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| Journal of the New Zealand Medical Association,
27-January-2006, Vol 119 No 1228
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Contraceptive use by Maori youth in New Zealand: associated
risk and protective factors
Terryann Clark, Elizabeth Robinson, Sue Crengle, Peter
Watson
Sexual maturation and behaviour are significant components
of the developmental process of adolescence and important determinants of the
health and wellbeing of young people. Of concern to many families and
communities are young people who suffer negative sexual and reproductive health
outcomes as a consequence of their sexual behaviour.1–3
For sexually active young people, avoiding these negative
consequences of sexual behaviour in adolescence is most effective when
contraception (to avoid pregnancy) and barrier protection (to prevent sexually
transmitted infections) are consistently used correctly.4 This can often be
achieved through the consistent and proper use of condoms.
Like many of the World’s indigenous people, Maori
youth in New Zealand are a particularly vulnerable group that bears greater than
expected poor health (including sexual and reproductive health). Previous
research has identified Maori youth as initiating sexual activity earlier than
their New Zealand European peers,5–7 and they are more likely to become
pregnant during their teenage years.3,8,9 Maori youth are also more likely than
other youth to acquire a sexually transmitted disease.10,11 Given these sexual
health indicators, relatively little is known with regard the true population
prevalence of sexual health indicators for Maori youth. Data sources are often
incomplete and there are no systematic surveillance systems for gathering this
data in a reliable manner.1,11 Indeed, to date there is a paucity of research
literature that explores the use of contraception by Maori youth.1,12
In recent years, youth health research has gone beyond the
identification of risk factors to the examination of protective factors that
promote good outcomes or resilience. The resilience framework seeks to
understand and identify factors that protect vulnerable youth, and encourages
them to thrive.13–18 The resilience framework also acknowledges that
behaviour is influenced by the complex interplay of individual, biological,
social, cultural, environmental, societal, and historical
influences.19,20 A dual strategy of supporting protective
resources and minimising risks is a central tenet of promoting resilience in
public health.21 For Maori communities, this framework seems very consistent
with Maori aspirations for development of capacities and
self-determination.22,23
Using a dataset from a nationally representative secondary
school survey, this research sought to identify risk and protective factors
associated with consistent contraceptive use among sexually active Maori
youth.
MethodologyNew Zealand’s first national cross-sectional
population-based youth health and wellbeing survey (Youth2000) was conducted in
2001. The study method is described in detail elsewhere.24 In brief, 9570
randomly selected secondary school students completed the survey, accounting for
4% of the total secondary school population in New Zealand. Response rates for
schools and students were 86% and 75% respectively. The anonymous comprehensive
523-item survey questionnaire was administered by Multimedia Computer-Assisted
Self-Interview (M-CASI) on laptop computers.25 Ethics approval was gained from
the University of Auckland Human Subjects Ethics Committee.
For the purposes of this study, a sub-sample of 2340
participating students (24.7% of Youth2000 sample) who reported that they
belonged to the Maori ethnic group was identified. Of the Maori students 52.9%
were male and 76.1% were 15 years or younger.
For the purposes of these analyses, the outcome
variable for Maori sexually active youth who use consistent contraception is
defined by two survey questions:
The independent variables are 14 hypothesised
protective factors and 12 hypothesised risk factors previously identified in the
literature (Table 3).13–18,26–31 An instrument measuring depressive
symptoms (Reynolds Adolescent Depression Scale32) and conduct-related behaviour
problems were are also used to investigate risk factors.
Control variables were age, gender, and socioeconomic
status. Socioeconomic status was measured by the variables: school decile (a
proxy socioeconomic variable at the school level incorporating a scale of 1
[poorest] to 10 [richest]; overcrowding; being in a two-parent family; family
owning a car and telephone; and whether someone in the home was in paid
employment.
Students were recruited using a clustered sample design
with unequal probabilities of selection. In all analyses, the data have been
weighted and the variance of estimates adjusted to allow for correlated data
from the same school. Chi-squared tests were used to test for differences in
proportions. Multiple logistic regressions were used to investigate the
associations between risk and protective factors and consistent contraception
use. All analyses have been conducted using SAS (version 9.1) software.
ResultsApproximately half of the Maori students (54% males; 48%
females) reported ever having had sexual intercourse. As Maori students got
older they were more likely to have ever had sexual intercourse (Table 1).
Table 1. All Maori students’ sexual intercourse
by age and gender
*2
males and 2 females did not have data on
age; 30 males and 36 females did not have
data on current sexual activity.
