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Understanding Perceived Risks and Sexual Behavior Among Adolescents and Young Adults During the COVID-19 Pandemic

      Abstract

      Purpose

      We sought to describe the relationship between COVID-19 risk perception and sexual behaviors among urban adolescents and young adults (AYA).

      Methods

      Data were collected from 159 urban AYAs on COVID-19 risk perception, COVID-19 infections and deaths, romantic relationships, and sexual behavior during the stay-at-home order using a telephone survey.

      Results

      Seventy-nine percent of the study participants engaged in sexual intercourse during the stay-at-home order. Only 38% of these used condoms during their last sexual encounter. Experiencing COVID-19 positivity within their social circle was not related to COVID-19 testing. Concern for COVID-19 infection or experiencing a COVID-19 diagnosis or death in one's social circles was not associated with sexual intercourse or condom use.

      Discussion

      Urban AYA remained at risk for sexually transmitted infections, and COVID-19, given high baseline community rates of sexually transmitted infections and COVID-19, low condom use, and low COVID-19 risk perception at the time of the survey.

      Keywords

      Implications and Contribution
      Urban adolescents and young adults (AYA) remained at risk for sexually transmitted infections during the COVID-19 pandemic while the AYA sexual health care system infrastructure was temporarily dismantled. Therefore, additional stable public health strategies are warranted to optimize AYA self- and dyadic care for sexually transmitted infections and other disease prevention during public health crises.
      Efforts to curtail the COVID-19 pandemic had the unintended consequence of reduced access to sexual and reproductive health services and now documented increases in risks for sexually transmitted infections (STIs) among adolescents and young adults (AYA) [
      • Thomson-Glover R.
      • Hamlett H.
      • Weston D.
      • Ashby J.
      Coronavirus (COVID-19) and young people’s sexual health.
      ,
      • Church K.
      • Gassner J.
      • Elliott M.
      Reproductive health under COVID-19 - challenges of responding in a global crisis.
      ,
      • Nagendra G.
      • Carnevale C.
      • Neu N.
      • et al.
      The potential impact and availability of sexual health services during the COVID-19 pandemic.
      ,
      • Mmeje O.O.
      • Coleman J.S.
      • Chang T.
      Unintended consequences of the COVID-19 pandemic on the sexual and reproductive health of youth.
      ]. While the transition from in-person sexual health services to telehealth visits allowed many youth to access confidential services, emerging evidence suggests that the current pandemic may have differential impacts on the sexual behavior of AYA versus adults.
      AYA received mixed messages about the risk of serious COVID-19 infections [
      • Commodari E.
      • La Rosa V.L.
      Adolescents in quarantine during COVID-19 pandemic in Italy: Perceived health risk, beliefs, psychological experiences and expectations for the future.
      ,
      • Dardas L.A.
      • Khalaf I.
      • Nabolsi M.
      • et al.
      Developing an understanding of adolescents’ knowledge, attitudes, and practices toward COVID-19.
      ,
      • Waselewski E.
      • Waselewski M.
      • Harper C.
      • et al.
      Perspectives of US youth during initial month of the COVID-19 pandemic.
      ]. Perceived risk for infection may have impacted adherence to COVID-19 and STI prevention behaviors. In addition to the COVID-19 pandemic, urban youth remained at risk for STIs based on recently published public health data [
      CDC
      Adolescents and young adults STD prevention.
      ]. Following an initial decline in STI rates believed to result from decreased screening and sexual and reproductive health visits imposed by COVID-19 restrictions, the overall rate of STIs has increased [
      CDC
      2020 STD trend report.
      ]. These findings highlight the ongoing risk of STI for AYA at the height of the pandemic [
      CDC
      2020 STD trend report.
      ,
      • Crane M.A.
      • Popovic A.
      • Stolbach A.I.
      • Ghanem K.G.
      Reporting of sexually transmitted infections during the COVID-19 pandemic.
      ]. However, there is limited evidence on the relationship between AYA's perception of COVID-19 risk and sexual behavior. Therefore, we sought to describe the relationship between COVID-19 risk perceptions and sexual behaviors among urban AYAs at risk for STIs during the pandemic since the direct impacts of COVID-19 on adolescents' social networks may compound the proximal influences and subsequent health outcomes in the theorized pathways of influence of COVID-19 on the sexual health of adolescents [
      • Lindberg L.D.
      • Bell D.L.
      • Kantor L.M.
      The sexual and reproductive health of adolescents and young adults during the COVID-19 pandemic.
      ].

