Infrequent Parental Monitoring Predicts Sexually Transmitted Infections Among Low-Income African American Female Adolescents FREE

SEXUALLY TRANSMITTED infections (STIs) are a significant and immediate health risk to adolescents.¹ In the United States, African American female adolescents are disproportionately likely to acquire STIs including human immunodeficiency virus.^{2 - 3} Evidence suggests that family-level interventions are a promising approach to reducing STI incidence among African American female adolescents.^{4 - 7} Parental monitoring is one aspect of family-level intervention that may be a particularly important focal point for these efforts.^{8 - 12}

Cross-sectional and prospective studies provide evidence suggesting that female adolescents who perceive infrequent parental monitoring may be more likely to engage in sexual risk behaviors.^{8 - 9 ,11} Unfortunately, the outcome measures for these studies were self-reported, and past evidence suggests that adolescents' self-reported sexual risk behaviors may lack validity.¹³ Previously, we reported significant cross-sectional associations between African American female adolescents' perceptions of parental monitoring and the prevalence of biologically confirmed chlamydial, gonococcal, and trichomonad infections.¹⁰ The purpose of our study was to prospectively test (using an 18-month follow-up period) the association between African American female adolescents' perceptions of parental monitoring and their acquisition of biologically confirmed infection with Chlamydia trachomatis, Neisseria gonorrhoeae, and Trichomonas vaginalis.

A prospective cohort study design was used. The study participants were female adolescents enrolled in a randomized trial of a human immunodeficiency virus prevention program. Only those randomized to receive an attention control intervention were included in the analysis. The attention control curriculum provided the adolescents with information related to health but unrelated to sexual risk behaviors. Baseline data and 6-month, 12-month, and 18-month follow-up data collected from adolescents randomized to the control condition were used for this study.

From December 1996 through April 1999, sexually active African American female adolescents (aged 14-18 years) were recruited from low-income neighborhoods in Birmingham, Ala, that were characterized by high rates of unemployment, substance abuse, violence, teen pregnancy, and sexually transmitted diseases. The study achieved an 85.7% baseline participation rate. Retention rates for the control group were 90% (6 months), 89% (12 months), and 85% (18 months). More detailed descriptions of the study have been published elsewhere.^{10 ,14} All study protocols were approved by the university institutional review board.

At the conclusion of the 18-month follow-up period, data for 230 adolescents were available for analysis. Of these, 217 (94%) provided usable specimens at each assessment interval. Our analyses were based on these 217 female adolescents.

Data collection was conducted at the University of Alabama Family Medicine Clinic in Birmingham. A self-administered questionnaire was developed for adolescents with a fifth-grade reading level. The questionnaire was administered in a group setting with monitors providing assistance to those with limited literacy and helping to assure confidentiality of the responses. The adolescents were assured that their names could not be linked to the codes used to identify documents containing their responses. Subsequently, participants were instructed in the correct procedure for self-collecting a vaginal swab specimen. They were asked to provide 2 self-collected vaginal swab specimens for sexually transmitted disease testing.

Although a uniform definition of parental monitoring has not been applied in the research literature, most studies measure 2 important aspects of parental monitoring: (1) adolescents' perceptions of their parents' knowledge of where they go, and (2) adolescents' perceptions about parents' knowledge of whom they are with when the adolescent is not at home or at school. Given that perceptions are powerful determinants of behavior, adolescents' perceptions of parental monitoring rather than assessments from parents have been used to assess this construct.^{8 - 12}

At baseline, participants completed a 2-item measure assessing parental monitoring. These items were strongly correlated (Pearson r = 0.70; P = .01), yet the correlations were not strong enough to suggest that the items were redundant. One item asked the adolescents how often parents (or parental figures) knew where they were when they were not at home or at school. The other assessed how often their parents knew whom they were with when not at home or at school. Responses were provided on a 5-point scale: 1, "never or almost never," 2, "rarely," 3, "sometimes," 4, "usually," and 5, "almost always." Adolescents who responded "almost always" or "usually" to both items were classified as perceiving frequent parental monitoring; the remainder were classified as perceiving infrequent parental monitoring.

