|
Predictors
of Mother-Adolescent Discussions
About
Condoms: Implications for Providers
Who
Serve Youth
PEDIATRICS
Vol. 108 No. 2 August 2001, p. e28
Kim
S. Miller, PhD and Daniel J. Whitaker, PhD
From
the Division of HIV/AIDS Prevention, Surveillance and
Epidemiology,
National
Center for HIV, STD, and TB Prevention, Centers for Disease
Control
and
Prevention, Atlanta, Georgia.
ABSTRACT
Objective.
To examine predictors of mother-adolescent
communication about condoms.
Methods.
Interviews were conducted with 907 mothers of
adolescents aged 14 to 17 years in the Bronx, New York;
Montgomery, Alabama; and San Juan, Puerto Rico, to determine
whether mothers had talked with their adolescent about
condoms.
Results.
By univariate analysis, mother-adolescent communication
about condoms was associated with greater knowledge about
sexuality and acquired immunodeficiency syndrome, perception
of having enough information to discuss condoms, information
from a health-related source, less conservative attitudes
about adolescent sexuality, perception that the adolescent was
at risk for human immunodeficiency virus, greater ability and
comfort in discussing condoms, stronger belief that condoms
prevent human immunodeficiency virus/acquired immunodeficiency
syndrome, and a more favorable endorsement of condoms. In
multivariate analyses, mother-adolescent communication about
condoms was associated with a less conservative attitude about
abstinence until marriage (odds ratio [OR]: 0.73; 95%
confidence interval [CI]: 0.54-0.74), greater skill in
communicating about sex (OR: 1.13; 95% CI: 1.06-1.20), greater
comfort in communicating about sex (OR: 1.31; 95% CI:
1.01-1.69), a more favorable endorsement
of condoms (OR: 1.85; 95% CI: 1.17-2.78), and the perception
that the adolescent's friends were sexually active (OR: 3.53;
95% CI: 1.97-7.16).
Conclusion.
Parents who communicate effectively about sexuality and
safer sex behaviors can influence their adolescents'
risk-taking behavior. Health care providers, particularly
physicians, can facilitate this communication by providing to
parents information about the sexual behavior of adolescents,
the risks that adolescents encounter, condom use, condom
effectiveness, and how to discuss condoms. They also can make
referrals to programs that teach communication skills.
Key words: condoms,
adolescents, maternal communication, HIV, STD, African
Americans, Hispanics.
Promoting condom use among sexually
active adolescents is an important public health goal.1
Adolescents who have unprotected sex are at risk for sexually
transmitted diseases (STDs), including human immunodeficiency
virus (HIV). According to the Youth Risk Behavior Survey, a
Centers for Disease Control and Prevention survey of students
in grades 9 through 12, 48% of all high school students had
engaged in sexual intercourse; of the students who had engaged
in sexual intercourse during the 3 months before the survey
(35%), only 57% reported that they had used a condom during
their most recent sexual intercourse.2 Seven percent of
students reported sexual initiation before the age of 13.2
Other representative data sources show that adolescents have
the highest age-specific risk for many STDs,3,4 and according
to recent estimates, 50% of new HIV infections occur among
people who are younger than 25 years.5 New strategies are
needed to promote more use of condoms by adolescents.
Although considerable attention has been
directed toward individual,6-8 peer,9,10 and partner11-15
factors associated with condom use by adolescents, recent
research suggests that parent-child communication can
influence adolescents' use of condoms. One study found that
mother-adolescent discussion about condoms that took place
before the adolescent's sexual initiation was associated with
more use of condoms at sexual initiation, which set the stage
for later condom use.16 Other research showed that
comprehensive communication about sexuality and communication
skills are related to less sexual risk behavior among
adolescents17,18 and to adolescents' greater communication
about condoms and condom use with their partners.19 Despite
these findings indicating the importance of early parental
discussions about condoms, many parents either are not talking
to their children about this issue or are not initiating these
discussions early enough.20
Our purpose was to examine factors
associated with mother-adolescent communication about condoms.
By understanding which factors influence whether mothers talk
with their children about condoms and by understanding the
barriers that parents may perceive in talking with their
children, specific recommendations and strategies to promote
communication can be developed and implemented.