      Methods

      Samples and measures

      Participants aged 13–36 years were recruited from a pool of sexually experienced individuals who originally enrolled in four sexual health research studies when they were 13–25 years of age (TECH-N(NCT01643079; NCT03828994), Sexperience (NCT03275168), Women's Biohealth, and Tech2Check (NCT03600103) [
      • Trent M.
      • Coleman J.S.
      • Hardick J.
      • et al.
      Clinical and sexual risk correlates of mycoplasma genitalium in urban pregnant and non-pregnant young women: Cross-sectional outcomes using the baseline data from the Women’s BioHealth study.
      ,
      • Agwu A.L.
      • Yusuf H.E.
      • D’Angelo L.
      • et al.
      Recruitment of youth living with HIV to optimize adherence and virologic suppression: Testing the design of technology-based community health nursing to improve antiretroviral therapy (ART) clinical trials.
      ,
      • Trent M.
      • Yusuf H.E.
      • Rowell J.
      • et al.
      Dyadic intervention for sexually transmitted infection prevention in urban adolescents and young adults (the SEXPERIENCE study): Protocol for a randomized controlled trial.
      ,
      • Trent M.
      • Perin J.
      • Gaydos C.A.
      • et al.
      Efficacy of a technology-enhanced community health Nursing intervention vs. Standard of care for female adolescents and young adults with pelvic inflammatory disease: A randomized clinical trial.
      ]. Structured phone interviews were conducted between July 2020 and November 2021 using a 76-item questionnaire focused on multiple domains of adolescent well-being. This analysis specifically focuses on participant responses to queries about COVID-19 testing, history of COVID-19 diagnoses among family, close friends, and romantic or sexual partners), COVID -19 deaths among anyone they know, level of concern about general risk for getting COVID-19, and COVID-19 risks through sexual contact/intimacy, cohabitation with a sexual partner, sexual intercourse during COVID-19, and condom use during sexual intercourse. This cross-sectional analysis specifically evaluates the effect of COVID-19 risk perceptions on sexual behaviors. Participation in the study was voluntary, and participants who completed the survey received a $25 gift card. Approval for this study was obtained through the Johns Hopkins Medicine Institutional Review Board.

      Analysis

      Descriptive and bivariate analyses were used to determine the sample characteristics and potential associations between demographic data, COVID-19 within social circles, and sexual behaviors. In addition, the association between COVID-19 infection within the social circle of participants and (1) COVID-19 testing, (2) COVID-19 risk perception, and (3) condom use/sexual intercourse was evaluated using logistic regression analyses. All analyses were performed using STATA statistical software [
      StataCorp
      2019. Stata statistical software: Release 16. College station, TX: StataCorp LLC. Stata |StataCorp LLC.
      ].

      Results

      Of the 393 participants potentially eligible, 239 were reached for informed consent, and 159 enrolled and completed the telephone survey for an effective 66.5% acceptance rate. Most respondents were female (134, 84%), with a mean age of 23.0 years (standard deviation, 2.7), had public insurance (70%), and were in romantic relationships (61%) (Table 1). Half of the respondents had been tested for COVID-19. Eight percent of respondents had someone within their social circle die from COVID-19. Most respondents (79%) engaged in sexual intercourse during the stay-at-home order, 34% stayed in the same place as their partner, and 38% used a condom during their last sexual encounter. Using a 10-point Likert scale (10 = most concerned), the mean concern score for contracting COVID-19 generally was 5.2 (3.8) and during intercourse was 3.3 (4.1). Those with COVID-19 positivity within their social circle were not more likely to have COVID-19 testing (adjusted odds ratio: 0.92, 95% confidence interval: 0.75–1.12, p = .417). The concern for COVID-19 infection 0.95 (95% confidence interval: 0.86–1.06) and COVID-19 in social circles (0.57 (0.19–1.61) was not associated with engaging in sexual intercourse during COVID-19 or condom use at last sex (1.03 (0.95–1.13) and 1.13 (0.49–2.62), respectively).
      Table 1Description of 194 Participants in a survey related to Perceived Risk for COVID-19
      Overall (n = 159)Those younger than 25 years (n = 124)Those 25 years and older (n = 35)Difference (p)
      Determined by a Fisher's exact test for categorical factors, and Student's t-test for continuous factors.
      Age, years; N (%)-
       <188 (5%)8 (6%)0 (0%)
       18–2145 (28%)45 (36%)0 (0%)
       22–2471 (45%)71 (57%)0 (0%)
       25–3635 (22%)0 (0%)35 (100%)
       Age, years; mean (SD); range 15–3623 (2.7)22 (2.1)26.2 (1.9)-
       Female; N (%)134 (84%)111 (90%)23 (66%).003
      Insurance; N (%).966
       Public111 (70%)87 (70%)24 (69%)
       Private25 (16%)19 (15%)6 (17%)
       Other23 (14%)18 (15%)5 (14%)
      COVID Concern; Mean (SD)
       General (0–10, low to high)5.2 (3.8)5.1 (3.8)5.3 (3.7).771
       During sexual intercourse/intimacy (0–10, low to high)3.3 (4.1)3.2 (4.1)3.7 (4.2).559
      COVID impact; N (%)
       Tested for COVID-1979 (50%)63 (51%)16 (46%).702
       Positive COVID-19 in social network48 (49%)31 (42%)17 (68%).037
       Death due to COVID-19 in social network13 (8%)7 (6%)6 (17%).039
      Sexual behavior; N (%)
       Current romantic relationship97 (61%)76 (62%)21 (60%).847
       Sexual Intercourse during the stay-at-home orders125 (79%)101 (82%)24 (69%).100
       Cohabitation54 (34%)43 (35%)11 (31%).841
       Condom use at last sexual intercourse60 (38%)39 (32%)21 (60%).003
      SD, standard deviation.
      a Determined by a Fisher's exact test for categorical factors, and Student's t-test for continuous factors.

