Elise Kosunen

Pubertal timing, sexual behaviour and self-reported depression in middle adolescence

The associations between pubertal timing, sexual activity and self-reported depression were analysed in a population sample of 17,082 girls and 15,922 boys aged 14-16 as a par of a classroom survey. Pubertal timing was assessed by age at onset of menstruation (menarche) or ejaculations (oigarche). Sexual experiences elicited included kissing, light petting, heavy petting and intercourse. Self-reported depression was measured by the 13-item Beck Depression Inventory. Among girls, self-reported depression was associated with early puberty and intimate sexual relationship. Among boys depression was associated with very early and late puberty and experience of intercourse. Early puberty is a risk factor for self-reported depression. Intimate sexual relationships in middle adolescent are likely to indicate problems in adolescent development rather than successful adolescent passage.

Enrolment of 22,000 adolescent women to cancer registry follow-up for long-term human papillomavirus vaccine efficacy: guarding against guessing

Human papillomaviruses (HPVs, most notably types 16 and 18) cause cervical carcinoma, the second most common cancer among women. Vaccination of adolescents against HPV16/18 might prevent large proportion of cervical and other anogenital cancers. However, because of ethical reasons this cannot be proven by clinical studies. To determine the long-term vaccine efficacy (VE) of HPV16/18 virus-like-particle (VLP) vaccine against cervical carcinoma in situ (CIS+) and invasive cervical carcinoma, the following three population-based cohorts of adolescent women have been enrolled: (1) women vaccinated with the HPV vaccine; (2) women vaccinated with hepatitis A control vaccine; and (3) unvaccinated control women. These cohorts will be passively followed for cumulative incidence of CIS+ endpoints by population-based cancer registry. Overall 24,046 16- to 17-year-old adolescent women from 18 cities in Finland were invited between May 2004 and June 2005 to participate in a phase III trial with bivalent HPV16/18 VLP vaccine. A total of 58,996 18- to 19-year-old women were invited in May 2005 to participate as unvaccinated controls. Women who reported their willingness to participate in an HPV vaccination trial had they been 1–2 years younger were eligible. Cumulative incidence (CI) of CIS+ in our cohorts over 15 years is approximately 0.45%. VE of 70% against CIS+ with 80% power requires 3357–3189 HPV16/18 vaccine recipients, 3357–3189 other vaccine recipients, and 6714–9567 unvaccinated controls. We have now enrolled 2404 HPV16/18 vaccine recipients, 2404 hepatitis A-vaccine recipients, and 5130 unvaccinated controls. This enrolment in addition to our earlier enrolment in another phase III trial guarantees enough power so that by 2020 we can ultimately provide data on the efficacy of HPV16/18 vaccination against CIS+.

Sociodemographic differences in the occurrence of teenage pregnancies in Finland in 1987–1998: a follow up study

Study objective: To analyse sociodemographic differences in the occurrence of pregnancies to 14 to 19 year olds and changes in these differences from 1987 to 1998. Design: Follow up of adolescent survey respondents using registers. Setting and subjects: The dataset includes information on all registered pregnancies (abortions, births, and miscarriages, n=2743) of the female respondents (n=28 914) to the Adolescent Health and Lifestyle Survey (AHLS) from 1987 to 1998. In the AHLS, self administered questionnaires were mailed every second year to independent samples of 12, 14, 16, and 18 year olds representative for Finland. Main outcome measure: Relative risk (hazard) of becoming pregnant at teenage. Main results: Girls from lower socioeconomic background had a higher pregnancy risk. Girls who did not live with both parents at the baseline survey had higher pregnancy risk than those who did, and girls who lived in a stepfamily had a higher risk than those who lived in a one parent family. Swedish speaking girls had a lower pregnancy risk than the Finnish speaking girls. There was no systematic change from 1987 to 1998 in most sociodemographic differentials in the teenage pregnancy risk, however, there was some increase in the differences by family structure. Changes in the sociodemographic structure did not explain the levelling off of the downward trend in teenage pregnancy risk, nor did the regional socioeconomic differences explain regional differentials in teenage pregnancy risk. Conclusion: Although the reduction of socioeconomic and regional differences has been a general objective in Finnish social and health policies, the relative differences in teenage pregnancies have not decreased.

Sexual behavior and drinking style among teenagers: a population-based study in Finland.

