The Journal of School Nursing2023, Vol. 39(4) 285–294© The Author(s) 2021Article reuse guidelines:sagepub.com/journals-permissionsDOI: 10.1177/1059840520987534journals.sagepub.com/home/jsn
Although the rate of sexual intercourse among adolescents has increased in Asian countries, including Korea, many sexually active adolescents still do not use contraception. The aim of this study was to identify the risk factors for contraceptive nonuse among adolescents using decision tree analysis of the 2018 Korea Youth Risk Behavior Survey data from 2,460 high school students who had an experience of sexual intercourse. The findings indicated that the highest risk group who did not use contraception during sexual intercourse did not receive sexual health education in school and was involved in habitual or purposeful drug use. The experience of ever receiving treatment due to violence and the experience of sexual intercourse after drinking were also identified as risk factors for contraceptive nonuse. To encourage contraceptive use, development of standard sexual health education, counseling, and educational intervention intended to prevent risky behaviors is needed.
Keywordsadolescent, contraceptive use, decision tree model, reproductive health
Given that the issues of pregnancy and childbirth among adolescents worldwide are social concerns, the importance of contraception for adolescents is being emphasized. Since the number of sexual intercourse experiences of adolescents has rapidly increased in accordance with changes in the social and cultural environment, the incidence of sex-related problems such as unintended pregnancies, induced abortion, and sexually transmitted infections (STI) among adolescents has also increased (Cho & Ra, 2014; Kim & Lee, 2016). In addition, complications of adolescent pregnancy and childbirth are related to a high maternal mortality rate and are reported to be the main causes of mortality among female adolescents aged 15–19 years (Kassa et al., 2018; Neal et al., 2012). Rapid physical and mental changes occur during adolescence (Clarke et al., 2016), and in particular, adolescents may become curious about sexual issues (Lee, 2017). Moreover, smartphone addiction in adolescents is associated with exposure to harmful media such as pornography and distorted sexual information. Increased exposure to such harmful media causes sexual assault behaviors in adolescents (Kim & Kwak, 2017; Kim & Lee, 2016). Therefore, although their perceptions of sexual behaviors and attitudes have not fully formed, adolescents become interested in sexual behaviors and experiencing sexual intercourse.
In accordance with the results of a previous study using data from the Korea Youth Risk Behavior Survey (KYRBS), among high school students who had experience with sexual intercourse, approximately 7.2% had an experience of STI (Kim & Lee, 2016). Further, 7.9% of female high school students who had experience with sexual intercourse also reported becoming pregnant (Hong & Kang, 2017). Adolescent pregnancy is a major concern because of inadequate prenatal care, premature birth, and economic instability (Hong & Kang, 2017; Zhao et al., 2016). In addition, pregnant adolescents are stigmatized by others and forced to drop out of school or transfer to another school (Kim, 2014). In Korea, although the importance of contraceptive use to prevent STI or pregnancy among adolescents is known, previous research has reported that less than 50%–60% of adolescents who had engaged in sexual intercourse used contraceptive methods (Jang & Choi, 2020; Lee & Kang, 2011). In the last decade, Korean adolescents’ experience in sexual health education has increased from 58.7% to 77% (Jang & Choi, 2020). However, the rate of contraceptive use has increased from 40.3% to 58.9% (Jang & Choi, 2020), which is much lower than that in the United States where more than 86% of sexually active adolescents use contraceptives (Centers for Disease Control and Prevention [CDC], 2018). In the United States, substantial resources were spent on the abstinence-only-until-marriage program to prevent premarital sex in the 1990s; however, today more resources are devoted to a number of advocacy and practical programs aimed at preventing adolescent pregnancy and STI (Marques & Ressa, 2013). These programs, including increased access to contraceptives, contributed to reducing the rate of adolescent pregnancy from 117 per 1,000 young women aged 15–19 years in 1990 to 18.8 in 2017, and contraceptive use was the biggest contributor to reducing adolescent pregnancy (CDC, 2019; Marques & Ressa, 2013). In contrast, due to the traditional mindset of the society in Korea, providing or purchasing contraceptives for adolescents is looked down upon. Furthermore, contraceptives such as pills are not covered by health insurance (Seon, 2017). Moreover, although school nurses of all middle and high schools in Korea are required to conduct sexual education classes for more than 10 hours per year, only around three-quarters of the students surveyed confirmed to having received sexual health education (Baek et al., 2019).
