experience negative sexual health than their wealthier peers. They are also more likely to be the victims of violence; yet, associations between different experiences of community violence and sexual behaviors have been rarely studied in poor, urban populations. Methods: Using data from adolescents in the Well-Being of Adolescents in Vulnerable Environments (WAVE) Study, I explored relationships between adolescent perceptions of community violence and sexual activity. I hypothesized that experiencing violence would be associated with increased risk taking. In the first paper I used multiple logistic regression analyses to examine the association of experiences of three different types of violence in the community (fear of violence, observation of violence, and personal victimization) with two sexual behaviors (sexual intercourse in the last year and condom use at last sex) in Baltimore. Each violence variable was included separately in three different models and then in one model that included all three experiences of violence together. One outcome (sexual intercourse in the last year) was not hypothesized to be risky per se and therefore to be less associated with violence while the other (condom use) was hypothesized to more strongly correlated with negative sexual outcomes and therefore more strongly associated with violence. In the next step of the analysis, I performed multiple logistic regression modeling to examine whether depression or post-traumatic stress disorder confounded the associations between violence and sexual behaviors. Finally, in the third paper, I conducted logistic regression analyses among respondents in Johannesburg to assess whether similar patterns were observed compared to Baltimore. Results: In Baltimore, results showed that violence was associated with sexual activity in the last year for both boys and girls. All three experiences of violence were associated with more sexual activity for girls though associations with fear were attenuated in the model adjusting for other violence experiences. For boys, fear was associated with less sexual activity, observation with more, and victimization was not significantly associated with sexual activity. In terms of condom use, there were fewer associations across both genders. Fear was associated with lower odds of condom use for girls while observation was associated with lower odds of condom use for boys. There was no evidence that mental health confounded these relationships. In Johannesburg, there were some similarities and differences in relation to Baltimore results. For girls, observation was associated with greater odds of having had sexual intercourse in the last year while victimization was associated with lower odds. For boys, fear was also associated with lower odds of sexual intercourse and other forms of violence were not significantly related. Violence was not associated with condom use in Johannesburg. Conclusions: Violence is not strongly associated with non-use of condoms in either Baltimore or Johannesburg and therefore reducing violence may have little effect on poor sexual health outcomes. However, the associations between violence – a negative exposure – and sexual activity suggests that exploring with more depth the negative or positive experiences of adolescent sexual activity is essential. Types of partnerships, measures of sexual satisfaction, and measures of efficacy in decision-making may allow a better understanding of the effect of on risky types of sexual activity.