Participants provided 2 vaginal swab specimens. The first was placed in a transport tube (Abbott LCx Probe System; Abbott Laboratories, Abbott Park, Ill) and tested for C trachomatis and N gonorrhoeae DNA with ligase chain reaction.^{15 - 16} The second was used to inoculate culture medium for T vaginalis (InPouch TV test; BioMed Diagnostics Inc, Santa Clara, Calif).¹⁷ Identical assay procedures were repeated at each 6-month follow-up interval. Adolescents who tested positive for an STI were notified by telephone or in person (with written documentation) and requested to return for an oral single-dose treatment.

Identification of covariates is an important method of controlling for their potentially confounding effects. Therefore, several variables were tested as potential covariates between adolescents' perceived level of parental monitoring and acquisition of STIs during the 18-month follow-up period. Potential key covariates were age, whether participants tested positive for any of the STIs assessed at baseline, and frequency of adolescents' communication with parents about sex-related issues. The latter measure was assessed using a scale that asked participants how frequently they discussed each of 5 topics with their parents: sex, how to use condoms, how to prevent infection with an STI, how to prevent infection with the virus that causes acquired immunodeficiency syndrome, and how to prevent pregnancy. The scale achieved adequate inter-item reliability (α = .88). Only 1 of the covariates that we tested (Table 1) met the statistical criteria for a covariate (ie, a significant association using a screening level of P≤.10 with parental monitoring and at least 1 of the outcome measures).

Bivariate associations between baseline levels of parental monitoring and STI acquisition were assessed using contingency table analysis. Relative risk ratios compared STI incidence rates between adolescents who reported relatively infrequent parental monitoring and those who reported more frequent monitoring. To control for the identified covariate, hierarchical logistic regression was used to calculate an adjusted odds ratio that controlled for the prevalence of biologically confirmed STIs at baseline. Significance was defined by 95% confidence intervals and an obtained P value of less than .05.

At enrollment, the age of the adolescents was mean ± SD, 16.0 ± 1.2 years. At baseline, 36.5% of participants were classified as perceiving infrequent parental monitoring. More than half (53.5%) of the adolescents tested positive at least once for 1 of the 3 assessed STIs. Thirty-three adolescents (15.2%) tested positive for gonorrhea during at least 1 of the 3 assessment periods. In addition, 84 participants (38.7%) tested positive for chlamydia and 48 (22.1%) tested positive for trichomoniasis during at least 1 of the 3 assessment periods.

Table 2 presents relative risk ratios, 95% confidence intervals, and their respective P values. In contrast to those who perceived frequent monitoring, adolescents perceiving infrequent monitoring were significantly more likely to test positive for at least 1 STI during the 18-month follow-up period. As indicated, the strongest association observed was for trichomoniasis. More than one third (35.7%) of the adolescents who perceived infrequent parental monitoring tested positive for trichomoniasis at least once during the 18-month follow-up period, as compared with 17.7% among those perceiving more frequent monitoring. The association between parental monitoring and incidence of chlamydia was also significant. Nearly half (47.4%) of the adolescents who perceived infrequent parental monitoring tested positive for chlamydia at least once during the 18-month follow-up period, as compared with 33.6% among those perceiving more frequent monitoring. Significant bivariate associations between parental monitoring and incidence of gonorrhea or acquisition of multiple STIs were not observed.

Table 2 also presents odds ratios adjusted for the effects of STI prevalence at baseline. Adjusted odds ratios indicate that adolescents who perceived infrequent parental monitoring at baseline were 1.8 and 2.4 times more likely to acquire chlamydia or trichomoniasis, respectively, compared with their counterparts who perceived greater levels of monitoring. Similarly, adolescents who perceived infrequent parental monitoring were more than twice as likely to test positive for an STI during the course of the 18-month follow-up period.

To the best of our knowledge, this is the first prospective report showing that female adolescents' perceptions of infrequent parental monitoring predict subsequent biologically confirmed acquisition of STIs. This evidence adds to the emerging empirical literature supporting family-level programs designed to reduce adolescents' STI risk.^{7 - 12} Our findings are strengthened by the fact that all participants began the prospective period free of infection (ie, those testing positive at baseline were effectively treated).