METHODS
The Family Adolescent Risk Behavior and
Communication Study was a cross-sectional study of 907 adolescents and their mothers who
were recruited from 2 public high schools in Montgomery, Alabama, and the Bronx, New York, and 1
public high school in San Juan, Puerto Rico. Recruitment took
place between October 1993 and June 1994 at high schools that
had a prominent representation of blacks and Puerto Ricans,
populations that have been affected disproportionately by the
HIV/acquired immunodeficiency syndrome (AIDS)
epidemic.21 A description of the sample appears elsewhere.22
Procedures
A list of potential participants was
obtained from each high school, and students were recruited
through fliers distributed in homerooms and mailed to their
homes. Interested mothers and adolescents telephoned the
researchers; those who wished to participate were screened for
eligibility. To be eligible, both the adolescent and the
mother had to be willing to participate; the adolescent had to
be 14 to 16 years old, had to be enrolled in grades 9 to 11,
and had to have lived with the mother in the recruitment area
for at least the past 10 years; and the mother had to be the
adolescent's biological or adoptive mother or stepmother. Of
the 1733 pairs who provided screening information, 1124 were
eligible and 982 (87% of the eligible pairs) were interviewed.
Separate face-to-face interviews were
conducted with the mother and the adolescent by interviewers
of the same ethnicity and gender as the adolescent and the
mother. Mothers were interviewed first whenever possible (for
91% of the pairs) to ease the adolescents' concerns that their
responses would be discussed with their mother. Mothers were
reimbursed $45, and adolescents were reimbursed $25 for their
participation. Before the interview, the interviewer explained
the purpose of the study, reviewed the consent form with the
mother and the adolescent separately, and had each sign the
consent form. Institutional review boards approved the study
at each site. The sample comprised 907 adolescent-mother pairs
(75 pairs did not meet eligibility requirements).
Instruments and Measures
The research instrument was a structured
questionnaire developed by study investigators. Questions for
adolescents and mothers were similar but not identical.
Main Outcome Measure
The main outcome measure was the mothers'
yes/no response to the question, "Have you and your child
ever talked about condoms?"
Demographics
Demographic variables were site (New
York, Alabama, or Puerto Rico), ethnicity (black or Hispanic),
adolescent's gender, mother's age, adolescent's age, income,
mother's education, and father's presence in the home.
Information was elicited on 6 distinct
domains drawn from 3 influential behavioral theories: the
theory of reasoned action,23,24 the health belief model,25,26
and social-cognitive theory.27,28 These domains were mother's
knowledge and information about HIV, STDs, and sexuality;
mother's attitudes and beliefs about sexuality and
religiousness; mother's perception of her adolescent's risk;
mother's perception of her ability to discuss sex and condoms;
mother's beliefs about condom effectiveness; and mother's endorsement of condoms.
Domain 1: Mother's Knowledge and
Information HIV knowledge was measured with 7 items. Each
correct response was scored 1 point so that higher scores
reflected greater knowledge about HIV/AIDS transmission.
Similarly, knowledge about STD and sex was assessed with 7
true/false items. Each correct response was scored 1 point so
that higher scores reflected more knowledge about STDs and
sex.
Information Sources were measured several
ways. First, mothers were asked to answer yes or no regarding
whether they had enough information to talk with their
adolescent about condoms, sex, STDs, and AIDS. Second, to
examine mothers' sources of information about sex-related
topics, mothers were asked, "Where or from whom do you
currently receive information about the topics we just talked
about: mother or father; other relative; boyfriend,
girlfriend, or friend; book or TV; school; pamphlet, physician, or health
department?"
Domain 2: Mother's Attitudes, Beliefs,
and Religiousness
Adolescent Sex and Sex Outcomes We
measured mothers' attitudes about sex during adolescence (3
items measured; 1 = never OK, 3 = always OK;
= 0.78), her attitude about abstinence until marriage
(1 item measured: "I think my son/daughter should wait
until he's/she's married to have sex"; 1 = strongly
disagree, 4 = strongly agree), and her beliefs that
"getting pregnant or getting a girl pregnant would ruin
her son's/daughter's future" (1 item measured; 1 =
strongly disagree, 4 = strongly agree).
Religiousness Mothers reported how often
they attended religious services (1 = never, 4 = about once a
week or more) and how important their religious beliefs were
to them (1 = not at all, 5 = very). The questions were similar
conceptually and therefore were averaged to form a single
index (r = 0.34); higher scores reflected higher
religiousness.
Domain 3: Mother's Perception of Her
Adolescent's Risk We used 4 measures of the mother's
perception of her adolescent's risk: mother's perception that
her child's had had sex (yes/no); whether the mother knew
someone with HIV/AIDS (yes/no); mother's perception of her
child's chances of having HIV at the time of interview (0 = no
chance at all, 4 = already HIV positive); and mother's
perception of the percentage of her child's friends that had
had sex (0%-100%).
