The Journal of School Nursing
2021, Vol. 37(2) 109-116
© The Author(s) 2019
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DOI: 10.1177/1059840519849097
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Melissa A. Saftner, PhD, CNM1 , Kelsey S. Pruitt, DNP, WHNP1,2, and Annie-Laurie McRee, DrPH2
Communication with sexual partners about protection against sexually transmitted infections (STIs) is associated with safer sexual behaviors among general populations of youth, but little is known about partner communication among American Indian youth. We assessed the prevalence of adolescents’ communication with sexual partners about STI prevention and used multivariable logistic regression to examine associations between communication and safer sexual behaviors (condom use, reliable contraceptive use, and dual method use) among a statewide sample of in-school, American Indian youth in Minnesota in 2013 and 2016 (n = 739). Half (49.5%) of sexually experienced American Indian youth reported talking about STI prevention at least once with every sexual partner. Communication was associated with all examined safer sexual behaviors among females and only with condom use among males. Study findings highlight the importance of school nurses, health educators, and other clinicians addressing partner communication when counseling adolescent patients.
sexual health, adolescents, sexual communication, condom use, contraceptive use, American Indian, school nurse
Adolescent sexual risk behaviors remain a concern nationally as sexually transmitted infection (STI) rates increase. Despite the overall decrease in the teen pregnancy rate (Martin, Hamilton, Osterman, Driscoll, & Drake, 2018), STI infections remain alarmingly high and are increasing in the population. Among those aged 15–19, chlamydia increased by 7.5% from 2016 to 2017—representing 62.6% of all chlamydia infections—and gonorrhea increased by 15.5% (Centers for Disease Control and Prevention, 2018). These trends are particularly alarming in communities of color, specifically American Indian communities. Nationally, the rate of chlamydia infections was 2.5 times greater for American Indian adolescents compared to their White counterparts (Centers for Disease Control and Prevention, 2018), and gonorrhea dramatically increased among 15- to 19-yearold American Indian youth from 444.7 cases per 100,000 in 2016 to 2,411.9 cases per 100,000 in 2017 (Centers for Disease Control and Prevention, 2017). The Indian Health Service’s most recent report on STIs notes that American Indian infection rates are likely underreported given the classification of American Indian people, and in fact their data find a higher rate of STIs in the population compared to the Centers for Disease Control data (Centers for Disease Control and Prevention & Indian Health Service, 2014).
In Minnesota, the disparities for American Indian adolescents largely reflect the national chasm. Between 2015 and 2016, American Indian adolescent pregnancy rates increased 5.9%, the only increase across racial and ethnic groups in the state (Farris, Austin, & Brown, 2018). Additionally, American Indian STI rates remained elevated compared to their White counterparts, and those living in rural areas in Minnesota are more at risk (Farris et al., 2018). This rural–urban gap is particularly an issue for American Indian youth as the majority of American Indian people in Minnesota live in rural areas (Minnesota Department of Health, 2017), and early sexual initiation, no condom use at last intercourse, and American Indian race are associated with having an STI (Eitle, Greene, & Eitle, 2015). Moreover, American Indian youth are more likely to use substances, have multiple sexual partners, and report earlier sexual debut (de Ravello, Everett Jones, Tulloch, Taylor, & Doshi, 2014; Markham et al., 2015).
Although evidence exists about sexual risk behavior in American Indian communities, there are gaps in our knowledge about behaviors that may promote safer sexual behaviors among American Indian adolescents. A social–ecological model of health and health promotion (McLeroy, Bibeau, Steckler, & Glanz, 1988) suggests that adolescent sexual behavior is impacted by factors across various levels of influence (e.g., individual, interpersonal/relationship, group/community, and environmental). Because safer sex practices occur within interpersonal relationships, it is critical to understand adolescents’ communication with their sexual partners. In other racial and ethnic groups, youth who report positive communication practices with their sexual partners have more consistent condom and contraceptive use (Amialchuk & Gerhardinger, 2015; Johnson, Sieving, Pettingell, & McRee, 2015; Kenyon, Sieving, Jerstad, Pettingell, & Skay, 2010; Salazar et al., 2004; Sales et al., 2012), though the type and content of these discussions also matter. For example, talking with partners about condom use is a better indicator of condom use than is talking about past sexual partners (Widman, Noar, Choukas-Bradley, & Francis, 2014). However, little is known about communication with sexual partners among American Indian youth who likely have unique cultural, tribal, and geographical influences on their perceptions of sexual risk, condom use, and partner communication.
