AJPH RESEARCH
Intimate Partner Victimization and Health Risk Behaviors Among Pregnant Adolescents Ifeyinwa E. Udo, DrPH, Jessica B. Lewis, LMFT, Jonathan N. Tobin, PhD, and Jeannette R. Ickovics, PhD Objectives. To provide lifetime estimates of intimate partner victimization among pregnant adolescents and examine associations between victimization and health risk behaviors identified by the Centers for Disease Control and Prevention as leading causes of adolescent morbidity and mortality. Methods. Participants (n = 1233) were predominantly Latina (58%) and non-Latina Black (34%) pregnant adolescents (aged 14–21 years) enrolled in a randomized controlled trial of group prenatal care in 14 clinical sites in New York City (2008–2012). They completed surveys to assess interpersonal victimization and risk behaviors: substance use, risky sexual behaviors, injuries or violence, unhealthy dietary behavior, and inadequate physical activity. Results. Fifty-two percent reported intimate partner victimization, which was associated with nearly all health risk behaviors. Conclusions. Pregnant adolescents who experienced intimate partner victimization were significantly more likely to engage in health risk behaviors, which can have adverse health consequences. Expanded prevention programs tailored to specific needs of pregnant adolescents are needed. Health care providers and others who work with pregnant adolescents should consistently screen for and intervene in intimate partner victimization. (Am J Public Health. 2016;106:1457–1459. doi:10.2105/ AJPH.2016.303202)
N
early one quarter of women who experience intimate partner victimization were first victimized between ages 11 and 17.1 Adolescents are at higher risk for having abusive partners2 and are likely more vulnerable because of immaturity and financial dependence.3 Vulnerability to intimate partner victimization also increases during pregnancy.4 Adolescents who experience intimate partner victimization are more likely to engage in the health risk behaviors that the Centers for Disease Control and Prevention (CDC) identified as the leading causes of morbidity for US adolescents: substance use, risky sexual behaviors, injuries or violence, unhealthy dietary behavior, and inadequate physical activity.1,5 For pregnant adolescents, risks may be compounded because they often lead to adverse maternal and child health outcomes.4 Despite the high prevalence of intimate partner victimization among adolescents and young adults in the United States, research on
August 2016, Vol 106, No. 8
AJPH
intimate partner victimization has primarily focused on older women4,5 and has not examined co-occurring risk behaviors. The objectives of this study were to (1) provide lifetime estimates of intimate partner victimization among pregnant adolescents, and (2) examine the association between victimization and CDC-identified health risk behaviors. To the best of our knowledge, this was one of the first comprehensive studies to examine the association between intimate partner victimization and all leading health risk behaviors simultaneously among pregnant adolescents: substance use, risky sexual behaviors, injuries or violence, unhealthy
dietary behavior, and inadequate physical activity. Understanding these associations can provide critical evidence that can be used to develop and implement tailored prevention interventions for this vulnerable population.
METHODS Study participants (n = 1233) were predominantly Latina (58%) and non-Latina Black (34%) pregnant adolescents aged 14 to 21 years (mean = 18.67 years), less than 24 weeks gestational age, and medically low risk. They were enrolled in a cluster randomized controlled trial of group prenatal care in 14 health centers and hospitals in New York City between 2008 and 2012.6 Eligibility criteria included being less than 24 weeks gestational age, having no medical indication of a high-risk pregnancy, being able to speak English or Spanish, and being willing to participate in the study and be randomly assigned. We used audio-handheld assisted personal interview technology to collect data during pregnancy, and we examined data collected at baseline. We assessed intimate partner victimization via a short form of the Revised Conflict Tactics Scale, including sexual, physical, and verbal abuse.7 CDC-identified leading causes of morbidity were measured with validated indicators used in previous research with pregnant adolescents6 (Appendix A available as a supplement to the online version of this article at http://www.ajph.org). We used
ABOUT THE AUTHORS Ifeyinwa E. Udo, Jessica B. Lewis, and Jeannette R. Ickovics are with Yale School of Public Health and Yale Center for Interdisciplinary Research on AIDS, Yale University, New Haven, CT. Jonathan N. Tobin is with the Clinical Directors Network, New York, NY. Correspondence should be sent to Ifeyinwa E. Udo, DrPH, Yale School of Public Health New Haven, CT 06510 (e-mail: [email protected]). Reprints can be ordered at http://www.ajph.org by clicking the “Reprints” link. This brief was accepted March 19, 2016. doi: 10.2105/AJPH.2016.303202
Udo et al.
