Adolescent Sexual Health Communication and Condom Use: A Meta-Analysis

Consistent condom use among sexually active adolescents and young adults is of paramount importance for sexual health. Condoms are the most effective method to prevent sexually transmitted infections (STIs) and HIV for sexually active youth, and condoms can also prevent unwanted pregnancy (Centers for Disease Control and Prevention [CDC], 2010; Holmes, Levine, & Weaver, 2004). While new prevention options and strategies for curbing HIV have advanced, such as pre-exposure prophylaxis (Baeten et al., 2012) and treatment as prevention (Cohen et al., 2011), condoms remain a critical, cost-effective, and accessible HIV/AIDS prevention tool, particularly for adolescents who engage in multiple short-term sexual relationships. Despite the risk of STIs, HIV, and unwanted pregnancy, nearly half of sexually active youth in the U.S. do not use condoms consistently (CDC, 2010). Such risk behavior results in serious health consequences: There are currently over 9 million STIs and 8,300 new cases of HIV among adolescents and young adults each year (CDC, 2013). Identifying those factors that are proximally associated with condom use and potentially modifiable has been a top priority for research and prevention efforts seeking to improve adolescent health (House, Bates, Markham, & Lesesne, 2010). Increasingly, one factor that has been associated with safer sexual behavior is sexual communication, defined as the ability to discuss and negotiate safer sex with a partner (Noar, 2007). The link between communication and condom use is understandable given the interpersonal nature of sexual activity and the need for sexual partners – particularly girls – to negotiate safer sexual practices if they are to occur (Amaro, 1995). Yet, open communication about sexual health topics often does not take place during sexual encounters (DiClemente, 1991; Ryan, Franzetta, Manlove, & Holcombe, 2007). Conversations about sexual health are sensitive and potentially embarrassing for adolescents who are still learning to develop and maintain intimate relationships and are often negotiating intimate experiences for the first time (Collins, Welsh, & Furman, 2009; Diamond & Savin-Williams, 2009). Discussing sexual health topics also may violate cultural norms for indirectness around sexual behavior, especially for adolescent girls who are not socialized to assert their sexual desires or preferences in relationships (Lear, 1995; Metts & Spitzberg, 1996; Tolman, 2005). Further, compared to adults, adolescents are in a developmental period during which immaturity in the prefrontal cortex contributes to heightened impulsivity and a lower likelihood to plan ahead and consider the future consequences of risky behavior (Steinberg, 2007, 2008). For these reasons, it is perhaps no surprise that many adolescents – more than half in some studies (DiClemente, 1991; Ryan et al., 2007; Welch Cline, Johnson, & Freeman, 1992) – report that they have not discussed condoms or other safer sex topics with their sexual partners. Sexual communication has been increasingly recognized in health behavior theories that explain condom use behavior (for review, see Noar, 2007). Historically, condom use has pushed the limits of behavioral theories because, unlike most health behaviors that are enacted by individuals, condom use requires the cooperation of two people. In some cases, new theories have been developed that include a dyadic communication component, such as the Information-Motivation-Behavioral Skills Model (Fisher & Fisher, 1992), which posits that both perceived and actual sexual communication skills are key behavioral skills required for condom use. Other theories, such as the Reasoned Action Model (Fishbein & Ajzen, 2009) and Social Cognitive Theory (SCT; Bandura, 1999), have been expanded to incorporate the role of sexual communication as an intervening variable that can account for the roles of other, more distal predictors of condom use, such as condom attitudes and intentions (Bryan, Fisher, & Fisher, 2002; Widman, Golin, & Noar, 2013; Zimmerman, Noar, Feist-Price, Dekthar, Cupp, Anderman, & Lock, 2007). Among adults, the empirical literature largely supports the theoretical proposition that partner sexual communication is associated with condom use (Allen, Emmers-Sommer, & Crowell, 2002; Noar, Carlyle, & Cole, 2006; Sheeran, Abraham, & Orbell, 1999). A meta-analysis of over 40 psychosocial predictors of condom use found that sexual communication between partners was the most robust indicator of condom use (Sheeran et al., 1999). A second, more recent meta-analysis confirmed the significant overall association between communication and condom use and found several factors moderated this relationship, including communication topic and format (Noar, Carlyle, & Cole, 2006). Specifically, the strongest relationship between communication and condom use was found in studies that specifically assessed communication about condoms as well as those that assessed communication behaviors, rather than communication self-efficacy or intentions to communicate. While the results in largely adult populations are promising, prior reviews have included only a small subset of studies of adolescents and these studies were not analyzed separately; thus, it is not clear if sexual communication is equally as likely – or perhaps more or less likely – to influence condom use among youth. It is known, however, that adolescents’ patterns of both communication and sexual risk behaviors differ from those patterns shown in adults. For example, adolescents are less likely to be sexually active than adults, but their sexual practices are often riskier. Condom use is typically sporadic, and the transient nature of adolescent relationships can result in multiple sexual partnerships over short periods of time (CDC, 2010). Additionally, youth often lack the appropriate skills and prior experience needed to successfully negotiate safer sexual behavior (Metts & Spitzberg, 1996), and as noted previously, they may also lack the appropriate brain maturity to make deliberate, rational choices that will impact their long term sexual health (Steinberg, 2007, 2008). This brain immaturity may result in less thoughtful planning around sexual activity and less communication with partners, as compared to adults. When it comes to the link between adolescent sexual communication and condom use, there is some inconsistency in the literature. Whereas many studies of youth find strong positive associations between communication and condom use (Brown et al., 2008; Grossman, Hadley, Brown, Houck, Peters, & Tolou-Shams, 2008; Harrison et al., 2012), others report no significant relationships (Maxwell, Bastani, & Yan, 1995; Roye, 1998), or even negative relationships (Deardorff, Tschann, Flores, & Ozer, 2010; Hart & Heimberg, 2005). For example, in an ethnically diverse sample of over 1,200 youth, Brown et al. (2008) found that sexual communication was associated with a greater likelihood of condom use at last sex; whereas in a sample of 839 Latino youth, Deardorff et al. (2010) found that comfort with sexual communication was associated with significantly less consistent condom use in the past month. Despite this inconsistency, the sexual communication field is burgeoning and scores of sexual health intervention programs for youth have been targeting communication skill building as key program components (DiClemente et al., 2009; Tortolero, Markham, Peskin, Shegog, Addy, Escobar-Chaves, & Baumler, 2010). The lack of a systematic meta-analysis of adolescent communication is a key gap in the literature; such a synthesis could provide much needed guidance to future intervention efforts as well as health behavior theories that are specific to adolescent condom use. Thus, the primary purpose of the current study was to conduct a meta-analysis that synthesizes the current evidence to determine the degree to which sexual communication between adolescent partners is associated with condom use. Given the heterogeneity in effects of communication observed in the literature, a second goal was to examine the possible influence of several potential moderators. These included gender, age, recruitment setting, study location, topic of communication (i.e., communication about condoms specifically, partner sexual history, or safer sex more generally), and format for communication measurement (i.e., behavior, self-efficacy, intentions, fear, or comfort). Finally, due to the variability in the way in which condom use has been assessed in past studies (for a discussion of this issue, see Noar, Cole, & Carlyle, 2006), we also examined the timeframe of condom use as an additional moderator.