All students who had ever had sex were asked what type of
contraception they used to prevent pregnancy. Condoms (82%) were the most common
method of contraception used, followed by the oral contraceptive pill (36%), and
then the emergency contraceptive pill (morning-after pill) (14%). The least
common methods of contraception used by Maori students were the rhythm method
(2%), Depo-Provera (6%), or the withdrawal method (7%). No contraception to
prevent pregnancy was reported by 5% of students.
One-third (33.3% males; 33.7% females) of the Maori students
reported being currently sexual active (having had sexual intercourse in the
previous 3 months). Consistent use of contraception was reported by the majority
of currently sexually active Maori students (males 71%; females 70%) (Table 2).
Table 2. Consistent* contraception use by currently
sexually active students by age and gender (N=717).
(*Consistent
defined as always or usual use of contraception)
There were no significant differences by age or gender for
consistent contraception use. Table 3 describes the associations between
consistent contraception use and previously identified risk and protective
factors controlling for age and gender.
Table 3. Associations between consistent contraceptive
use and selected risk and protective factors amongst sexually active Maori youth
(adjusting for age and gender)
#RADS=Reynolds Adolescent
Depression Scale; *Statistically significant with a p<0.05
Protective variables that demonstrated statistical
significance were: getting enough time with parents (p=0.002); having a family
meal together (p=0.03); feeling teachers cared about them (p=0.02); having an
adult they could talk to (p=0.005); and feeling neighbourhoods are safe
(p=0.008).
Risk factors associated with inconsistent contraception
were: depressed for 2 weeks in the last 4 weeks (p=0.004); thoughts about
suicide in the last month (p=0.04); attempted suicide in the last year (p=0.01);
and weekly marijuana use (p<0.0001).
Protective factors associated with consistent contraception
use (Table 3: getting enough time with parents; feel their teachers care about
them; feel their neighbourhoods are safe; having an adult to talk to) were
included in a logistic regression model along with risk factors (depressive
symptoms in the last 4 weeks and weekly marijuana use); and the potential
confounders age and gender and school decile (a proxy socioeconomic variable at
the school level) (Table 4).
Table 4. Consistent contraception use among Maori youth
in logistic regression model (controlling for age, gender). N=536
*Statistically
significant with a p<0.05
Only one depressive variable (depressive symptoms in the
last 4 weeks) was utilised to avoid problems with collinearlity in the model
(Table 4). There were 536 students who were currently sexually active and had
full information; thus they could be included in the model.
The results of the model reveal that sexually active Maori
youth attending secondary school are more likely to consistently use
contraception when they report getting enough time with a parent or someone who
acts as a parent (p=0.03) (Table 4). Moreover, Maori youth who report weekly
marijuana use are significantly less likely to use contraception consistently
(p=0.0006).
DiscussionHalf of Maori youth aged 13 to 17 years in a nationally
representative sample of secondary school students report having sexual
intercourse, and over 80% of these students report using a condom as their
method of contraception to prevent pregnancy. About one-third of Maori students
in secondary school are currently sexually active (sexually active within the
past 3 months), and 70% of this group report consistent use of contraception.
Consistent contraception use did not differ by age or gender. Sexually active
Maori students who consistently use contraception are more likely to report
getting enough time with a parent and less likely to report regular marijuana
use.
Little published research has investigated the role of
protective factors and resilience for Maori or other indigenous youth,
particularly with regard to sexual and reproductive health. Our findings support
previous authors who suggest strong positive and caring family connections are a
significant protective factor for safer sexual behaviour.17,33–36
Ecological theories tell us that
making responsible
sexual decisions and being resilient is not solely an individual trait, rather
it is mediated by multiple domains in the wider family, social, economic and
political environments.19,37
The holistic beliefs of Maori about the interconnectedness
of health to the broader whanau
(family) environment are consistent with the resilience framework, and a move
from blaming individuals to understanding that multiple systems and contexts
influence health behaviours of individuals and groups. This positive contextual
concept is a vital foundation when promoting the sexual and reproductive
wellbeing of Maori
youth to avoid the stigma and shame frequently associated with sexuality.
Consistent contraception use is a useful public health
concept, as it frames the sexual development and behaviour of Maori youth as a
normal developmental task, and the use of contraception as a normal adult
behaviour to be learned and mastered. Condoms are a popular choice amongst Maori
youth; in addition to affording protection against pregnancy condom use, condoms
protect against many sexually transmitted infections. Public health activities
that aim to reduce barriers to condoms such as lowering cost, and increasing
knowledge and education should be considered vital strategies for Maori youth.