We sought to describe partner communication among American Indian adolescents and examine associations between partner communication and safer sex behaviors. We predicted that consistent communication with sexual partners would be associated with increased safer sexual behaviors among American Indian males and females. This secondary analysis aims to fill the gap in knowledge related to American Indian sexual risk and partner communication.
The study design is a secondary data analysis using data from the Minnesota Student Survey (MSS), a statewide surveillance system coordinated by the Departments of Education, Health, Human Services, and Public Safety. The MSS is an anonymous, school-based questionnaire that comprehensively assesses protective and risk health behaviors among Minnesota youth. It is administered every 3 years to students in 5th, 8th, 9th, and 11th grades who attend public schools, tribal schools, and charter schools in Minnesota. Parents are notified of MSS administration and can opt out their children from participating. Students can decline to participate, skip questions, or stop participating at any time. For the present study, we combined data from 2013 and 2016 to increase the number of American Indian youth for analysis. In 2013, 84% of Minnesota public school districts chose to participate, followed by 85% in 2016. The institutional review board at the University of Minnesota deemed this study exempt from review as a secondary analysis of existing anonymous data.
The aim of the study was to examine sexual partner communication among sexually experienced American Indian youth. Our sample was restricted to students in 9th and 11th grades as the MSS items related to sexual activity were included only for these grades. Among these students, only youth who identified their race as “American Indian or Alaska Native,” reported that they ever “had sexual intercourse (‘had sex’),” and had complete data for all covariates were included in analyses, resulting in an analytic sample of 739 students.
Safer sexual behaviors. We examined three dichotomous (yes vs. no) safer sexual behavior outcomes: condom use, reliable contraceptive use, and dual method use. The survey assessed condom use with the question: “The last time you had sexual intercourse, did you or your partner use a condom?” A single item assessed contraceptive use: “The last time you had sexual intercourse, what one method did you or your partner use to prevent pregnancy?” To create an indicator of reliable contraceptive method use, we categorized responses of (a) birth control pills, (b) birth control shot, (c) birth control ring, (d) implant, or (e) any IUD as using a reliable contraceptive method. We constructed an indicator of dual method use based on a combination of condom use and reliable contraceptive method use items, categorizing respondents who indicated both condom use and reliable contraceptive use as having used dual methods at last sexual intercourse.
Partner communication. The survey assessed partner communication about STI prevention with the item: “Have you talked with your partner(s) about protecting yourselves from getting sexually transmitted infections/HIV/AIDS?” Response options included (a) never, (b) not with every partner, and (c) at least once with every partner. We combined the responses of “never” and “not with every partner” to create an indicator of consistent partner communication (at least once with every partner vs. never or not with every partner).
Demographic and sexual health characteristics. Students indicated their grade, biological sex, family structure (lives with two biological or adoptive parents vs. another family structure), and area of residence (categorized as within the 7-county Twin Cities metropolitan area vs. outside the metropolitan area). We used student report of receiving free or reduced-price lunch at school as an indicator of poverty status. Students also reported on their sexual orientation whether they drank alcohol or used drugs before last sex and the number of sexual partners (of either sex) they had in the last 12 months.
We assessed the relationship between partner communication about STI prevention and safer sexual behaviors using multivariable logistic regression. Models were stratified by sex and adjusted for grade, family structure, socioeconomic status, area of residence, sexual orientation, substance use before last sexual intercourse, and number of sexual partners as these have shown to impact adolescents’ safer sexual behaviors (Kirby, 2002) and partner communication (Ryan, Franzetta, Manlove, & Holcombe, 2007). We conducted all analyses using Stata Version 14.0 (StataCorp, College Station, TX). Statistical tests were two-tailed with a critical α of .05.
As shown in Table 1, overall, roughly half of American Indian youth were in 11th grade (54%) and over a quarter (28%) lived in households with two biological or adoptive parents. Nearly three quarters (78%) lived outside of the Twin Cities metropolitan area, and over two thirds (65%) received free or reduced-price lunch. Most students identified as heterosexual (83%). Almost one quarter of youth (22%) reported using substances prior to last sexual intercourse and almost half (48%) reported having two or more partners in the past year. Family structure, sexual orientation, and number of sexual partners varied (p <.05)by students’ sex.