Domain 4: Mother's Perception of Ability
to Discuss Sex and Condoms We used 2 indexes and 2 items to
examine the mother's perception of her ability to discuss sex
and condoms with her adolescent. The general communication
index comprised 7 questions from Barnes and Olson's
communication scale.29 Mothers' responses to items were summed
to form an index ( = 0.85 for mothers). Each item was scored
on a Likert scale ranging from 1 (strongly disagree) to 4
(strongly agree); higher scores indicated better general
communication. The sexual communication skills index17
comprised 9 items. After reporting on whether they had
communicated about various sex topics, mothers responded to
items such as, "I don't know enough about topics like
this to talk to my son/daughter," and, "My
son/daughter and I talk openly and freely about these
topics" (1 = strongly disagree, 4 = strongly agree).
Negatively worded items were reverse-scored, and responses
were summed ( = 0.82) so that higher scores indicated better
sexual communication skills. Mothers' comfort with discussing
sex with their adolescents and mothers'
perception of their adolescents' comfort about discussing sex
were measured separately with single items (1 = feels very
uncomfortable, 4 = feels very comfortable).
Domain 5: Mother's Beliefs About Condom
Effectiveness Responses to 3 questions were used to assess
beliefs about the effectiveness of condoms: 1) "How
effective do you think the use of a condom is to prevent
getting the AIDS virus (HIV)?" (1 = not at all effective,
3 = very effective). 2) "Do you feel like you can protect
yourself against the AIDS virus (HIV) by always using a condom
during sex?" (yes/no). 3) "Does sex with latex
condoms and spermicide decrease a person's chance of getting
the AIDS virus(HIV)?" (yes/no).
Domain 6: Mother's Endorsement of Condoms
We used responses to 2 questions to assess mothers' beliefs
about condom access: "Do you think high schools should
make condoms available to students?" (yes/no), and,
"I think my son/daughter should carry condoms" (1 =
strongly disagree, 4 = strongly agree).
Analytic Plan
First, bivariate analyses were performed
between each predictor (demographics and the variables in each
of the 6 domains) and communication about condoms. Next,
multivariate analyses were conducted using a series of
logistic regression models. The first model examined the
multivariate relationship between the demographic variables
and communication about condoms. All significant or marginally
significant demographic predictors were included in all
subsequent regression models. Next, to examine predictors
within each domain, we conducted 6 regression models (1 for
each domain) with all variables within a domain entered
simultaneously. A final model examined predictors across
domains. This final model included all predictors that were
significant from the within-domain regression models. (Note
that a separate model that included all predictors both
significant and nonsignificant yielded nearly identical
results.)
RESULTS
Bivariate Analyses
Of the 907 mothers surveyed, 666 (73.4%)
had talked with their adolescent about condoms. Table 1 shows
the relationship between each predictor and communication
about condoms and the associated P value from the 2 or
Student's t test. Among the demographic factors, differences
were found for site, ethnicity, mother's age, income,
education, and presence of a father in the home. Condom
communication was greater for mothers who were from New York,
black, younger, wealthier, better educated, and when no father
was present in the home. For domain 1 (knowledge and
information), more knowledge of AIDS and more knowledge of sex
were related to more communication, as was the mother's belief
that she had enough information to discuss condoms, sex, AIDS,
and STDs with her adolescent. Regarding information sources,
only one variablehaving obtained information from a pamphlet,
physician, or health departmentwas associated with more
communication. For domain 2 (attitudes, beliefs, and
religiousness), 3 of the 4 measures were associated with
communication about condoms, and for each measure, less
conservative attitudes or less religiousness was associated
with more communication. For domain 3 (perceived risk), 3 of
the 4 variables were associated with communication about
condoms; for each, perception of higher risk was related to
more communication about condoms. Next, for domain 4
(perception of ability to discuss sex and condoms), better
general communication skills, more skills in communicating
about sex, and mother's comfort in discussing sex were related
to more communication about condoms; mother's perception of
her adolescent's comfort was not. For domains 5 and 6 (beliefs
about condom effectiveness and mother's endorsement of
condoms), all variables were associated with more
communication about condoms. Mothers who considered condoms more effective and
mothers who endorsed condoms for adolescents were more likely
to have talked with their adolescent about condoms.
Multivariate Analyses
In the initial regression model, only the
8 demographic factors were considered (Table 2). Four
variables were significant predictors of communication about
condoms (site, mother's age, mother's education, and father's
presence in home), and 2 were marginally significant (gender
and adolescent's age). These 6 variables were included in all
later regression models.
