Dissertations and Theses

Date of Degree

12-15-2020

Document Type

Dissertation

Degree Name

Doctor of Public Health (DPH)

Department

Epidemiology and Biostatistics

Advisor(s)

Luisa N. Borrell

Committee Members

Diana Romero

Daniel Herman

Subject Categories

Public Health

Keywords

Age of Sexual Debut, Adolescent Pregnancy, Out-of-Home Placement, Child Welfare System, Sexual and Reproductive Health, Adverse Childhood Experiences

Abstract

Background: Studies of youth in out-of-home (OOH) care and adults with histories of OOH placements have found evidence of poorer sexual and reproductive health (SRH) compared with their counterparts in the general population, including inconsistent use of male condoms and contraceptives, higher prevalence of adolescent pregnancy, and history of unwanted sexual debut. However, within the population of youth involved in child welfare, the effects of OOH placement on SRH have been difficult to establish. The overall goals of the current study were to compare SRH indicators (ever having penile–vaginal intercourse; early age of sexual debut; reported pregnancy) among youth involved with the child welfare system through OOH placement. Data were drawn from the Second National Survey of Child and Adolescent Well-Being (NSCAW II), a nationally representative sample of children who were referred to child welfare because of a report of abuse or neglect over a 15-month period. The sample included youth administered the sexual risk behaviors assessment module of NSCAW II (n = 1,573). The specific aims of the present study were:

Aim 1: To examine the association between OOH placement and ever having PVI among youth in the child welfare system after controlling for age, gender, and race/ethnicity and to determine whether this association is modified by history of neglect; physical, sexual, or emotional maltreatment; and exposure to household violence. We expect to find a significant association after adjusting for all covariates, such that youth placed in OOH have increased odds of ever having PVI and that trauma will magnify the effect of OOH placement.

Aim 2: To examine the association between frequency of OOH placement and ever having PVI among youth in the child welfare system after controlling for age, gender, race/ethnicity, proportion of time spent in OOH care, and exposure to household violence and to determine whether this association is modified by age, gender, proportion of time spent in OOH care and exposure to household violence. We expect to find that the odds of ever having PVI will incrementally increase by frequency of OOH placement after adjusting for all covariates and that this association will significantly vary by older age, gender, increased time spent in OOH care, and higher exposure to household violence.

Aim 3: To examine the association of OOH placement with age of sexual debut and reported past pregnancy among youth in the child welfare system after controlling for age, gender, race/ethnicity, use of male condom at last sex, and contraceptive use at last sex and to determine whether this association is modified by age, gender, and experiences of past abuse/trauma. We expect to find significant associations of OOH placement and early age of sexual debut and pregnancy, respectively, after adjusting for all covariates and that among youth with OOH placement, older youth, females, and youth with histories of trauma will have higher odds of both earlier age of sexual debut and pregnancy.

Methods: Using data from the three waves of the NSCAW II, youth aged 11 years and older with complete data were selected as the population of interest; the data included the following covariates: age, gender, race/ethnicity, baseline scores for exposure to household violence, baseline histories of maltreatment and neglect; exposure variables: placement characteristics (type, frequency, and proportion of time spent in OOH care); and dependent variables (ever had PVI yes/no). Descriptive statistics were used to examine the distribution of the exposure by the demographic, history of traumatic events, and placement characteristic covariates.

For Aims 1 and 3, exposure was defined as ever having OOH placement (yes/no). For Aim 2, exposure was defined as the frequency of OOH placement categorized as zero; one; two or three; and four or more times. Descriptive statistics were used to determine the prevalence of the outcomes among the entire sample and by exposure status. The outcome for Aims 1 and 2 was ever having PVI (yes/no). For Aim 3, two outcomes were examined: age of sexual debut (defined as younger than 13 years of age or older) and pregnancy reported (yes/no). Wald chi-square tests were used in bivariate analyses to assess the associations of each categorically defined covariate with the defined exposure and outcomes, respectively, in each aim.

T-tests were used to assess significant differences based on the exposure status of the means of continuous variables. Logistic regression was used to estimate the strength of the association between the exposure and outcomes before and after adjusting for selected covariates.

Results: After full adjustment for demographic characteristics (age, gender, and race/ethnicity), histories of trauma, abuse, and neglect (physical and nonphysical), and exposure to household violence, the findings indicated that placement in OOH care was not significantly associated with PVI. We observed heterogeneity of the association between OOH and ever having PVI by sexual maltreatment and nonphysical neglect but not by experiences of physical maltreatment, emotional maltreatment, physical neglect, or witnessing household violence. Among youth who did not experience sexual maltreatment, those ever placed in OOH care had more than double the odds of PVI compared with youth not placed. Similarly, among youth who did not experience nonphysical neglect, those ever placed in OOH care had almost three times the odds of PVI compared with youth not placed in OOH. The findings indicated that placement in OOH care regardless of number of placements was not significantly associated with PVI after adjustment for demographic characteristics (age, gender, and race/ethnicity), time spent in OOH care, and exposure to household violence. The interaction of age and placement frequency was significant. However, there were no significant interactions of placement frequency with gender, proportion of time spent in OOH care, or exposure to household violence. Youth older than 12 years of age at baseline with one placement in OOH care only had nine times the odds of ever having penile–vaginal intercourse compared with similarly aged youth without placement. However, there was no association between placement in OOH care and ever having penile–vaginal intercourse among youth aged 12 years and younger at baseline regardless of the number of placements. The findings indicated that there was no association of ever placed in OOH care and early age of sexual debut before or after adjusting for all covariates. However, this association varied with age and gender. Among youth older than 14 years of age, those with a placement history were almost three times more likely to have had a younger age of sexual debut compared with those not placed. This association was not observed among younger youth. Among boys, those with a placement history were more than three times as likely to have had a younger age of sexual debut compared with those without a placement. This association was not observed among girls. The findings indicated that there was no association of ever having an OOH placement with pregnancy before or after adjusting for all covariates. We did not observe heterogeneity of this association by age, gender, younger age of sexual debut, forced first sex, the worst type of abuse/maltreatment experienced, or exposure to household violence.

Discussion: Our study did not find a significant association of OOH placement or frequency of repeated OOH placements and SRH indicators of ever having PVI, younger age sexual debut, or pregnancy after adjusting for the selected covariates. Importantly, experiences of trauma and abuse modified the association of OOH placement and SRH indicators as our endpoints after adjusting for demographics. OOH placement did not alter the odds of ever having PVI, early age of sexual debut, or pregnancy. Child welfare intervention in and of itself may most strongly impact the SRH outcomes throughout the life course of youth having contact with CPS. Although studies have established that histories of OOH placement are linked to poor SRH outcomes in the general population, the effect of OOH placement among populations with histories of child welfare involvement in youth has been less clear. It has yet to be established what, if any, is the effect of OOH placement on SRH risk behaviors among child welfare–involved youth during adolescence. Experiences of abuse, trauma, and other adverse events that are salient for this population’s SRH have not been consistently examined in the literature. Future research is needed to better understand whether and how experiences of trauma (or the lack thereof) interact with the system-level factors prompting child welfare attention and decision to remove youth from the home, along with SRH in this population.

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