Half of American Indian youth (50%) reported that they talked about STI prevention at least once with every sexual partner. Safer sexual behaviors varied by sex. Fewer females than males reported condom use at last sex (51% vs. 61%, p < .01), but more females reported using a reliable contraceptive method (27% vs.17%, p < .01). Overall, 9% of youth in our sample reported using dual methods at last sex.
Associations Between Partner Communication and Safer Sexual Behaviors
Females. In multivariable analyses, consistent partner communication was associated with all safer sexual behavior outcomes among females (Table 2). Compared to females whose communication with sexual partners about STI prevention was inconsistent, those who talked about STI prevention at least once with all sexual partners had greater odds of using condoms (OR = 1.6, CI = [1.0, 2.5], p < .05) or reliable contraceptive methods at last sex (OR = 1.8, CI = [1.0, 3.1], p < .05) and were almost 3 times as likely to use a dual method (OR = 2.8, CI = [1.1, 7.0], p < .05). After adjusting for covariates, safer sexual behavior also differed by grade. Females in 11th grade had greater odds of using a reliable method of contraception than those in 9th grade, but other covariates were not statistically significant in multivariable models.
Males. In multivariable analyses, males who communicated about STI prevention at least one time with all sexual partners had over twice the odds of using condoms at last sexual intercourse compared to those whose communication was inconsistent (OR = 2.5, CI = [1.6, 3.8], p < .001; Table 3). However, consistent partner communication was not associated with other safer sexual behavior outcomes. After adjusting for covariates, safer sexual behaviors also differed by grade and reports of substance use. Males in 11th grade were less likely to report using condoms at last sex, and they had twice the odds of using reliable contraception. Males who used substances before last sex were less likely to use condoms.
Safer sexual behavior is important in reducing unintended pregnancy and STIs. We sought to describe partner communication among American Indian adolescents and examine associations between partner communication and safer sexual behaviors. First, we found that over half of American Indian youth discussed STI prevention with every partner, a prevalence similar (or higher for males) than among general populations of youth (Hicks, McRee, & Eisenberg, 2013; Ryan et al., 2007). Importantly, our findings indicate that consistent communication with sexual partners may increase safer sexual behaviors. The positive influence of partner communication on sexual behavior among American Indian adolescents is similar to studies with other racial and ethnic groups and therefore points to partner communication being a universal health promotion opportunity (Johnson et al., 2015; Kenyon et al., 2010; Salazar et al., 2004).
In this study, we found that American Indian females who reported consistent communication with their partners about STI prevention had greater odds of condom, reliable method, and dual method use. However, reports of consistent communication among American Indian males were associated with greater odds of condom use but not the other safe sex practices examined. These gender differences make sense as females who feel confident in their ability to talk to their partners may be more likely to consider contraceptive options that give them agency. The lack of association between communication and reliable- and dual-method use among males may be due in part to young men’s lack of awareness of their female partners’ use of methods (such as long-acting reversible contraceptive methods) that do not require male knowledge or cooperation (Richards, Peters, Sheeder, & Kaul, 2016). Other research with general populations of youth (Amialchuk & Gerhardinger, 2015) finds that ever discussing contraception with a partner prior to having sex increased reports of contraceptive use among both genders; it is possible that a different pattern of findings would emerge if our measure of communication focused on pregnancy, rather than STI, prevention which may better capture communication about these other types of methods.
Using an ecological model (McLeroy et al., 1988) to frame sexual health influences, there are significant opportunities to intervene and promote healthy sexual behavior. Previous research supports a myriad of influences on American Indian adolescents’ sexual risk behaviors across levels of the social–ecological model including parent–adolescent communication and relationships (Saftner, 2016), peer norms (Chambers et al., 2018; Saftner, Martyn, Momper, Loveland-Cherry, & Low, 2015), perceived impact of risky sexual behavior (Chambers et al., 2018), intention to have sex (Tingey et al., 2018), and condom use self-efficacy (Tingey et al., 2018).
The present study adds new support for the influence of partner communication about STIs. We also found that using alcohol or other substances prior to intercourse decreased the odds of reporting condom use at last sex for males, though not for females. Findings regarding the relationship of substance use and unprotected sexual behavior from other studies have been equivocal differing based on the timing of intercourse (e.g., first-time sexual events), extent and type of substance use, and the type of sexual relationship (Halpern-Felsher, Millstein, & Ellen, 1996). Longitudinal research is needed to evaluate the extent to which alcohol and other substances have a causal influence on American Indian adolescents’ safer sexual behaviors.