Peer Reviewed
Research
1457
AJPH RESEARCH
Stata version 13 (StataCorp LP, College Station, TX) to conduct all analyses. We recorded all variables in a manner that enabled us to calculate odds ratios (ORs) for engaging in the health risk behaviors. Beyond descriptive statistics, we used logistic regression to examine the association between intimate partner victimization and health risk behaviors: substance use, risky sexual behaviors, injuries or violence, unhealthy dietary behavior, and inadequate physical activity. All analyses were cross-sectional and statistically controlled for age, race/ethnicity, education, marital status, and employment. We used the clustered robust SE method in the logistic regression models to correct for intraclass correlations within clusters (i.e., patients nested within clinical sites).
intimate partner victimization also were 3 times more likely to initiate physical (AOR = 3.03; 95% CI = 2.35, 3.92) and verbal violence (AOR = 3.40; 95% CI = 2.47, 4.66). Finally, they were less adherent to dietary guidelines for prenatal vitamins (AOR = 1.60; 95% CI = 1.28, 1.99), fruit and vegetable consumption (AOR = 1.75; 95% CI = 1.29, 2.37), and breakfast (AOR = 1.31; 95% CI = 1.01, 1.72) and more likely to be sedentary (AOR = 1.28; 95% CI = 1.01, 1.63) during pregnancy compared with peers who were not victimized (Table 1).
DISCUSSION More than half of the pregnant adolescents reported intimate partner victimization. This rate is substantially higher than the rates
reported for both nonpregnant adolescents (25%–31%) and women (19%–33%).8 Pregnant adolescents who experienced intimate partner victimization were significantly more likely to engage in health behaviors that contribute to the leading causes of morbidity and mortality in the United States: substance use, risky sexual behaviors, injuries or violence, unhealthy dietary behavior, and inadequate physical activity. Engaging in these risk behaviors during pregnancy can have adverse health consequences such as pregnancy complications, preterm birth, and low birth weight.4 For example, unprotected intercourse increases the risk of sexually transmitted disease, especially during pregnancy, and this can result in intrauterine infection and preterm delivery.9 Poor diet during pregnancy is associated with adverse birth outcomes,10 and prenatal vitamins prevent
RESULTS Of the pregnant adolescents in this study, 52% (n = 637) experienced intimate partner victimization. Prevalence was higher among Latina adolescents, those with less than high school education, and those living with a partner (all P £ .002). There was no difference in age between pregnant adolescents who experienced intimate partner victimization and those who did not (mean = 18.67 years; SD = 1.73). Compared with those who did not experience intimate partner victimization, pregnant adolescents who experienced intimate partner victimization were more likely to be Black (38.2% vs 28.5%), less likely to be Hispanic (53.4% vs 62.3%), less likely to have graduated from high school (54.6% vs 64.6%), and less likely to be married (8.5% vs 16.3%; all P < .01). As hypothesized, intimate partner victimization was associated with CDC-identified leading causes of morbidity and mortality. Specifically, pregnant adolescents who experienced intimate partner victimization were 2 to 4 times more likely to use alcohol (adjusted OR [AOR] = 1.95; 95% confidence interval [CI] = 1.29, 2.93), tobacco (AOR = 4.05; 95% CI = 2.10, 5.71), and marijuana (AOR = 3.14; 95% CI = 1.50, 6.62) during pregnancy. They were more likely to have unprotected sex (AOR = 1.42; 95% CI = 1.10, 1.90) and multiple sexual partners (AOR = 2.01; 95% CI = 1.34, 2.82). Pregnant adolescents who experienced
1458
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TABLE 1—Participant Sociodemographic Characteristics and Multivariate Analysis of the Associations Between Intimate Partner Victimization and Health Risk Behaviors Among Pregnant Adolescents: New York City, 2008–2012 Intimate Partner Victimization Characteristics and Outcomesa Total
Total, % (No.)