In this large-scale study, we examined the relationship between an adolescents sexual behavior and drinking style. Three aspects of sexual risk-taking were included: early activity, unprotected sexual intercourse and having sex with multiple partners. A distinction was made between different drinking styles, i.e. alcohol drinking and drunkenness-related drinking. Cross-sectional school survey data from the School Health Promotion Study was collected in Finland in 2002-2003. The national sample consisted of adolescents from the eighth and ninth grades (n = 100,790). The mean ages were 14.8 and 15.8 years. Using logistic regression analysis, we investigated the association between sexual behavior and drinking style among teenagers. The likelihood of engaging in sexual intercourse increased with the frequency of alcohol use. In particular, frequent drunkenness-related drinking increased the probability that the teenager had experienced sexual intercourse. The likelihood of engaging in unprotected sex and/or having multiple sexual partners was many-fold for adolescents drinking frequently until they were in a state of drunkenness. Particularly for girls, weekly drunkenness-related drinking was associated with multiple partners. The vast majority of sexually experienced under-aged adolescents drink alcohol, many of them until they are drunk. Thus, it could be effective to combine both alcohol education and sex education, including contraceptive counseling, in early adolescence.

Knowledge and use of hormonal emergency contraception in Finland

We studied the knowledge and use of hormonal emergency contraception (EC) in Finland by mailing a questionnaire to a national sample of 3000 women aged 18-44 years (response rate 74%). Ten percent of the women aged under 25 and 4% of all respondents had sometimes used EC. Unmarried women were more likely to report having used hormonal EC than were married women, and nulliparous women reported more use than did parous women. However, no statistically significant difference in EC use among women with or without previous abortion history was observed. Older women were less aware of EC than of other methods; only one-third of the women aged over 35 knew about this method. Current contraceptive practices were otherwise similar among ever-users and never-users of EC, but EC users more commonly reported using condom together with oral contraceptives or IUD. Nobody reported using EC as her only contraceptive method. Our findings suggest that EC is appropriately used in Finland, but more information about use of the method is still needed.

Population-based enrolment of adolescents in a long-term follow-up trial of human papillomavirus vaccine efficacy

We evaluated a study setting for assessment of the long-term vaccine efficacy (VE) of human papillomavirus (HPV) virus-like-particle (VLP) vaccine against cervical carcinoma. A total of 22,412 16- to 17-year old adolescent women from seven cities in Finland were invited by letter to participate in a phase III study of a quadrivalent HPV (types 6, 11, 16, 18) VLP vaccine, between September 2002 and March 2003. A total of 30,947 18-year old women were invited to participate as unvaccinated controls. These women were asked about their willingness to participate in an HPV vaccination trial and to fill a health questionnaire. These three population-based cohorts of adolescent women, including women vaccinated with HPV vaccine or placebo vaccine and unvaccinated control women, are systematically followed over time. The study cohort database will be linked with the Finnish Cancer Registry using cervical carcinoma in situ (CIS) and invasive cervical carcinoma (ICC) as endpoints. Assuming that the cumulative incidence of CIS and ICC over 15 years is 0.45%, and that there is no loss to follow-up, and power of 80%, the determination of 70% total VE will require 3357 HPV vaccine recipients, 3357 placebo vaccine recipients, and 6714 unvaccinated controls. At the baseline, 2632 (12%) of the invited adolescents volunteered to the phase III vaccination trial, and 6790 (22%) responded to the questionnaire study. During a recruitment period of 10 months, 874 HPV vaccine recipients, 875 placebo recipients and 1919 unvaccinated controls were enrolled. Population-based enrolment of large cohorts of vaccinated and unvaccinated adolescents for passive registry-based follow-up with cervical carcinoma as the end-point is feasible and currently going on in Finland.