Given the conflicting research on types of partner communication that influence condom consistency and sexual risk (Johnson et al., 2015; Ryan et al., 2007; Widman et al., 2014), future research should focus on the types of communication American Indian youth are having with their partners to determine whether specific discussion about contraception or general sexual conversations are predictive of sexual behavior. Furthermore, researchers should consider investigating the differences between rural and urban dwelling American Indian youth as tribal connectivity may influence decisions about sex (Saftner, 2016).
Study findings highlight the importance of school nurses and health educators in encouraging adolescents to talk withalloftheirsexualpartnersabout STI prevention. For those working in school-based clinics that provide sexual health counseling, contraception, and screening, there are increased opportunities to enhance safe sexual behavior for both male and female students. School nurses should individually tailor counseling to educate students about condoms and other contraceptive methods, as adolescents who perceive that they have greater knowledge are more likely to discuss safer sexual practices prior to first sex (Ryan et al., 2007).
School nurses can also help students identify and develop effective strategies for discussing safer sexual behaviors with their partners and support youth’s self-efficacy for having these conversations. There are many ways to ask adolescents about partner communication self-efficacy, but there are tools available that may help initiate a conversation about communication and highlight gaps in self-efficacy. School nurses should use reliable, valid tools to query this important information. For example, the Sexual Communication Self-Efficacy Scale is one such screening tool available that nurses can use to build understanding of students’ ability to communicate well with their sex partner(s) and target counseling based on individual need (Quinn-Nilas et al., 2016). Additionally, nurses can emphasize the importance of parental communication to encourage sexual well-being (MacArthur et al., 2018).
Study limitations include a cross-sectional design and a lack of temporal ordering of questions which preclude causal inference about partner communication and safer sexual behaviors. Second, our analytic sample was based on student self-report of ever having sexual intercourse or “sex.” While research supports the validity and reliability of adolescent self-report of sensitive topics (Sieving et al., 2001), students may have interpreted this term in different ways (e.g., whether oral sex should be categorized as “sex”); this approach could lead to further exclusion of lesbian, gay, and bisexual youth who may be unclear of whether their behavior fits the intended definition. Third, our measure of partner communication may be subject to social desirability bias and not accurately represent actual discussions. This measure also does not provide information about the quality of the communication which may influence associations between communication and safer sexual behaviors. The MSS did not assess some characteristics and perceptions (e.g., cultural identity, peer norms) that may influence American Indian adolescents’ sexual communication and behaviors. Finally, while the MSS reflects the general demographics of Minnesota students, generalizability to other populations of American Indian youth needs to be established.
Compared to other groups, American Indian youth experience STIs at higher rates, and in Minnesota, pregnancy rates for the group are increasing. Given the relationship between consistent partner communication and safer sexual behavior outcomes, our findings are significant for nurses and health educators working with American Indian youth. Nurses can impact American Indian health by educating youth about safer sexual behaviors and targeting counseling services that support communication self-efficacy and intention to use condoms and contraception.
Kelsey S. Pruitt and Annie-Laurie McRee contributed to the conception of the manuscript. All authors contributed to the analysis and interpretation of the data, drafting of the manuscript, critical revisions, giving final approval, and agreed to be accountable for all aspects of work ensuring integrity and accuracy.
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was supported by the Leadership Education in Adolescent Health training program at the University of Minnesota (HRSA #T71MC00006-39-02: PI: Sieving).
Melissa A. Saftner, PhD, CNM https://orcid.org/0000-0003-0385-4864
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Melissa A. Saftner, PhD, CNM, is a clinical associate professor at School of Nursing, University of Minnesota.
Kelsey S. Pruitt, DNP, WHNP, leadership education in Adolescent Health Fellow, Captain, United States Air Force.
Annie-Laurie McRee, DrPH, is an assistant professor at School of Medicine, University of Minnesota.
1 School of Nursing, University of Minnesota, Minneapolis, MN, USA
2 Division of General Pediatrics and Adolescent Health, Medical School, University of Minnesota, Duluth, MN, USA
Corresponding Author:Melissa A. Saftner, PhD, CNM, School of Nursing, University of Minnesota, 1035 University Dr, SMed 351, Minneapolis, MN 55455, USA.Email: msaftner@umn.edu