Yes, % (No.)
No, % (No.)
100 (1233)
51.7 (637)
48.3 (596)
AORb (95% CI)
Substance abuse (during pregnancy) Alcohol
7.3 (90)
9.4 (60)
5.0 (30)
1.95 (1.29, 2.93)
Tobacco
5.4 (66)
8.5 (54)
2.0 (12)
4.05 (2.10, 5.71)
Marijuana
4.1 (51)
6.4 (41)
1.7 (10)
3.14 (1.50, 6.62)
61.2 (755) 13.5 (167)
65.8 (392) 17.4 (111)
57.0 (363) 9.4 (56)
1.42 (1.10, 1.90) 2.01 (1.34, 2.82)
Physical violence
14.4 (178)
20.7 (132)
7.7 (46)
3.03 (2.35, 3.92)
Verbal violence
22.5 (277)
32.3 (206)
11.9 (71)
3.40 (2.47, 4.66)
Sexual risk behavior (6 mo) Condom nonuse Multiple sexual partners Initiated violent behavior (during pregnancy)
Dietary behavior (7 d) Prenatal vitamins nonuse
34.6 (427)
39.7 (253)
29.2 (174)
1.60 (1.28, 1.99)
Fruit and vegetable nonconsumption
79.8 (984)
82.9 (528)
76.5 (456)
1.75 (1.29, 2.37)
Fast-food consumption
36.7 (453)
40.8 (260)
32.4 (193)
1.25 (0.03, 1.59)
Skip breakfast
60.6 (747)
63.0 (401)
58.1 (346)
1.31 (1.01, 1.72)
Physical activity (7 d) Sedentary lifestyle
56.6 (698)
60.6 (386)
52.3 (312)
1.28 (1.01, 1.63)
No exercise built into daily activities
42.5 (524)
43.2 (275)
41.8 (249)
1.19 (0.92, 1.52)
No daily moderate activity
60.3 (743)
58.6 (373)
62.1 (370)
1.03 (0.79, 1.34)
Note. AOR = adjusted odds ratio; CI = confidence interval. a Percentages (no.) reflect “yes” responses (i.e., engaged in risky behaviors). b All models adjusted for age, race/ethnicity, employment status, education, relationship status, intervention, and variables that were associated with outcomes in the bivariate analysis.
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AJPH RESEARCH
congenital anomalies such as neural tube defects.11 Sedentary lifestyle is associated with excess maternal weight gain, which increases the risk of complications (e.g., diabetes, preeclampsia) and low birth weight.12 We recognize some limitations of this study. All data were self-reported by participants, and we used a shorter and adapted version of the Conflict Tactics Scale, which may be less reliable than a more detailed instrument. Study participants were predominantly Latina and non-Latina Black, reflecting the population seen at the health centers and hospitals. Hence results may not be generalizable to all women. Data examined in this analysis were cross-sectional; however, issues regarding temporality were taken into account in the wording of the questions as we assessed history of intimate partner victimization and health risk behaviors during pregnancy. Given that this study was a secondary analysis, measures were restricted to available data (e.g., limited information on other risks of unintentional injuries and violence). However, this large cohort of pregnant adolescents is at great risk for intimate partner victimization and adverse health behaviors. We believe that this was one of the first studies to examine all CDC health risk behaviors simultaneously, and the only one during adolescent pregnancy, with important implications for maternal and child health. This study extends previous research by examining the association between intimate partner victimization and health risks among pregnant adolescents. Risk behaviors initiated during adolescence often extend into adulthood and increase the risk of chronic diseases.8 Findings have implications for expanded prevention programs tailored to specific needs of pregnant adolescents. Health care providers and others who work with pregnant adolescents should consistently screen for and intervene in intimate partner victimization. Future studies should evaluate approaches to incorporating screening into prenatal care, identify additional risk factors for pregnant adolescents such as nonintimate partner victimization and family conflicts, document determinants and consequences of victimization for maternal and child health, and design and test interventions to prevent
August 2016, Vol 106, No. 8
AJPH
victimization and reduce its negative health consequences. CONTRIBUTORS
I. E. Udo conducted statistical analysis and wrote the first draft of the brief. J. B. Lewis contributed to the study design and coordinated all data collection and management efforts. J. N. Tobin contributed to the study design and served as the primary liaison to the clinical sites. J. R. Ickovics was responsible for study conceptualization, design, and oversight. All authors provided feedback on multiple versions of the brief and contributed to the final version.
