BACKGROUND Adolescence and young adulthood are critical life stages for maintaining sexual and reproductive health (SRH), especially for women. There is a vast research literature dedicated to the determinants of young women’s SRH and related risk behaviors—e.g., contraception and condom use. While the factors influencing women’s SRH are broadly understood, it is less clear how risk mechanisms operate within specific contexts. Illuminating the unique settings that exacerbate or mitigate young women’s SRH risks could guide the development of more potent interventions. This dissertation examines young women’s SRH in the context of international travel. Traveling to a foreign country precipitates an abrupt shift in women’s psychosocial, physical, and cultural environments that may, in turn, influence SRH risk behaviors. Existing studies focus on travelers’ sexual behaviors in predominantly European and clinic-based samples. Data for women are mostly limited to prevalence estimates. Notably, no published studies report on women’s use of contraception, other than condoms, during international travel. With few studies comparing travelers with non-travelers, it is also unclear whether SRH outcomes are attributable to travel itself or if high-risk individuals disproportionately engage in international travel. DATA SOURCE We conducted a mixed-methods study of female university students who had traveled outside the United States in the past three months (“Traveler”) or planned to do so in the next three months (“Pre-Traveler”). Participants had a history of sex with men and considered the United States their home country. For the quantitative study, Travelers, (n=340) and Pre-Travelers (n=170) completed a cross-sectional online survey about their SRH and recent or upcoming trip (“index trip”). In the retrospective portion of the survey, Travelers reported on their index trip and Pre-Travelers for a recent period of similar duration in the United States. The qualitative study consisted of in-depth, semi-structured interviews with 25 Travelers and 19 Pre-Travelers. This dissertation is presented in three manuscripts, whose aims, methods, and results are described below. MANUSCRIPT 1 Aim: To evaluate whether traveling internationally increases young women’s risk of adverse SRH outcomes, compared to not traveling. Methods: Using multivariable modified Poisson regression, we estimated relative risk of contraceptive lapse (errors or non-adherence) and new male sexual partnership associated with international travel (Travelers) versus staying in the United States (Pre-Travelers). Results: During international travel, women were no more likely to lapse on their contraception (RR 1.05, 95% CI 0.83—1.32) but were 70% more likely to report a new male sex partner (RR 1.71, 95% CI 1.07—2.74). MANUSCRIPT 2 Aim: To describe the prevalence and correlates of contraceptive lapse among young women during international travel. Methods: In this exploratory analysis of surveyed Travelers (n=340), we examined crude bivariate associations between contraceptive lapse and potential correlates in three domains: baseline/pre-travel variables, travel characteristics and experiences, and SRH-related travel variables. Correlates associated with lapse at p<.20 were evaluated using multivariable modified Poisson regression, including two sensitivity analyses restricted to pill users and women who had sex while traveling. Results: Prevalence of contraceptive lapse was 29% overall and especially high among pill users (50%) and travelers who had trouble communicating with male sex partners about contraception (57%). Multivariable correlates of lapse were: using the pill (RR 4.51, 95% CI 2.57—7.94) compared to other or no contraception; trip duration of >30 days versus 1-7 days (RR 2.02, 95% CI 1.14—3.57); having trouble communicating with a male sex partner about contraception (RR 1.79, 95% CI 1.16—2.75); a high perceived impact of language barriers (RR 1.77, 95% CI 1.02—3.08); and perceiving local access to abortion as difficult (RR 1.67, 95% CI 1.22—2.27). There was a trend toward increased lapse risk among participants who had difficulty maintaining their contraceptive schedule while traveling across time zones (RR 1.38, 95% CI 1.00—1.91). Findings were generally similar in sensitivity analyses except for attenuation in the effect for pill use among sexually active travelers (RR 2.47, 95% CI 1.14—5.35). MANUSCRIPT 3 Aim: To characterize the spectrum and antecedents of young women’s sexual and contraceptive behaviors during international travel. Methods: We analyzed qualitative interview transcripts to identify themes related to: (1) Participants’ pre-travel expectations of sex; (2) The circumstances surrounding their sexual encounters with men while traveling; (3) Negotiation of condoms and contraception with these sex partners; and (4) Facilitators and barriers affecting contraceptive adherence. Results: Participants frequently expected to be abstinent during travel, citing myriad rationales that included personal values, no perceived opportunities for sex, and the nature of the trip. Some Travelers had unexpected sexual encounters, which were typified by health-promoting behaviors but also by unprotected sex, substance use, and condom errors. New sexual partnerships were fueled by increased attention from men, situational disinhibition, and heightened intimacy among travel companions. We observed an array of contraceptive considerations brought on by international travel—e.g., procuring extra supplies, adjusting schedules, and maintaining use during air travel—and obstacles that triggered contraceptive lapses and discontinuation. The logistical requirements of travel magnified differences between contraceptive methods: challenges were most acute for pill users, while women with intrauterine devices appreciated their maintenance-free contraception. CONCLUSION Young women may be at higher risk of new sexual partnership during international travel, while contraceptive lapse is frequent in both travel and non-travel settings. During international travel, risk of contraceptive lapse varies by women’s chosen contraceptive method as well as trip-specific factors. Pre-departure counseling by clinicians and other travel specialists should address travel-related barriers to women’s contraceptive use, prepare women for the possibility of unexpected sexual encounters, and encourage behavioral strategies that prevent both unintended pregnancy and sexually transmitted infections.
University of Minnesota Ph.D. dissertation. 2017. Major: Epidemiology. Advisors: Wendy Hellerstedt, Susan Mason. 1 computer file (PDF); 129 pages.
International travel, contraceptive use, and sexual behavior: A mixed methods study of female university students.
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