Physicians are in a unique position to facilitate parental involvement in the lives of their adolescent patients. Our findings suggest that one potentially beneficial talking point between physicians and parents may be the importance of frequent parental monitoring. Beyond the reduced risk of acquiring STIs, more frequent parental monitoring may lead to adolescents' less frequent engagement in antisocial activities,^{8 - 11} decreased odds of substance use,^{10 ,18 - 20} and decreased risk of pregnancy.²¹ Thus, physicians' efforts to promote parental monitoring may be beneficial on multiple levels.

Recent evidence from a randomized controlled trial suggests that programs designed to promote parental monitoring can be effective.¹² Research has increasingly focused on parental involvement as a strategy for promoting health-protective behaviors among adolescents.^{22 - 23} Parental monitoring may be viewed as one component of "authoritative parenting," which can be defined as a combination of parenting behaviors (eg, setting and enforcing clear standards, encouraging autonomy and communication with parents, and being involved and supportive in adolescents' activities).²³ Although brief, clinic-based interventions designed to promote parental monitoring have not been described by published report, our findings suggest that such research is warranted with respect to reducing the incidence of STI infection among African American female adolescents. Key issues that could be addressed by future research include the effects of increased parental monitoring both on adolescents' perceptions of monitoring and on other parental behaviors (eg, frequency of communication).

Of note, it was interesting that adolescent's age was not significantly associated with the measure of parental monitoring. This lack of association suggests that perceptions of monitoring change very little throughout the course of the teen years (ages 14-19 years). In addition, age was not significantly associated with STI incidence during the 18-month follow-up period. Also noteworthy is the lack of association between the incidence of gonorrhea and parental monitoring. Differences in the epidemiological patterns of gonorrhea as opposed to chlamydia and trichomoniasis may explain this observed lack of association.

Our findings are limited by the validity of the self-reported measure of parental monitoring. Furthermore, our study assessed parental monitoring only at enrollment; thus, changes in perceived monitoring during the 18-month follow-up period were not assessed. The findings are also limited by the use of a convenience sample of economically disadvantaged African American adolescents. Our results may not apply to other African American female adolescents, to those from other racial or ethnic groups, or to different socioeconomic strata. Clearly, further research is needed with diverse adolescent populations.

Adolescents' perceptions of their parental-monitoring levels predicted subsequent acquisition of biologically confirmed chlamydia and trichomoniasis infections. Our findings suggest that expanded efforts leading toward effective clinic- and community-based STI intervention programs involving parents may be warranted.

Corresponding author and reprints: Richard A. Crosby, PhD, Rollins School of Public Health, Department of Behavioral Sciences and Health Education, 1518 Clifton Rd NE, Fifth Floor, Atlanta, GA 30322 (e-mail: rcrosby@sph.emory.edu).

Accepted for publication September 19, 2002.

This study was supported by grant 1R01 MH54412 from the Center for Mental Health Research on AIDS, National Institute of Mental Health, Rockville, Md (Dr DiClemente).

We thank Susan L. Davies, PhD (School of Public Health), Edward Hook III, MD (School of Medicine, Division of Infectious Diseases), and M. Kim Oh, MD (School of Medicine, Department of Pediatrics), University of Alabama at Birmingham (UAB), for their assistance and input. We also thank Jane R. Schwebke, MD (UAB School of Medicine, Division of Infectious Diseases), for provision of cultures for Trichomonas vaginalis, and Kim Smith, MT(ASCP), for assistance and oversight of testing for Neisseria gonorrhoeae and Chlamydia trachomatis.

Previous evidence collected in cross-sectional studies suggests that parental monitoring may be an important protective factor against STI acquisition among female adolescents. Although a couple of studies have examined this question prospectively, the outcome measures were self-reported sexual risk behavior rather than biologically confirmed end points.

This study combined a prospective design with biologically confirmed outcome measures to provide a more rigorous test of the hypothesis that parental monitoring can be protective against STI infection among female adolescents. Our findings add further support to the hypothesis that parental monitoring serves a protective function. Expanded efforts leading toward effective clinic- and community-based STI intervention programs involving parents may be warranted.