10. Martin CL, Sotres-Alvarez D, Siega-Riz AM. Maternal dietary patterns during the second trimester are associated with preterm birth. J Nutr. 2015;145(8): 1857–1864. 11. Dean SV, Lassi ZS, Imam AM, Bhutta ZA. Preconception care: nutritional risks and interventions. Reprod Health. 2014;11(suppl 3):S3. 12. Xie Y, Madkour AS, Harville EW. Preconception nutrition, physical activity, and birth outcomes in adolescent girls. J Pediatr Adolesc Gynecol. 2015;28(6): 471–476.
ACKNOWLEDGMENTS This research was supported by the National Institute of Mental Health (grants RO1MHO74394 and T32MH020031). We express our sincere appreciation to Erika Montanaro and Shayna Cunningham from the Yale School of Public Health for their feedback on an initial draft of the brief.
HUMAN PARTICIPANT PROTECTION This study was approved by institutional review boards at Yale University, the Clinical Directors Network, and each study site. Participants provided written informed consent.
REFERENCES 1. Black MC, Basile KC, Breiding MJ, et al. The National Intimate Partner and Sexual Violence Survey (NISVS): 2010 Summary Report. Atlanta, GA: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention; 2011. 2. Sto¨ ckl H, March L, Pallitto C, Garcia-Moreno C, WHO Multi-Country Study Team. Intimate partner violence among adolescents and young women: prevalence and associated factors in nine countries: a crosssectional study. BMC Public Health. 2014;14:751. 3. Adams AE, Greeson MR, Kennedy AC, Tolman RM. The effects of adolescent intimate partner violence on women’s educational attainment and earnings. J Interpers Violence. 2013;28(17):3283–3300. 4. Alhusen JL, Ray E, Sharps P, Bullock L. Intimate partner violence during pregnancy: maternal and neonatal outcomes. J Womens Health (Larchmt). 2015;24(1): 100–106. 5. Kann L, Kinchen S, Shanklin SL, et al. Youth risk behavior surveillance–United States, 2013. MMWR Suppl. 2014;63(4):1–168. 6. Ickovics JR, Earnshaw V, Lewis JB, et al. Cluster randomized controlled trial of group prenatal care: perinatal outcomes among adolescents in New York City Health Centers. Am J Public Health. 2016;106(2): 359–365. 7. Straus MA, Douglas EM. A short form of the Revised Conflict Tactics Scales, and typologies for severity and mutuality. Violence Vict. 2004;19(5):507–520. 8. Decker MR, Miller E, McCauley HL, et al. Recent partner violence and sexual and drug-related STI/HIV risk among adolescent and young adult women attending family planning clinics. Sex Transm Infect. 2014;90(2): 145–149. 9. Kershaw TS, Ethier KA, Niccolai LM, et al. Let’s stay together: relationship dissolution and sexually transmitted diseases among parenting and non-parenting adolescents. J Behav Med. 2010;33(6):454–465.
Udo et al.
