Social Determinants of Contraceptive Use Disparities Among Rural Adolescents: Addressing a Significant Research Gap

Background and Purpose: Teen births in the U.S. are higher than in other industrialized nations, and adolescents account for much of the nation’s rising STI rates (Martin et al., 2021; Osterman et al., 2023). Contraceptive use is the most effective strategy for preventing unintended pregnancies and STIs. Yet, rural youth report low contraceptive use combined with higher sexual activity than urban youth (Thompson et al., 2016). This, alongside unique barriers to contraceptive access, increase rural youths’ risk for unintended pregnancy and STIs. Unsurprisingly, teen birth rates and STI risk are higher among rural youth (Pinto et al., 2017; