Many young people are at increased risk for unintended pregnancy and sexually transmitted disease (STD) because they wait until after they have begun having intercourse to visit a health care provider for preventive care. Why the delay--lack of knowledge? fear? the perception that methods available from other sources are good enough? In this issue of Perspectives on Sexual and Reproductive Health (see article), Nicole Stone and Roger Ingham explore when young people in the United Kingdom first use sexual health services and the circumstances surrounding the first visit.
Stone and Ingham surveyed men and women attending one of the many youth-oriented sexual health services that have opened during the last decade as part of government-backed efforts to reach UK young people with appropriate care. Nearly all of those surveyed were sexually experienced, but barely three in 10 had sought care before initiating sexual activity. Women who had delayed their first visit most commonly said that they had not expected to have sex; other reasons for the delay were that they had obtained condoms from a commercial source and they had been put off by a perceived lack of confidentiality, embarrassment or fear. Among men, the most frequent reasons given for having delayed the first visit were that they had gotten condoms elsewhere, had not thought about seeking services or had not felt it necessary to do so. Substantial proportions of women and men had not known that services were available or where to get them. Often, the delay in obtaining care had been lengthy, and contraceptive use in the meantime had been sporadic.
As Stone and Ingham remark, efforts to provide more youth-specific services and to dispel fears and myths about sexual health care will help encourage young people to use services before they begin their sexual lives. Moreover, they emphasize that embarrassment and fear related to visiting providers "are sustained only through a social context in which young people's sexuality is stigmatized." Therefore, according to the authors, "comfort in using services effectively will be fully achieved only when familial and social contexts change." The challenge is thus twofold: to improve young people's skills and knowledge, and to remove barriers to their use of services.
Stone and Ingham's results offer lessons for U.S. prevention efforts. In a viewpoint article (see article), Linda Hock-Long and colleagues argue that the United States has not made an adequate commitment to ensuring young people's access to services. As evidence, they point to systemic factors that threaten the affordability and confidentiality of services for teenagers, as well as the "societal ambivalence about adolescent sexuality [that] has limited creative efforts to institute truly youth-friendly services." Despite the formidable challenges involved, the authors urge the development of a tiered delivery system that would link a comprehensive set of clinical and nonclinical services that meet the needs of sexually experienced and inexperienced youth.
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• A sample of heterosexually active men studied by Mary Rogers Gillmore and colleagues (see article) expressed mixed beliefs about the outcomes of using four methods of STD prevention--abstinence, mutual monogamy, and male and female condoms--and perceived varying levels of support for using them. Married and single men reported significantly different views of these methods, but beliefs were otherwise generally similar across subgroups. By and large, whether men engaged in a behavior was related to their beliefs about it and the degree to which they thought their partner, health care provider and other important people supported their practicing it. Thus, the investigators conclude that STD prevention efforts need to address the aspects of method use that men view as drawbacks, reinforce positive expected outcomes and encourage partners' support for protective behavior.
• Using a large data set that permitted them to control for numerous demographic and medical risk factors, Nancy E. Reichman and Julien O. Teitler have analyzed what psychosocial risk factors and prenatal interventions were related to birth outcomes among poor women participating in New Jersey's comprehensive prenatal care program between 1988 and 1996 (see article). Surprisingly, they found that although smoking, drinking and drug use during pregnancy had very strong negative associations with birth weight, interventions addressing these behaviors were not independently associated with improved outcomes. By contrast, receipt of nutrition services was associated with an increase in mean birth weight and a decrease in the likelihood of low birth weight, and these results were consistent across several analyses. As a result, Reichman and Teitler characterize nutrition services as a "key feature" of prenatal programs for poor women.
• Being a parent entails substantial financial, emotional and supervisory demands; the demands on parents of a child with disability are especially great and may cause the parents to reconsider their fertility plans. As Jennifer M. Park and colleagues show, however (see article), these parents will not necessarily change their plans immediately. According to analyses using data from the 1993 National Health Interview Survey and the 1995 National Survey of Family Growth, the birth of a child with a disability does not affect a woman's likelihood of undergoing sterilization within the next month. However, the mother of a child with severe disability has an increased likelihood of having a sterilization soon after her next birth, and the mother of a newborn with severe disability has elevated odds of undergoing sterilization 1-36 months later. These findings, the authors comment, illustrate parents' desire to have a child without disability and their need to forgo additional births to adequately care for a child with disability.