Studies examining factors affecting adolescents’ contraceptive use have identified sex-related factors such as age during the first sexual intercourse experience (Lee, 2017), engaging in sexual intercourse after drinking (Cho & Ra, 2014; Hong & Kang, 2017; Lee, 2017), number of sexual partners (Zhao et al., 2016), and experience of sexual violence (Zhao et al., 2016); risk behavior-related factors such as drug use (Kingree et al., 2000; Lee, 2017; Tucker et al., 2012), drinking alcohol (Baskin-Sommers & Sommers, 2006), and smoking (Hong & Kang, 2017; Zhao et al., 2016); and general characteristics including socioeconomic status (Hong & Kang, 2017), academic performance (Hong & Kang, 2017), and co-residence with their parents (Cho & Ra, 2014; Hong & Kang, 2017; Lee, 2017). Although the current status of contraceptive use among adolescents has been examined in Korea (Lim et al., 2016), studies aimed at identifying risk factors for contraceptive nonuse and the decision-making process regarding contraceptive use among adolescents are limited.
The decision tree model using data mining is a useful analytical framework for classifying and predicting related factors by identifying meaningful patterns and rules. Decision tree analysis has been used to provide a strategy for improving the health of patients, for example, by identifying factors affecting the quality of life of cancer and hemodialysis patients (de Melo et al., 2018; Lira e Silva et al., 2017; Song & Ying, 2015). Therefore, the aim of this study was to identify the risk factors for contraceptive nonuse in adolescents by developing a decision tree model using KYRBS. The results of this study can be used to develop appropriate interventions designed to promote reproductive health in adolescents.
This study was a cross-sectional descriptive study using secondary data from the 14th (2018) KYRBS, which is an ongoing national survey conducted by the Ministry of Education and the Ministry of Health and Welfare of Korea, and the Korea Centers for Disease Control and Prevention. KYRBS is a self-reported online survey designed to identify health behaviors, including smoking, drinking, obesity, dietary habits, and physical activity, among Korean adolescents since 2005. In the population sampling stratification phase, 39 regions and school levels were used to divide the population into 117 sections. In the sample distribution phase, after determining the sample size for 400 middle schools and 400 high schools, 5 middle and 5 high schools were allocated to each of the 17 cities and provinces. School was used as the primary extraction unit, and class was used as the secondary extraction unit through extract stratified colonies. The sample school was selected by the permanent random number for each section, and the sample class was selected through random sampling.
KYRBS targets Korean adolescents from first grade in middle school to third grade in high school. The target population of the 14th (2018) KYRBS was 62,823 students from 400 selected middle schools and 400 high schools. In total, 60,040 students participated in this survey (95.6% response rate). In this study, 2,460 high school students who had experience with sexual intercourse out of 29,811 high school students formed the sample.
The variables regarding contraceptive use and 20 potential predictors for contraceptive use based on previous studies (Baskin-Sommers & Sommers, 2006; Cho & Ra, 2014; Hong & Kang, 2017; Kingree et al., 2000; Lee, 2017; Tucker et al., 2012; Zhao et al., 2016) were selected from the 14th (2018) KYRBS. Sex-related characteristics included sexual intercourse experience after drinking and sexual health education in school; health-related characteristics included subjective health status, depressive mood, suicidal ideation, suicidal plan, suicide attempt, violence, drinking, smoking, electronic cigarette use, and drug use. General characteristics included age, sex, grade, urbanicity, economic status, cohabitation with family, and academic achievement. Contraceptive use was assessed by asking, “Did you use contraceptive methods to prevent pregnancy during sexual intercourse?” Responses of “always,” “almost always,” and “sometimes” were coded as “yes,” and a response of “never” was coded as “no.”