Peer Reviewed
Research
1459
Intimate Partner Victimization and Health Risk Behaviors Among Pregnant Adolescents Ifeyinwa E. Udo, DrPH, Jessica B. Lewis, LMFT, Jonathan N. Tobin, PhD, and Jeannette R. Ickovics, PhD Objectives. To provide lifetime estimates of intimate partner victimization among pregnant adolescents and examine associations between victimization and health risk behaviors identified by the Centers for Disease Control and Prevention as leading causes of adolescent morbidity and mortality. Methods. Participants (n = 1233) were predominantly Latina (58%) and non-Latina Black (34%) pregnant adolescents (aged 14–21 years) enrolled in a randomized controlled trial of group prenatal care in 14 clinical sites in New York City (2008–2012). They completed surveys to assess interpersonal victimization and risk behaviors: substance use, risky sexual behaviors, injuries or violence, unhealthy dietary behavior, and inadequate physical activity. Results. Fifty-two percent reported intimate partner victimization, which was associated with nearly all health risk behaviors. Conclusions. Pregnant adolescents who experienced intimate partner victimization were significantly more likely to engage in health risk behaviors, which can have adverse health consequences. Expanded prevention programs tailored to specific needs of pregnant adolescents are needed. Health care providers and others who work with pregnant adolescents should consistently screen for and intervene in intimate partner victimization. (Am J Public Health. 2016;106:1457–1459. doi:10.2105/ AJPH.2016.303202)
N
early one quarter of women who experience intimate partner victimization were first victimized between ages 11 and 17.1 Adolescents are at higher risk for having abusive partners2 and are likely more vulnerable because of immaturity and financial dependence.3 Vulnerability to intimate partner victimization also increases during pregnancy.4 Adolescents who experience intimate partner victimization are more likely to engage in the health risk behaviors that the Centers for Disease Control and Prevention (CDC) identified as the leading causes of morbidity for US adolescents: substance use, risky sexual behaviors, injuries or violence, unhealthy dietary behavior, and inadequate physical activity.1,5 For pregnant adolescents, risks may be compounded because they often lead to adverse maternal and child health outcomes.4 Despite the high prevalence of intimate partner victimization among adolescents and young adults in the United States, research on
August 2016, Vol 106, No. 8
AJPH
intimate partner victimization has primarily focused on older women4,5 and has not examined co-occurring risk behaviors. The objectives of this study were to (1) provide lifetime estimates of intimate partner victimization among pregnant adolescents, and (2) examine the association between victimization and CDC-identified health risk behaviors. To the best of our knowledge, this was one of the first comprehensive studies to examine the association between intimate partner victimization and all leading health risk behaviors simultaneously among pregnant adolescents: substance use, risky sexual behaviors, injuries or violence, unhealthy
dietary behavior, and inadequate physical activity. Understanding these associations can provide critical evidence that can be used to develop and implement tailored prevention interventions for this vulnerable population.
METHODS Study participants (n = 1233) were predominantly Latina (58%) and non-Latina Black (34%) pregnant adolescents aged 14 to 21 years (mean = 18.67 years), less than 24 weeks gestational age, and medically low risk. They were enrolled in a cluster randomized controlled trial of group prenatal care in 14 health centers and hospitals in New York City between 2008 and 2012.6 Eligibility criteria included being less than 24 weeks gestational age, having no medical indication of a high-risk pregnancy, being able to speak English or Spanish, and being willing to participate in the study and be randomly assigned. We used audio-handheld assisted personal interview technology to collect data during pregnancy, and we examined data collected at baseline. We assessed intimate partner victimization via a short form of the Revised Conflict Tactics Scale, including sexual, physical, and verbal abuse.7 CDC-identified leading causes of morbidity were measured with validated indicators used in previous research with pregnant adolescents6 (Appendix A available as a supplement to the online version of this article at http://www.ajph.org). We used
ABOUT THE AUTHORS Ifeyinwa E. Udo, Jessica B. Lewis, and Jeannette R. Ickovics are with Yale School of Public Health and Yale Center for Interdisciplinary Research on AIDS, Yale University, New Haven, CT. Jonathan N. Tobin is with the Clinical Directors Network, New York, NY. Correspondence should be sent to Ifeyinwa E. Udo, DrPH, Yale School of Public Health New Haven, CT 06510 (e-mail: [email protected]). Reprints can be ordered at http://www.ajph.org by clicking the “Reprints” link. This brief was accepted March 19, 2016. doi: 10.2105/AJPH.2016.303202
Udo et al.