      Discussion

      We found a low COVID-19 risk perception related to sexual intercourse and low condom use at last sex among AYA during the height of the COVID-19 pandemic. Similar studies demonstrate that older adult populations with partnered sexual behaviors declined for most older adults during the pandemic [
      • Hensel D.J.
      • Rosenberg M.
      • Luetke M.
      • et al.
      The impact of household context on self-perceived changes in solo and partnered sexual behaviors during the covid-19 pandemic: findings from a U.S. probability survey.
      ]. Single adults engaged in less sexual activity due to the separation from sexual partners created by the pandemic. Partners with children were hindered by the presence of their children or COVID-19-related conflicts [
      • Hensel D.J.
      • Rosenberg M.
      • Luetke M.
      • et al.
      The impact of household context on self-perceived changes in solo and partnered sexual behaviors during the covid-19 pandemic: findings from a U.S. probability survey.
      ,
      • Luetke M.
      • Hensel D.
      • Herbenick D.
      • Rosenberg M.
      Romantic relationship conflict due to the COVID-19 pandemic and changes in intimate and sexual behaviors in a Nationally representative sample of American adults.
      ]. Our findings in this largely young adult population may represent a difference in relationship structure compared to older adults in relationships, even within similar contexts such as nonmarital cohabitation.
      Similar to other global data from youth, AYAs in this study were only marginally concerned about their risk of contracting COVID-19 [
      • Dardas L.A.
      • Khalaf I.
      • Nabolsi M.
      • et al.
      Developing an understanding of adolescents’ knowledge, attitudes, and practices toward COVID-19.
      ,
      • Waselewski E.
      • Waselewski M.
      • Harper C.
      • et al.
      Perspectives of US youth during initial month of the COVID-19 pandemic.
      ,
      • Yang X.Y.
      • Gong R.N.
      • Sassine S.
      • et al.
      Risk perception of COVID-19 infection and adherence to preventive measures among adolescents and young adults.
      ]. In a survey of 3000 AYA with similar demographics as those in our study, the perceived risk for becoming infected with COVID-19 was 5.6/10, consistent with the level of concern for COVID-19 observed for this study [
      • Yang X.Y.
      • Gong R.N.
      • Sassine S.
      • et al.
      Risk perception of COVID-19 infection and adherence to preventive measures among adolescents and young adults.
      ,
      • Burrai J.
      • Barchielli B.
      • Cricenti C.
      • et al.
      Older adolescents who did or did not experience COVID-19 symptoms: Associations with mental health, risk perception and social connection.
      ]. AYA in our study were notably less concerned with contracting COVID-19 during intercourse; this may be attributable to the trust often associated with relationships in this population.
      Counterintuitively, having members of one's social circle affected by COVID-19 and personal concerns about exposure to COVID-19 did not affect engagement in sexual intercourse during COVID-19. Studies of older adults suggest that a fear of COVID-19 acts as a deterrent and promotes adherence to guidelines [
      • Yang X.Y.
      • Gong R.N.
      • Sassine S.
      • et al.
      Risk perception of COVID-19 infection and adherence to preventive measures among adolescents and young adults.
      ].
      Our study must be considered in light of several general limitations. While the study harnesses the infrastructure of multiple research studies and collaboration to better understand contextual factors of COVID-19 in this single urban community with high STI prevalence and COVID-19 health disparities, there is a small sample size and limited generalizability to other communities or youth not involved in sexual health research. Like other recent studies, much of these data are regionally specific and leveraged youth already in research studies due to the limited access to youth during the pandemic [
      • Yarger J.
      • Gutmann-Gonzalez A.
      • Han S.
      • et al.
      Young people's romantic relationships and sexual activity before and during the COVID-19 pandemic.
      ,
      • Craig-Kuhn M.C.
      • Schmidt N.
      • Scott Jr., G.
      • et al.
      Changes in sexual behavior related to the COVID-19 stay-at-home orders among young black men who have sex with women in New Orleans, LA.
      ]. The present study further adds to our knowledge about youth sexual behavior during COVID-19 and suggests that factors aside from the impacts of COVID-19 on social circles influence the sexual health of AYA. In conclusion, urban AYA remained at risk for STIs and COVID-19, given disproportionate community disease rates, low condom use, and low COVID-19 risk perception generally and in sexual relationships.

      Acknowledgments

      We are grateful to the participants across these research studies who trusted us to do this work and the research staff across studies who worked together to conduct outreach to study participants during the COVID-19 pandemic.

      Funding Sources

      This article was made possible through the following grants: TECH-N NINR (R01NR013507), TECH-2 CHECK NIMHD (1R01MD011770), BioHealth, and unrestricted funds to Johns Hopkins University from Hologic, Inc, and SEXperience (NIMHD R21HD090498). The contents of this article are the authors' responsibility and do not necessarily represent the official views of the government funding agencies that support the research.

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