In terms of sex-related characteristics, engaging in sexual intercourse after drinking was assessed by the question, “Have you ever had sexual intercourse after drinking?” The available responses were “yes” or “no.” Sexual education in school was determined by asking “Have you had sexual education in school in the last 12 months?” The possible responses were “yes” or “no.”
Regarding health-related characteristics, subjective health status was assessed by the question, “What do you think is the status of your health?” The available responses were “good,” “moderate,” or “bad.” Depressive mood was determined by asking “Have you ever felt sad or depressed enough to stop your daily life for 2 weeks in the last 12 months?” The possible responses were “yes” or “no.” Suicidal ideation was assessed using the question, “Have you ever seriously considered committing suicide in the last 12 months?” The available responses were “yes” or “no.” Suicide plan was assessed by the question, “Have you made any specific plans to commit suicide in the last 12 months?” The possible responses were “yes” or “no.” Suicide attempt was assessed by the question, “Have you tried to commit suicide in the last 12 months?” The possible responses were “yes” or “no.” The experience of violence was examined by asking, “Have you ever been treated in a hospital because of violence by a friend, senior, or adult?” The possible responses were “yes” or “no.” Drinking was assessed by the question, “Have you ever had more than one drink?” The possible responses were “yes” or “no.” Smoking was assessed by asking, “Have you ever smoked a cigarette, even one puff?” The possible responses were “yes” or “no.” Electronic cigarette use was identified by the question “Have you ever used electronic cigarettes?” The possible responses were “yes” or “no.” Drug use was assessed by the question, “Have you ever taken drugs, including butane gas or glue habitually or on purpose?” The possible responses were “yes” or “no.”
In terms of general characteristics, family economic status was categorized as high, middle, and low. Cohabitation with their family was assessed by asking, “What is your present residence type?” In the case of cohabitation with family or relatives, this response was coded as “yes,” and other cases including living apart from their family, living in dormitories, or living in orphanages were coded as “no.” The validity and reliability of the data were good with a kappa value of 0.62 (95% CI: 0.45–0.78, p = .03) for contraception rate (Korea Centers for Disease Control and Prevention [KCDC], 2009).
The data were analyzed using IBM SPSS Version 25.0. Descriptive statistics were used for general characteristics, sex-related characteristics, and health-related characteristics. An exhaustive χ2 automatic interaction detection of the decision tree model was used to identify high-risk groups for contraceptive nonuse among adolescents. Participants were divided into two groups depending on whether they used contraception or not. The minimum number of cases of the parent node was set at 100, and the child node was set at 50. The decision tree model had 12 terminal nodes. The five nodes in which the prevalence of contraceptive nonuse was higher than the mean prevalence rate were identified as the high-risk group for contraceptive nonuse. The risk estimate of the model was 0.243 (standard error = 0.009). The decision tree model classified around 75.7% of the participants correctly. To test the decision tree model, split-sample validation was conducted. The risk estimate of the training sample was 0.263 (standard error = 0.012) and that of the testing sample was 0.239 (standard error = 0.012).
This study used secondary data that ensured anonymity, participant’s confidentiality, and privacy. The study was approved by the institutional review board (IRB) of the Public Institutional Bioethics Committee designated by the Ministry of Health and Welfare (IRB-P01-201910-21-003).
The average age of participants was 16.8 (+0.92) years and 64.6% were male (Table 1). Approximately half of the participants lived in metropolitan cities (53.2%), and 39.0% of the participants had a high economic status, followed by middle economic status (38.1%) and low economic status (22.9%). More than 90% of the participants lived with their family, and 44.1% of participants reported low academic achievement. In terms of sex-related characteristics, 25.4% of participants never used contraception and 36.5% of participants had experienced sexual intercourse after drinking. Around three-quarters of the participants received sexual health education in school (74.1%). Regarding healthrelated characteristics, 10.8% of the participants reported that their subjective health status was poor. Almost half of the participants reported depressive mood (42.6%), while 21.3% of the participants had suicidal ideation, 9.8% had a suicidal plan, and 8.1% reported suicide attempts. A total of 7.7% of the participants had ever received treatment due to violence. More than 80% of the participants reported experiencing drinking alcohol (85.0%). Approximately 60% of the participants had an experience of smoking, while 42.8% of the participants responded that they had used electronic cigarettes. Further, 6.8% of the participants reported habitual or purposeful drug use.
