摘要：Objectives . We used Bronfenbrenner's ecological systems theory to identify factors that predicted never or sometimes using condoms in a multiethnic cohort of adolescent mothers. Methods . We interviewed adolescent mothers within 48 hours of delivery and surveyed them 6 and 12 months after delivery (n = 636). We used multinomial logistic regression to identify individual-, dyad-, family-, and peer and community-level factors associated with never or sometimes using versus always using condoms during intercourse at 12 months postpartum. Results . Pregnancy status, partner refusal to use condoms, intimate partner violence, and race/ethnicity predicted both never and sometimes using condoms. Condom use 6 months earlier and church attendance also predicted never using condoms, whereas maternal monitoring was an additional predictor for sometimes using condoms. Conclusions . Overlapping yet distinct risk profiles predicted never or sometimes using versus always using condoms. Factors from multiple levels of influence affected the condom use behaviors of adolescent mothers indicating that multilevel interventions are needed to promote safer sexual practices among these young women. US female adolescents between the ages of 15 and 19 years have the highest rates of sexually transmitted infections (STIs) when compared with other age and gender groups, and minority, pregnant, and parenting adolescents are at particularly high risk. 1 , 2 In fact, depending on the population studied, 14% to 39% of adolescent mothers have an STI diagnosis within 6 to 10 months of delivery. 3 These high rates of STIs are directly related to the significant proportions of adolescent mothers who report never or inconsistently using condoms (32%–63%). 3 Given the frequent occurrence of STIs among young women and the negative and potentially severe sequelae of STIs, a greater understanding of the factors associated with condom use in this high-risk population is needed. Studies of pregnant, never pregnant, and parenting adolescents have found that condom use is influenced by multiple factors, including hormonal contraceptive use, 4 – 7 pregnancy status, 4 , 8 self-esteem, 9 , 10 drug and alcohol use, 11 – 13 type of relationship with one's partner, 5 , 6 , 10 , 14 living situation, 11 , 15 intimate partner violence, 16 , 17 and peers’ beliefs. 11 , 18 , 19 Other factors that may be related to condom use include race/ethnicity, 4 , 20 , 21 HIV/STI or condom-specific knowledge, 4 , 8 , 11 , 20 , 22 sexual history, 4 , 11 , 23 , 24 and religiosity, 4 , 9 , 25 – 27 although the results of studies examining these factors have been equivocal. Few studies on adolescent mothers have simultaneously focused on more than one level of influence to include the dyad, family, and larger community. Bronfenbrenner's ecological systems theory (EST) has recently been used to better understand the sexual behavior of nonparenting and parenting adolescents. 3 , 11 , 28 , 29 This theory asserts that the individual is nested within a set of interconnected domains (individual, dyad, family, social, and community) that both directly and indirectly influence the behavior of the individual. 30 – 32 EST organizes risk factors by domain so that they can be targeted separately and in parallel, which allows program planners to identify strategies at each level of influence and develop more effective interventions. This is critical because recent evidence suggests that multilevel intervention approaches are essential to elicit behavioral changes. 33 Figure 1 , which is taken from a recent review by Meade and Ickovics, 3 illustrates how the EST model applies to the sexual behaviors of adolescent mothers. Factors at the individual, dyad, and peer and community levels were found to predict rapid repeat pregnancy within 24 months after delivery in a previous study examining the same multiethnic cohort of adolescent mothers. 29 Open in a separate window FIGURE 1 Ecological model of sexual risk. Note . Reprinted from Meade and Ickovics. 3 We sought to further apply EST to determine the multiple levels of influence (individual, dyad, family, social, and community) that predict never or sometimes using condoms at 12 months after delivery among a multiethnic cohort of adolescent mothers. Note that our study focused specifically on the effects of multiple levels of analysis on condom use and did not attempt to construct a model that addressed the extent to which these levels of analysis affected each other; nor did our study take into account the individual's history before delivery. We used an analytic approach to generate separate profiles of factors associated with never using condoms and sometimes using condoms as compared with always using condoms. We hypothesized that significant factors would be identified from each level of influence and that the profile of factors would differ for adolescent mothers who sometimes used condoms and adolescent mothers who never used condoms.