Whanau (families)
should be supported so that they spend time and talk to their
tamariki (children) about sexuality as
a normal part of growing up for the child. Moreover, clinicians have a role in
supporting and educating parents to communicate effectively about sexuality,
mental health, substance use, and other risky behaviours with their children.
Indeed, research on effective pregnancy prevention programs tell us that
programs must go beyond sexual health knowledge and skills to involve multiple
components including substance use, mental health, family relationships,
education, and the broader social and political contexts.32
Maori youth who are the most vulnerable for negative sexual
health outcomes (unintended pregnancy and sexually transmitted infections) are
the 29% who do not consistently use contraception. No significant differences by
age or gender amongst youth who use contraception inconsistently were found in
this study, which suggests that a broad-based public health program which
addresses all Maori youth may be appropriate to address this vulnerable group.
This study indicates how programmes, which influence a
broader set of risk and protective factors, are worthwhile avenues for public
health intervention. Substance abuse has previously been highlighted as a
significant risk factor associated with inconsistent contraception use.38,39 In
this study, marijuana-use is a significant risk factor for Maori youth who do
not use contraception consistently. The use of other drugs and alcohol, however,
was not found to be significant in this study so may require further
investigation in this population.
This study’s finding that weekly marijuana-use is
associated with inconsistent contraception-use, highlights (for Maori youth) the
importance of addressing substance-abuse amongst Maori youth as well as its
associations with other risky health behaviours.
This study’s strength is this data comes from the
largest randomly selected sample of young Maori ever surveyed on their health
and wellbeing. The study’s acceptability to young people and its anonymity
promote honest responses to personal and sensitive questionnaire items.40 A
limitation of this study is the ability of the questionnaire items to provide
reliable and valid measures of complex concepts such as socioeconomic factors
and risk and protective factors for Maori youth. Although these factors and
question items were identified from relevant literature and research, there is
little research to guide the applicability of these factors to young Maori. A
further limitation is missing data for some variables in the multiple regression
models, which reduce the statistical power to detect differences.
The most frequent missing variables were marijuana-use,
feeling safe in your neighbourhood, and having an adult to talk to (reducing the
number of students in the model to 536 out of 717 sexually active Maori
students). Finally, the youth who were absent from school the day the survey was
administered, or who have dropped out of school, are not represented in this
data. Therefore this study is likely to underestimate the prevalence of risky
sexual behaviours in the youth population.
The existent disparities in negative health outcomes
for Maori youth
underline the challenges facing contemporary New Zealand sexual and
reproductive health programmes.
This study has
significant implications for those responsible for addressing this important
public health issue. Furthermore, its findings support a broad strategy
of promoting protective factors such as strengthening youth-parent
relationships, and reducing risk factors such as substance-misuse in addition to
enhancing specific sexual health knowledge, skills, and access.
These comprehensive strategies will strengthen Maori
whanau (families) and communities, and
ensure that Maori youth have healthier sexual and reproductive health
outcomes.
Author information:
Terryann Clark, Adolescent Health Fellow/Nursing Doctoral Student, University of
Minnesota, Minneapolis, USA; Elizabeth Robinson, Biostatistican, School of
Population Health, University of Auckland, Auckland; Sue Crengle, Head of
Discipline, Maori Department of Maori and Pacific Health, School of Population
Health, University of Auckland, Auckland; Peter Watson, Senior Lecturer, School
of Population Health, University of Auckland, Auckland (all authors are members
of the Adolescent Health Research Group)
Acknowledgements:
This research was supported by grant 00/208 from the Health Research
Council of New Zealand while Portables Plus Ltd and the Starship Foundation
provided support with laptop computers. We also thank the participating school
students (and schools), project workers, project advisory groups, and other
members of the Adolescent Health Research Group. Terryann Clark also
acknowledges support from HRC Maori PhD scholarship, Nestle Training Fellowship
and the Kidzfirst South Auckland Foundation. Finally, our gratitude goes to
Professor Lyn Bearinger, School of Nursing and the adolescent health fellows,
and Division of Adolescent Health staff (at the University of Minnesota) for
their thoughtful feedback on earlier drafts.
Correspondence:
Terryann Clark, School of Nursing, University of Minnesota, 6-138 Weaver
Densford Hall, 308 Harvard Street SE, Minneapolis MN 55455, USA. email: clar0574@umn.edu
References:
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