Table 2 shows contraceptive use by general characteristics and sexual and health-related characteristics of participants. In terms of general characteristics, contraceptive use differed significantly according to participants’ age ( χ2 (p) = 14.04 (.001)), sex ( χ2 (p) = 20.38 (<.001)), and grade ( χ2 (p) = 21.26 (<.001)). Younger participants were less likely to report contraceptive use than were older participants, and males (71.6%) were less likely to report contraceptive use than were females (79.9%). In addition, contraceptive use significantly differed based on cohabitation with family ( χ2 (p) = 21.70 (<.001)), economic status ( χ2 (p) = 9.25 (.010)), and academic achievement ( χ2 (p) = 14.78 (.001)).
Regarding sexual and health-related characteristics, contraceptive use was significantly different by sexual intercourse after drinking ( χ2 (p) = 21.97 (<.001)) and receiving sexual health education in school ( χ2 (p) = 40.45 (<.001)). There were significant differences in contraceptive use according to suicide plans ( χ2 (p) = 8.45 (.004)), suicide attempts ( χ2 (p) = 15.73 (<.001)), ever received treatment due to violence ( χ2 (p) = 49.68, (<.001)), ever drinking ( χ2 (p) = 13.0 (<.001)), ever using electronic cigarettes ( χ2 (p) = 7.38 (.007)), and ever habitual or purposeful drug use ( χ2 (p) = 70.11 (<.001)).
Five groups were identified as high-risk groups with no contraceptive use by the decision tree model (Figure 1). The factors affecting contraceptive nonuse were the experience of habitual or purposeful drug use, followed by not receiving sexual health education in school, the experience of ever receiving treatment due to violence, and the experience of sexual intercourse after drinking. The highest risk group in this study were those who did not receive sexual health education in school and who also had the experience of habitual or purposeful drug use (node 6); 72.1% of this group never used contraception. The second highest risk group was node 12, which includes participants who had ever received treatment due to violence, had received sexual health education in school, and had an experience of habitual or purposeful drug use; 52.0% of this group reported no contraceptive use. The third highest risk group had an experience of sexual intercourse after drinking, never received sexual health education in school, and never experienced habitual or purposeful drug use (node 10); 38.2% of this group had sexual intercourse without using contraception. The fourth highest risk group had never received treatment due to violence, had received sexual health education in school, and had experience with habitual or purposeful drug use (node 11); 32.1% of this group reported no contraceptive use. The fifth and final high-risk group included those who never had sexual intercourse after drinking, did not receive sexual health education in school, and had no habitual or purposeful drug experience (node 9), with 26.5% of the participants indicating no contraceptive use.
With increasing social concerns about adolescent pregnancy, efforts to increase the rate of contraceptive use among adolescents are being made at schools, institutions, and by the government. In the United States, a variety of advocacy activities and programs such as the protection of adolescents’ right to sexual health education have been implemented. Collaboration with policymakers, allotment of large budgets, and active interventions for the same at the national level have been effective in increasing adolescents’ contraceptive use and reducing adolescent pregnancy (CDC, 2019; Marques & Ressa, 2013). Adolescents’ contraceptive use reflects a lifestyle related to health behaviors. It is important to encourage adolescent use of contraceptives by providing sexual health education and improving awareness of sexual behavior. In addition, customized sexual health education according to the age of adolescents is required for them to recognize the purpose, method, timing, and effectiveness of using contraceptives. In Korea, only fragmentary information such as the percentage of contraceptive use among adolescents has been presented (Lim et al., 2016), and the available studies regarding adolescents’ contraceptive use are insufficient. Therefore, it is necessary to provide evidence on risk factors affecting contraceptive nonuse among adolescents.