Peer Reviewed
Research
1457
AJPH RESEARCH
Stata version 13 (StataCorp LP, College Station, TX) to conduct all analyses. We recorded all variables in a manner that enabled us to calculate odds ratios (ORs) for engaging in the health risk behaviors. Beyond descriptive statistics, we used logistic regression to examine the association between intimate partner victimization and health risk behaviors: substance use, risky sexual behaviors, injuries or violence, unhealthy dietary behavior, and inadequate physical activity. All analyses were cross-sectional and statistically controlled for age, race/ethnicity, education, marital status, and employment. We used the clustered robust SE method in the logistic regression models to correct for intraclass correlations within clusters (i.e., patients nested within clinical sites).
intimate partner victimization also were 3 times more likely to initiate physical (AOR = 3.03; 95% CI = 2.35, 3.92) and verbal violence (AOR = 3.40; 95% CI = 2.47, 4.66). Finally, they were less adherent to dietary guidelines for prenatal vitamins (AOR = 1.60; 95% CI = 1.28, 1.99), fruit and vegetable consumption (AOR = 1.75; 95% CI = 1.29, 2.37), and breakfast (AOR = 1.31; 95% CI = 1.01, 1.72) and more likely to be sedentary (AOR = 1.28; 95% CI = 1.01, 1.63) during pregnancy compared with peers who were not victimized (Table 1).
DISCUSSION More than half of the pregnant adolescents reported intimate partner victimization. This rate is substantially higher than the rates
reported for both nonpregnant adolescents (25%–31%) and women (19%–33%).8 Pregnant adolescents who experienced intimate partner victimization were significantly more likely to engage in health behaviors that contribute to the leading causes of morbidity and mortality in the United States: substance use, risky sexual behaviors, injuries or violence, unhealthy dietary behavior, and inadequate physical activity. Engaging in these risk behaviors during pregnancy can have adverse health consequences such as pregnancy complications, preterm birth, and low birth weight.4 For example, unprotected intercourse increases the risk of sexually transmitted disease, especially during pregnancy, and this can result in intrauterine infection and preterm delivery.9 Poor diet during pregnancy is associated with adverse birth outcomes,10 and prenatal vitamins prevent
RESULTS Of the pregnant adolescents in this study, 52% (n = 637) experienced intimate partner victimization. Prevalence was higher among Latina adolescents, those with less than high school education, and those living with a partner (all P £ .002). There was no difference in age between pregnant adolescents who experienced intimate partner victimization and those who did not (mean = 18.67 years; SD = 1.73). Compared with those who did not experience intimate partner victimization, pregnant adolescents who experienced intimate partner victimization were more likely to be Black (38.2% vs 28.5%), less likely to be Hispanic (53.4% vs 62.3%), less likely to have graduated from high school (54.6% vs 64.6%), and less likely to be married (8.5% vs 16.3%; all P < .01). As hypothesized, intimate partner victimization was associated with CDC-identified leading causes of morbidity and mortality. Specifically, pregnant adolescents who experienced intimate partner victimization were 2 to 4 times more likely to use alcohol (adjusted OR [AOR] = 1.95; 95% confidence interval [CI] = 1.29, 2.93), tobacco (AOR = 4.05; 95% CI = 2.10, 5.71), and marijuana (AOR = 3.14; 95% CI = 1.50, 6.62) during pregnancy. They were more likely to have unprotected sex (AOR = 1.42; 95% CI = 1.10, 1.90) and multiple sexual partners (AOR = 2.01; 95% CI = 1.34, 2.82). Pregnant adolescents who experienced
1458
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Peer Reviewed
Udo et al.