Emergency contraception among Finnish adolescents: awareness, use and the effect of non-prescription status

BackgroundAdolescents need to be aware that there is a method of preventing pregnancy even after an unprotected intercourse. Limited information is available on the awareness of young adolescents and the effects of selling emergency contraception (EC) over-the-counter, and the findings are controversial. The aims of this study were to investigate awareness and use of EC among Finnish girls aged 12–18 years in 1999–2003, and to assess the effect of the 2002 non-prescription status on the use.MethodsA self-administered questionnaire was sent to a population-based sample of 12–18-year-olds girls in 1999, 2001, and 2003. Response rate was 83% in 1999 (N = 4,369), 79% in 2001 (N = 4,024) and 77% in 2003 (N = 3,728), altogether N = 12,121. Logistic regression model was used to examine the association of unawareness and use of EC with socio-economic background and health behaviour.ResultsIn 2001, nearly all 14–18-year-olds and a majority of 12-year-olds were aware of EC. Among 12–14-year-olds, a slight increase in awareness between 1999 and 2003 was observed but this was not related to non-prescription status. Health-compromising behavior (alcohol use, smoking), dating and having good school achievement were related to higher awareness of EC.Nine percent of 14–18-year-olds had used EC once and 1% three times or more. No statistically significant change in EC use was found after non-prescription status. EC use increased with increasing alcohol consumption, particularly at age 14. Smoking, dating, and poor school achievement were related to increased use as well as not living in nuclear family. A lower use was observed if living in rural area or fathers education was high. Mothers education was not related to use.ConclusionAdolescent girls were well aware of the existence of emergency contraception even before the non-prescription status. Over-the-counter selling did not increase the use.

Trends in teenage fertility, abortion, and pregnancy rates in Iceland compared with other Nordic countries, 1976–99

Acta Obstet Gynecol Scand 2003; 82: 38–47.

Use of oral contraceptives by adolescents and its consequences in Finland 1981-91.

OBJECTIVES--To study use of oral contraceptives among Finnish teenagers during 1981-91 and how abortions, childbirths, sexually transmitted diseases, and cardiovascular diseases changed during this period. DESIGN--Biannual cross sectional surveys with mailed questionnaires from 1981 onwards and analysis of national statistics. SETTING--Finland. SUBJECTS--A nationwide sample of 14, 16, and 18 year olds. Sample size varied from 1249 to 3887 and response rate from 85% to 94%. MAIN OUTCOME MEASURES--Proportion taking oral contraceptive, fertility and abortion rates, hospital discharge rates, rates of sexually transmitted diseases. RESULTS--The proportion of teenagers taking oral contraceptives increased steadily. In 1991 the percentages among 14, 16, and 18 year olds were 2%, 18%, and 41% compared with 0.2%, 7% and 22% in 1981. Most users had a steady partner (80% of 16 year olds and 85% of 18 year olds). By 1989 rates of abortion had fallen from 12/1000 to 9.3/1000 in 16 year olds and from 25/1000 to 19.2/1000 in 18 year olds; fertility rates had fallen from 4.5/1000 to 2.3/1000 and from 23.5/1000 to 15.3/1000 respectively. Rates in 14 year olds fell only slightly. Gonorrhoea infection fell and HIV infection remained rare. Rates of hospital discharge after thromboembolic venous disease rose slightly. CONCLUSIONS--The increased use of oral contraceptives is the most likely explanation for decreasing abortion and fertility rates among teenagers. Increased reliance on the condom because of the threat of AIDS may increase unwanted pregnancies.

Risk-taking behaviour is more frequent in teenage girls with multiple sexual partners

Objective. To investigate associations between sexual behaviour and risk-taking health behaviour among adolescent females in our changing sexual culture. Design. A questionnaire study. Girls who had had multiple sexual partners (at least five in their lifetime or four during the last six months) were compared with those with fewer partners. Logistic regression was applied. Setting. The Adolescent Clinic, a primary healthcare unit in the city of Tampere, Finland. Subjects. A sample of 247 female clients aged 15–18 years who had experienced sexual intercourse. Main outcome measures. Contraceptive practices, substance use, and sexual attitudes. Results. Girls with multiple sexual partners (n = 69) and the reference group (n = 178) did not differ from each other significantly by age, age at menarche, or educational status. In univariate analysis, age at sexual debut, contraceptive practices, and various substance uses were strongly associated with having multiple sexual partners. Ever-use of emergency contraception was marginally associated, while ever-use of conventional hormonal contraception or condoms was not. In multivariate analysis, low age at sexual debut (OR 8.75 for age 11–13), omitting contraception at the most recent intercourse (OR 3.48), ever-use of withdrawal as a contraceptive method (OR 2.34), and repeated use of drugs (OR 4.10) were associated with having multiple sexual partners. Conclusion. Different types of risk-taking behaviour are still interlinked. In discussions with adolescents showing one type of risk behaviour health service providers should make an effort to identify other modes of risk-taking.