Methods: Thirty-seven adolescents aged 15-17 were recruited from a community center serving two contiguous North Carolina counties with high STI rates. We conducted 4 focus groups stratified by gender in April 2006. Participants completed a brief questionnaire assessing their sexual, reproductive and STI histories. Focus group discussions assessed adolescent understanding of factors that mediate STI transmission, knowledge of safe sex behaviors and strategies used to reduce the risk of acquiring an STI. Focus groups were audio-taped, transcribed, and the data entered into a qualitative analysis package. Coding was performed by two independent individuals using grounded theory.

Results: Twenty females (54%) and 17 males (46%) participated. The average age was 16 and most (n=25, 69%) were sexually active. Adolescents understood how individual and partner behaviors (eg, number of sexual partners, frequency of intercourse, condom use), chance and sexual network factors (eg, STI prevalence) affect STI risk. They understood why safe sex behaviors such as avoiding concurrent partnerships and high risk partners reduce STI risk. Adolescents perceived many safe sex behaviors as unfeasible because they require partner compliance (eg, condom use, sexual history disclosure, disclosure of the number of current sexual partners) or because adolescents believe safe sex behaviors carry greater risks (e.g., loss of sexual opportunity, loss of partner trust) than the risks associated with acquiring an STI. Adolescents' primary risk reduction strategy is indirect partner assessments (e.g., physical appearance, reputation, meeting location, relationship quality, relationship duration). They are aware of meta-cognitive (eg, heat of the moment decision-making), partner and sexual network factors that both mediate STI risk and are outside their control.

Conclusions: Adolescents were aware that complex factors function at the individual and sexual network level to mediate STI risk. They primarily use partner selection strategies to reduce their STI risk, which is not reliable. Efforts to promote healthy adolescent sexual decision-making should improve adolescents' capacity to negotiate dating and sexual relationships and foster social environments where the adoption of safe sex behaviors is acceptable and normative.

Sources of Support: Robert Wood Johnson Foundation, NIH Roadmap K12 Award (1 KL2 RR024154-01)