TABLE 1—Participant Sociodemographic Characteristics and Multivariate Analysis of the Associations Between Intimate Partner Victimization and Health Risk Behaviors Among Pregnant Adolescents: New York City, 2008–2012 Intimate Partner Victimization Characteristics and Outcomesa Total
Total, % (No.)
Yes, % (No.)
No, % (No.)
100 (1233)
51.7 (637)
48.3 (596)
AORb (95% CI)
Substance abuse (during pregnancy) Alcohol
7.3 (90)
9.4 (60)
5.0 (30)
1.95 (1.29, 2.93)
Tobacco
5.4 (66)
8.5 (54)
2.0 (12)
4.05 (2.10, 5.71)
Marijuana
4.1 (51)
6.4 (41)
1.7 (10)
3.14 (1.50, 6.62)
61.2 (755) 13.5 (167)
65.8 (392) 17.4 (111)
57.0 (363) 9.4 (56)
1.42 (1.10, 1.90) 2.01 (1.34, 2.82)
Physical violence
14.4 (178)
20.7 (132)
7.7 (46)
3.03 (2.35, 3.92)
Verbal violence
22.5 (277)
32.3 (206)
11.9 (71)
3.40 (2.47, 4.66)
Sexual risk behavior (6 mo) Condom nonuse Multiple sexual partners Initiated violent behavior (during pregnancy)
Dietary behavior (7 d) Prenatal vitamins nonuse
34.6 (427)
39.7 (253)
29.2 (174)
1.60 (1.28, 1.99)
Fruit and vegetable nonconsumption
79.8 (984)
82.9 (528)
76.5 (456)
1.75 (1.29, 2.37)
Fast-food consumption
36.7 (453)
40.8 (260)
32.4 (193)
1.25 (0.03, 1.59)
Skip breakfast
60.6 (747)
63.0 (401)
58.1 (346)
1.31 (1.01, 1.72)
Physical activity (7 d) Sedentary lifestyle
56.6 (698)
60.6 (386)
52.3 (312)
1.28 (1.01, 1.63)
No exercise built into daily activities
42.5 (524)
43.2 (275)
41.8 (249)
1.19 (0.92, 1.52)
No daily moderate activity
60.3 (743)
58.6 (373)
62.1 (370)
1.03 (0.79, 1.34)
Note. AOR = adjusted odds ratio; CI = confidence interval. a Percentages (no.) reflect “yes” responses (i.e., engaged in risky behaviors). b All models adjusted for age, race/ethnicity, employment status, education, relationship status, intervention, and variables that were associated with outcomes in the bivariate analysis.
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AJPH RESEARCH
congenital anomalies such as neural tube defects.11 Sedentary lifestyle is associated with excess maternal weight gain, which increases the risk of complications (e.g., diabetes, preeclampsia) and low birth weight.12 We recognize some limitations of this study. All data were self-reported by participants, and we used a shorter and adapted version of the Conflict Tactics Scale, which may be less reliable than a more detailed instrument. Study participants were predominantly Latina and non-Latina Black, reflecting the population seen at the health centers and hospitals. Hence results may not be generalizable to all women. Data examined in this analysis were cross-sectional; however, issues regarding temporality were taken into account in the wording of the questions as we assessed history of intimate partner victimization and health risk behaviors during pregnancy. Given that this study was a secondary analysis, measures were restricted to available data (e.g., limited information on other risks of unintentional injuries and violence). However, this large cohort of pregnant adolescents is at great risk for intimate partner victimization and adverse health behaviors. We believe that this was one of the first studies to examine all CDC health risk behaviors simultaneously, and the only one during adolescent pregnancy, with important implications for maternal and child health. This study extends previous research by examining the association between intimate partner victimization and health risks among pregnant adolescents. Risk behaviors initiated during adolescence often extend into adulthood and increase the risk of chronic diseases.8 Findings have implications for expanded prevention programs tailored to specific needs of pregnant adolescents. Health care providers and others who work with pregnant adolescents should consistently screen for and intervene in intimate partner victimization. Future studies should evaluate approaches to incorporating screening into prenatal care, identify additional risk factors for pregnant adolescents such as nonintimate partner victimization and family conflicts, document determinants and consequences of victimization for maternal and child health, and design and test interventions to prevent
August 2016, Vol 106, No. 8
AJPH
victimization and reduce its negative health consequences. CONTRIBUTORS
I. E. Udo conducted statistical analysis and wrote the first draft of the brief. J. B. Lewis contributed to the study design and coordinated all data collection and management efforts. J. N. Tobin contributed to the study design and served as the primary liaison to the clinical sites. J. R. Ickovics was responsible for study conceptualization, design, and oversight. All authors provided feedback on multiple versions of the brief and contributed to the final version.