The next regression model included the 12
knowledge and information variables described previously. Of
those variables, the mother's perception that she had enough
information to discuss condoms with her son or daughter and
the mother's having obtained information from a health-related
source were associated with more condom communication. In the
second model (analysis of the 4 items concerning maternal
attitudes and beliefs and religiousness), only the mother's
endorsement of abstinence until marriage was significant, and
it was associated with less condom communication. In the third
model, which included the 4 items that assessed the mother's
perception of her adolescent's risk, only the mother's
perception of the sexual activity of her adolescent's friends
was significant, and it was associated with more
communication. In the fourth model, which included the 4
variables for the mother's perception of her ability to
discuss sex and condoms, the mother's skill and her comfort
with
discussing sex were associated with more
condom communication. In the fifth model (analysis of 3 items
concerning beliefs in the effectiveness of condoms), believing
condoms to be effective was associated with more communication
about condoms. In the final regression model, which included
beliefs about condom availability, each item was related
independently to communication about condoms; stronger
endorsement of condoms for adolescents was associated with
more communication.
A final regression model comprised the 9
significant predictors from the 6 models, along with the 6
demographic predictors (Table 3). Of the substantive
predictors, having enough information about condoms dropped to
marginal significance, and belief in the effectiveness of
condoms dropped to nonsignificant. The remaining variables
were associated independently with communication about
condoms. More communication about condoms was related to
having obtained information from a
health-related source, weaker endorsement
of abstinence until marriage, greater perception that the
child's friends were sexually active, better skills in
communicating about sex, more comfort with discussing sex, and
stronger endorsement that schools should distribute condoms
and that adolescents should carry condoms.
DISCUSSION
Adults play an important role in
promoting the sexual health of adolescents. Because
mother-adolescent discussions about condoms before sexual
initiation have been associated strongly with safer sexual
behaviors,16 it is important to promote mother-adolescent
communication about condoms. In our examination of factors
associated with mother-adolescent communication about condoms,
we found that variables in a variety of domains are related to
mother-adolescent communication.
Our findings suggest ways in which
parents and providers of youth services, particularly
physicians, can promote the sexual health of adolescents.
Specifically, in addition to direct contact with adolescent
patients, physicians can support adolescents' use of condoms
by providing parents with the information and the skills to
help them discuss sexuality and condom use with their children
early, before sexual activity begins.
The traditional way in which physicians
have promoted sexual health is by screening and counseling
adolescent patients about their sexual risk behavior. Barriers
such as lack of time and concern about the adolescent's or the
parent's discomfort30-34 may inhibit physicians from
counseling adolescent patients effectively. Moreover,
adolescents use health care services less than any other age
group does, and they are least likely to seek care at a
physician's office.35 Physicians who do talk with adolescents
probably talk too late that is, after
that adolescent has already had sex. If physicians could
facilitate parent-child communication, then barriers such as
lack of time and parental discomfort could be avoided. Our
findings suggest specific ways in which physicians can
facilitate parent-child communication about condoms.
First, condom communication was
associated with mothers' beliefs that they had enough
information to discuss condoms, having received information
from a health-related source, and beliefs that condoms prevent
HIV/AIDS. Physicians can serve as an important informational
resource by providing parents with information about the
importance of talking with their adolescent about sex and
condoms and by informing parents that aside from abstinence,
condom use is the only way to prevent STDs, including HIV.
Physicians should make sure that parents have all of the
information that they believe they need to discuss condoms, a
place to turn to if they need more information, and accurate
information about the effectiveness and use of condoms.
Second, condom communication was
associated with greater skill in and comfort with discussing
condoms. To be comfortable and confident in these discussions,
parents must know that the discussion is appropriate, and they
must know how to have such a discussion. Physicians can help
by informing parents of the potential benefits of discussing
condoms with their adolescent and can provide informational
brochures about how to do so. Physicians also can refer
parents to programs that teach parent-child communication
skills.
Third, mothers who endorsed abstinence
until marriage were less likely to talk with their adolescent
about condoms. Here the physician's role may not be to try to
change parental attitudes but to inform parents about the
realities of adolescent behavior.
Physicians should encourage parents to
communicate their values about premarital sexual activity to
their children, but they also should realize that it is highly
unlikely that their adolescent will abstain from sex until
marriage, as >72% of never-married female adolescents and
84% of never-married male adolescents have had sexual
intercourse by age 20.36,37 Parents also need to know that
providing information about safer sex does not increase
adolescents' sexual activity and that it is not inconsistent
to endorse both abstinence and condom use when the adolescent
does choose to have sex, even among adolescents who have never
had sex.