This study comprehensively identified the factors affecting contraceptive use among adolescents using personal factors such as age, sex, and cohabitation with family; school-related factors such as academic achievement, grade, and sexual health education in school; and health-related factors such as subjective health status, depressive mood, suicidal-related behaviors, drinking, smoking, and drug use. Moreover, this study provided the results visually by applying a decision tree model and generating a schematic diagram. The decision tree provided a predictive model by considering the various interactions among variables.
Habitual or purposeful drug use, sexual health education in school, ever receiving treatment due to violence, and sexual intercourse after drinking were identified as risk factors affecting adolescents’ contraceptive nonuse. Considering habitual or purposeful drug use, the group with the highest risk of contraceptive nonuse had experience of habitual or purposeful drug use and did not receive sexual health education in school. It should be noted that habitual or purposeful drug use is related to other misdemeanor behaviors among adolescents and may occur simultaneously with drinking, smoking, and undesirable behavior such as school violence and juvenile delinquency (Chung et al., 2016; Krantz et al., 2013). The results of this study were similar to those of a previous study in which habitual or purposeful drug use was related to unsafe sex such as sexual intercourse without using contraception, impulsive sex, and sexual intercourse with multiple sex partners (Gwon & Lee, 2016; Park, 2020). Habitual or purposeful drug use is a significant variable that increases the rates of STI (Chernick et al., 2020; Gwon & Lee, 2016) and is a key factor for intervention in the management of youth health guidance and STI prevention. In Korea, the rate of drug use is less than the rate of smoking and drinking among adolescents (KCDC, 2018), and exposure to drugs is low compared to Western countries. However, habitual or purposeful drug use should be considered as a risk factor because it increases other risky behaviors such as smoking, drinking (Lee et al., 2019), and contraceptive nonuse (Lee, 2017; Lee et al., 2019).
Sexual health education in school was also an important factor related to adolescents’ contraceptive use, particularly for those with habitual or purposeful drug use. The results of this study support the results of previous studies, in which sexual health education in school was an influencing factor for contraceptive use (Grose et al., 2014; Jiang & Ha, 2020; Park, 2020). In Korea, although sexual health education is conducted as part of the regular curriculum in all middle and high schools (Yoon et al., 2015), the standard of sexual health education is inadequate. Since 2008, integrated sexual health education including sexual knowledge, sexual behavior, and sexual sensibilities based on a health curriculum has been practiced. However, in 2015, the Korean government initiated a new sexual health education standard without considering the existing integrated sexual health curriculum (Kim, 2020). Moreover, the new sexual health education standard removed sexual behavior lessons from the curriculum for primary school students and was controlled by conservative people who were against integrated sexual health education that includes the practice of contraceptives (Kim, 2020). According to the school health act, all primary, middle, and high schools are required to recruit a school nurse who will oversee health education including sexual health education, first aid service, and health counseling (Korea Legislation Research Institute, 2019). However, the employment rate of school nurses in middle schools is less than 50%, which is low, compared to that in Japan and Taiwan (>90%) (Gwon & Lee, 2016). In addition, school nurses will be effective in imparting sexual health education because of their professionalism (guaranteed institutionally), but they must take additional administrative work which is beyond the scope of their role in Korea (Kim, 2020). Therefore, there is a high probability that students will not receive timely sexual health education during adolescence. As the results of this study showed that students who had sexual intercourse experience in lower grades were less likely to use contraception, it is necessary to develop a standard for sexual health education to establish proper values and attitudes toward contraceptive use among adolescents. A conservative perception of sexual behaviors is a common phenomenon in Asian countries, including Korea. For instance, contraception is not included in the sexual health education curriculum in China, and the lack of sexual health education in schools remains a social issue in Russia (Bolshakova et al., 2020; Jiang & Ha, 2020). In contrast, Germany and France offer contraceptive methods for free or reduced prices at national centers or specialized youth clinics, and sexual health education is provided from the age of 6 (International Planned Parenthood Federation European Network, 2015). Opportunities to experience sexual health education from early and middle school ages, considering the social and cultural background of Korea, need to be explored. It is necessary to provide standardized and integrated sexual health education programs in the regular school curriculum using multidisciplinary cooperation, including school nurses, health professionals, and sexual health education experts. Additionally, although sexual health education emphasizes the importance of contraceptive use, adolescents have difficulty in finding them. While adolescents can find condoms quite easily in drug stores or vending machines, other contraceptives such as emergency contraceptive pills need to be prescribed by doctors before they can be bought (Seon, 2017). Negative perceptions regarding sexual intercourse during adolescence may be barriers for access to contraceptives and providing contraceptives at school-based clinics (Kim, 2020; Seon, 2017). Therefore, accessibility to contraceptives for adolescents should be increased with the establishment of a new policy.