10. Martin CL, Sotres-Alvarez D, Siega-Riz AM. Maternal dietary patterns during the second trimester are associated with preterm birth. J Nutr. 2015;145(8): 1857–1864. 11. Dean SV, Lassi ZS, Imam AM, Bhutta ZA. Preconception care: nutritional risks and interventions. Reprod Health. 2014;11(suppl 3):S3. 12. Xie Y, Madkour AS, Harville EW. Preconception nutrition, physical activity, and birth outcomes in adolescent girls. J Pediatr Adolesc Gynecol. 2015;28(6): 471–476.
ACKNOWLEDGMENTS This research was supported by the National Institute of Mental Health (grants RO1MHO74394 and T32MH020031). We express our sincere appreciation to Erika Montanaro and Shayna Cunningham from the Yale School of Public Health for their feedback on an initial draft of the brief.
HUMAN PARTICIPANT PROTECTION This study was approved by institutional review boards at Yale University, the Clinical Directors Network, and each study site. Participants provided written informed consent.
REFERENCES 1. Black MC, Basile KC, Breiding MJ, et al. The National Intimate Partner and Sexual Violence Survey (NISVS): 2010 Summary Report. Atlanta, GA: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention; 2011. 2. Sto¨ ckl H, March L, Pallitto C, Garcia-Moreno C, WHO Multi-Country Study Team. Intimate partner violence among adolescents and young women: prevalence and associated factors in nine countries: a crosssectional study. BMC Public Health. 2014;14:751. 3. Adams AE, Greeson MR, Kennedy AC, Tolman RM. The effects of adolescent intimate partner violence on women’s educational attainment and earnings. J Interpers Violence. 2013;28(17):3283–3300. 4. Alhusen JL, Ray E, Sharps P, Bullock L. Intimate partner violence during pregnancy: maternal and neonatal outcomes. J Womens Health (Larchmt). 2015;24(1): 100–106. 5. Kann L, Kinchen S, Shanklin SL, et al. Youth risk behavior surveillance–United States, 2013. MMWR Suppl. 2014;63(4):1–168. 6. Ickovics JR, Earnshaw V, Lewis JB, et al. Cluster randomized controlled trial of group prenatal care: perinatal outcomes among adolescents in New York City Health Centers. Am J Public Health. 2016;106(2): 359–365. 7. Straus MA, Douglas EM. A short form of the Revised Conflict Tactics Scales, and typologies for severity and mutuality. Violence Vict. 2004;19(5):507–520. 8. Decker MR, Miller E, McCauley HL, et al. Recent partner violence and sexual and drug-related STI/HIV risk among adolescent and young adult women attending family planning clinics. Sex Transm Infect. 2014;90(2): 145–149. 9. Kershaw TS, Ethier KA, Niccolai LM, et al. Let’s stay together: relationship dissolution and sexually transmitted diseases among parenting and non-parenting adolescents. J Behav Med. 2010;33(6):454–465.
Udo et al.
Peer Reviewed
Research
1459