Finally, condom communication was
associated with mothers' perception that their adolescent was
at risk. Parents may not realize that their adolescent is
having sex and thus may underestimate the adolescent's risk.
(In this sample, of the female adolescents who had had sexual
intercourse, 47% of their mothers thought that they had not;
of male adolescents who had had sexual intercourse, 53% of
their mothers thought that they had not.) Here again,
physicians should inform parents about the realities of
adolescent sexual behavior, such as that adolescents whose
peers are having sex are likely to have sex themselves, as
mothers in our sample seemed to realize. Parents must learn
that talking with adolescents about sex and condoms is
associated with safer sexual behavior and with a reduced
association between adolescents' own behavior and the
adolescents' perception of their peers' behavior.38 Physicians
can provide the parents of their patients and their patients
who are parents with information, skills, and resources to
discuss sexuality and condoms if they choose to do so.
Clearly, the role of physicians is a critical one.
ACKNOWLEDGMENTS
Funding
for this study was provided by the Division of HIV/AIDS
Prevention, Surveillance and Epidemiology, National Center for
HIV, STD, and TB Prevention, Centers for Disease Control and
Prevention, Atlanta, Georgia.
FOOTNOTES
Received for publication Jan 12, 2001;
accepted Mar 26, 2001.
Reprint requests to Centers for Disease
Control and Prevention, Mailstop E45, 1600 Clifton Rd,
Atlanta, GA 30333. E-mail: kxm3@cdc.gov
ABBREVIATIONS
STD, sexually transmitted disease; HIV,
human immunodeficiency virus; AIDS, acquired immunodeficiency
syndrome.
REFERENCES
1.
US Department of Health and Human Services. Healthy
People 2000: National Health Promotion and Disease Prevention
Objectives. Washington, DC: US Department of Health and Human
Services, Public Health Service; 1991
2.
Centers for Disease Control and Prevention. Youth risk
behavior surveillance United States,1997. MMWR Morb Mortal Wkly Rep. 1998;47(SS-3):1-92
3.
Bell TA, Holmes KK Age-specific risks of syphilis,
gonorrhea, and hospitalized pelvic inflammatory disease in
sexually experienced U. S. women. Sex Transm Dis 1984;
11:291-295
4.
Centers for Disease Control and Prevention. Sexually
Transmitted Disease Surveillance, 1996. Atlanta: Centers for
Disease Control and Prevention; 1997
5.
Rosenberg PS Scope of the AIDS epidemic in the United
States. Science 1995; 270:1372-1375
6.
Helweg-Larson M, Collins BE The UCLA Multidimensional
Condom Attitudes Scale: documenting the complex determinants
of condom use in college students. Health Psychol 1994;
13:224-237
7.
Stiffman AR, Dore P, Cunningham RM Inner-city youths
and condom use: health beliefs, clinic care, welfare, and the
HIV epidemic. Adolescence 1994; 29:805-820
8.
DiClemente RJ Determinants of condom use among junior
high school students in a minority, inner-city district.
Pediatrics 1992; 89:197-202
9.
DiClemente RJ Predictors of HIV-preventive behavior in
a high-risk adolescent population: the influence of perceived
peer norms and sexual communication on incarcerated
adolescents' consistent use of condoms. J Adolesc Health 1991;
12:385-390
10.
Romer D, Black M, Ricardo I, Social influences on the
sexual behavior of youth at risk for HIV exposure. Am J Public
Health 1994; 84:977-985
11.
Rickman RL, Lodico M, DiClemente RJ, Morris R, Baker C,
Huscroft S Sexual communication is associated with condom use
by sexually active incarcerated adolescents. J Adolesc Health
1994; 15:383-388
12.
DiClemente RJ, Lanier MM, Horan PF, Lodico M Comparison
of AIDS knowledge, attitudes and behaviors among incarcerated
adolescents and a public high school sample in San Francisco.
Am J Public Health 1991; 81:628-630
13.
Catania JA, Dolcini M, Coates TJ, Predictors of condom
use and multiple partnered sex among sexually active
adolescent women: implications for AIDS-related health
interventions. J Sex Res 1989; 26:514-524
14.
Shoop DW, Davidson PM AIDS and adolescents: the
relation of parent and partner communication to adolescent
condom use. J Adolesc 1994; 17:137-148
15.