Ever receiving treatment due to violence was also related to contraceptive use among adolescents. Violence, including sexual abuse, can occur in a variety of situations. Unwanted sexual contact, sexual assault, and dating violence have been reported to have negative effects on sexual self-subjectivity and the justification of violence (Choi & Ko, 2017; Kim et al., 2018). This relationship has two possible meanings. The first is negative reinforcement of violence experience, such as not using contraception due to the violent situation they are facing or against the other’s will. The second is choosing not to use contraception by themselves due to psychological reinforcement of violent experiences. Victims of sexual or dating violence have lower sexual self-subjectivity and may justify violence as more exposure to violence. Further, they may not be able to use contraception due to coercion or threats from their assailants. In this study, ever receiving treatment due to violence was identified as a risk factor for not using contraception despite having received sexual health education. This raises the issue of the role and effectiveness of sexual health education and suggests that sexual health education should be provided as integrated education, including contraception, sexual violence, sexual self-subjectivity, and gender sensitivity. Sexual self-subjectivity has the same meaning as sexual self-determination with autonomy, which can establish self-esteem and help prevent sexual victimization (Choi & Ko, 2017). Strengthening sexual self-subjectivity helps adolescents to properly cope in situations such as unwanted sex and dating violence, establish their own sexual selfsubjectivity, and engage in appropriate sexual behavior. Therefore, it is necessary to include sexual selfsubjectivity in standardized sexual health education in the regular school curriculum. In addition, exposure to community violence could be direct or indirect. Girls victim to random violence reported a higher rate of sexual intercourse without contraception and adolescent pregnancy (Laursen et al., 2020; Osofsky, 1995). Various forms of violence such as domestic violence, school violence, stalking, and dating violence are important factors influencing adolescents’ contraceptive use; thus, efforts in terms of awareness, prevention, post-treatment, and recovery of violence are required with sexual health education. A previous study targeting school nurses in Korea reported that sexual violence was one of the core concepts in sexual health education; however, domestic violence and school violence were considered less important and less covered in school health education (Yi & Jung, 2015). Therefore, sexual health education should be conducted with a greater focus on the relationship between various forms of violence and adolescents’ contraceptive use.
Sexual intercourse after drinking was also identified as a risk factor for adolescents’ contraceptive nonuse. Among the group with no experience of habitual or purposeful drug use and not having sexual health education in school, the group with experience of sexual intercourse after drinking was a higher risk group than those who did not have experience of sexual intercourse after drinking. Sexual intercourse after drinking is also one of adolescents’ misdemeanor behaviors (Chung et al., 2016; Krantz et al., 2013). The results of this study are similar to those of previous studies which reported the relationship between engaging in sexual intercourse and drinking and found that the rate of engaging in sexual intercourse was significantly higher among adolescents with drinking experience than in those with no drinking experience (Hong & Kang, 2017; Yoon et al., 2015).
This study is significant in that it identified risk factors for adolescents’ contraceptive nonuse using personal factors, sex-related factors, and health-related factors with a decision tree model. The results of this study support previous evidence regarding contraceptive use among adolescents and suggest a direction for developing sexual health education standards and educational intervention.
