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Condoms and Tomorrows

Inside Adolescent Decision Making

Condoms may offer excellent protection, but they're certain to fail if young people aren't concerned enough about their futures to use them. An expert in adolescent sexuality and the William H. Gates Sr. Professor and Chair of Population, Family and Reproductive Health, Robert Wm. Blum explains the underlying factors that influence adolescents' sexual decision making.

Are researchers focusing on the right intervention strategies for teens?
When we're talking about preventing teen pregnancy, we focus on factors that are most proximal. For example, why aren't they using contraception? And we build our interventions on the very proximal factors that influence behavior. We do condom availability, abstinence-only education ... But we need to focus on those factors that influence sexually risky behavior. And those powerful determinants aren't always the factors that are most proximal.

So what are those powerful determinants?
Contracepting is like putting money in the bank. If you have a terminal disease and the doctors say you only have 48 hours, are you going to put money in the bank? No. You're going to say, "Hey man, let's live for today ... Let's spend it. Or it's gone, baby."

Kids aren't going to contracept if they don't think they have much of a tomorrow—or if they see tomorrow, but say, "It looks pretty poor to me." They'll contracept if the future looks good. So we are starting to see a whole set of risk and protective factors in a kid's life. If some of these protective factors are in place, kids do better ... they contracept, they delay first sex, they are less likely to get into a whole slew of other problems.

Are these protective factors the same for adolescents around the world?
Globally, some factors are different. But some are universal. Essentially, they come down to home, school and neighborhood. Being connected to a caring parent is a global, identifiable factor. Another is school engagement. A kid who is engaged in school, who likes coming to school and feels supported does better by every measure. The World Bank says, internationally, for every year that a girl stays in school past grade 7, her risk of becoming a pregnant teenager drops by 7 percent. There isn't a sex education program in the world that can drive down pregnancy rates by that amount. And finally, it's the adults [they encounter] in their neighborhoods, whether they are in religious institutions, youth groups, clubs and so on.

So to me, while there is need for work at the most proximal level—contraceptive, sexually transmitted disease prevention—if you are going to improve outcomes for kids, you have to impact the environments that they live in.

How big of a factor does economic opportunity play?
In some countries, adulthood is reached sooner than in the West. But you have situations where the resources are limited. Job opportunities are profoundly limited. Young people have a hard time entering into the adult world. So they are kept in a limbo status. ... This is a source of massive frustration among youth, especially in sub-Saharan Africa. You have huge cohorts of unemployed, underemployed young people who have no opportunity. And they are really, really pissed off. ... It's not a trivial contributor to the social upheaval seen in a lot of these countries.

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