Miller KS, Clark LF, Moore JS Sexual initiation with
older male partners and subsequent HIV risk behavior among
adolescent females. Fam Plann Perspect 1997; 29:212-214
16.
Miller KS, Levin ML, Whitaker DJ, Xu X Patterns of
condom use among adolescents: the impact of
maternal-adolescent communication. Am J Public Health 1998;
88:1542-1544
17.
Dutra R, Miller KS, Forehand R The process and content
of sexual communication with adolescents in two-parent
families: associations with sexual risk-taking behavior. AIDS
Behav 1999; 3:59-66
18.
Kotchick BA, Dorsey S, Miller KS, Forehand R Adolescent
sexual risk-taking behavior in single-parent ethnic minority
families. J Fam Psychol 1999; 13:93-102
19.
Whitaker DJ, Miller KS, May D, Levin ML Teenage
partners' communication about sexual risk and condom use: the
importance of parent-teenager discussions. Fam Plann Perspect
1999; 31:117-121
20.
Kaiser Family Study Results, 1999. Talking with kids
about sex and relationships. Available:
http://www.talkingwithkids.org/sex.html
21.
Lindegren M, Hanson C, Miller K, Byers RH, Onorato I
Epidemiology of human immunodeficiency virus infection in
adolescents, United States. Pediatr Infect Dis J 1994;
13:525-525
22.
Miller KS, Clark LF, Wendell DA, Adolescent
heterosexual experience: a new typology. J Adolesc Health
1997; 20:179-186
23.
Ajzen I, Fishbein M Attitude-behavior relations: a
theoretical analysis and review of empirical research. Psychol
Bull1977; 84:888-918
24.
Fishbein M, Middlestadt SE. Using the theory of
reasoned action as a framework for understanding and changing
AIDS-related behaviors. In Mays VM, Albee GW, eds. Primary
Prevention of AIDS: Psychological Approaches Vol. 13. Primary
Prevention of Psychopathology. Newbury Park, CA: Sage;
1989:93-110
25.
Janz NK, Becker MH The health belief model: a decade
later. Health Educ Q 1984; 11:1-47
26.
Montgomery SB, Joseph JG, Becker MH, Ostrow DG, Kessler
RC, Kirscht JP The health belief model in understanding
compliance with preventive recommendations for AIDS: how
useful? AIDS Educ Prev 1989; 1:303-323
27.
Bandura A Self-efficacy: toward a unifying theory of
behavioral change. Psychol Rev 1977; 84:191-215
28.
Bandura A Social cognitive theory of self-regulation.
Organ Behav Hum Decis Process 1991; 5 0:248-287
29.
Barnes HL, Olson DH Parent-adolescent communication and
the circumplex model. Child Dev 1985; 56:438-447
30.
Marks A, Fisher M, Lasker S Adolescent medicine in
pediatric practice. J Adolesc Health Care 1990; 11:149-153
31.
Fisher M Adolescent sexuality: overview and
implications for the pediatrician. Pediatric Ann 1991;
20:285-289
32.
Fisher M Parents' view of adolescent health issues.
Pediatrics 1992; 90:335-341
33.
Post SG, Botkin JR Adolescents and HIV prevention: the
pediatrician's role. Clin Pediatr 1995; 34:41-45
34.Maheux
B, Haley N, Rivard M, Gervais A STD risk assessment and risk
reduction counseling by recently trained family physicians. Acad
Med 1995; 70:726-728
35.Klein
JD. Adolescents and the health care delivery system, and
health care reform. In: Irwin CE Jr, Brindis C, Holt K,Langlykke K, eds. Health Care Reform: Opportunities for
Improving Adolescent Health. Arlington, VA: National Center for Education for Maternal and Child Health;
1994:17-28
36.Abma
JC, Chandra A, Mosher WD, Peterson L, Piccinino L. Fertility,
family planning, and women's health: new data
from the 1995 National Survey of Family Growth. Vital
Health Stat 23. 1997;19
37.Sonenstein
FL, Ku L, Lindberg LD, Turner CF, Pleck JH Changes in sexual
behavior and condom use among teenaged
males: 1988 to 1995. Am J Public Health. 1998;
88:956-959
38.Whitaker
DJ, Miller KS Parent-adolescent discussions about sex and
condoms: impact on peer influences of sexual risk
behavior. J Adolesc Res 2000; 15:251-273 Pediatrics (ISSN 0031 4005). Copyright ©2001
by the American Academy of Pediatrics
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