Despite the significance of this study, there are a few limitations. First, social desirability bias may have affected the participants’ answers. Sexual health-related behaviors such as sexual intercourse experience and contraceptive use among adolescents may have been underreported because of the negative perspective of the conservative society. Second, this study used secondary data analysis that was focused on individual factors. Social–cultural factors should be considered because they influence adolescents’ behaviors (Zhao et al., 2016). Lastly, only high school students were selected; therefore, the findings of this study are not generalizable.
We suggest future studies should include individual and social–cultural factors to expand the understanding of the risk factors of contraceptive nonuse among adolescents. Moreover, future studies using survey data from both middle school students and adolescents who stop studying or dropout from school may yield more generalizable results.
The findings of this study provide significant implications for school nurses. A school nurse is a key person who can influence adolescents’ sexual and health behaviors. Sexual behaviors are associated with other risk behaviors such as drinking (Cho & Ra, 2014; Hong & Kang, 2017; Lee, 2017) and drug use (Lee, 2017; Tucker et al., 2012). Therefore, sexual health education needs to be accompanied by health education to reduce risk behaviors. School nurses have an important role in delivering not only effective sexual health knowledge but also awareness about other substance-related health behaviors. Comprehensive risk reduction education may be effective in reducing risky sexual behaviors. Therefore, school nurses should pay more attention to adolescents with co-occurrence of sexual and health risk behaviors and assess their friend, family, and environmental structure.
School nurses assume several roles including health care provider, health educator, and counselor. As a counselor, school nurses should pay attention to adolescents who are victim to both physical and sexual violence. School nurses must have the right skill and knowledge to respond to adolescents suffering all types of violence. Such adolescents may feel helpless, blame themselves, and lose sexual selfsubjectivity. Therefore, school nurses should establish a sexual health education program that can increase adolescents’ sexual self-subjectivity and self-esteem.
The findings of this study suggest the necessity of a comprehensive risk behavior reduction and sexual health education curriculum with a focus on increasing adolescents’ sexual self-subjectivity and self-esteem. School nurses should perform their roles while supporting school policies to promote sexual health among adolescents.
This study was conducted to understand the factors affecting contraceptive use among Korean high school students using the 14th (2018) KYRBS. In this study, the risk group was schematically presented by applying the decision tree model of a data mining technique. The risk factors of contraceptive use among adolescents included habitual or purposeful drug use, sexual health education in school, ever receiving treatment due to violence, and sexual intercourse after drinking. In the decision tree model, the group with habitual or purposeful drug use and not receiving sexual health education in school was the highest risk group for contraceptive nonuse. The second highest risk group had habitual or purposeful drug use with sexual health education in school and having the experience of ever receiving treatment due to violence, and the next highest risk group did not have habitual or purposeful drug use, did not receive sexual health education in school, and had experience of sexual intercourse after drinking.
This study confirmed the importance of habitual or purposeful drug use, sexual health education in school, the experience of ever receiving treatment due to violence, and sexual intercourse after drinking in predicting adolescents’ contraceptive nonuse. Development of a comprehensive sexual health education curriculum and face-to-face or non-face-to-face counseling and support systems are needed to establish appropriate sexual attitudes among adolescents, improve gender sensitivity, and develop a healthy lifestyle related to sexual behaviors.
Sung Hae Kim and Yoona Choi contributed to conception or design; acquisition, analysis, or interpretation; drafted the manuscript; critically revised the manuscript; gave final approval; and agrees 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 work was supported by the 2020 Research Fund of Ulsan College.
Yoona Choi https://orcid.org/0000-0001-8039-1133
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Sung Hae Kim, PhD, RN, is an Assistant Professor at the Department of Nursing, College of Health. Welfare and Education, Tongmyong University, Busan, Korea.
Yoona Choi, PhD, RN, is an Assistant Professor at the Department of Nursing, Ulsan College, Ulsan, Korea.
1 Department of Nursing, College of Health. Welfare, and Education, Tongmyong University, Busan, Korea
2 Department of Nursing, Ulsan College, Ulsan, Korea
Corresponding Author:Yoona Choi, Department of Nursing, Ulsan College, 101 Bongsu-ro, Dong-gu, Ulsan, Korea.Email: yachoi@uc.ac.kr
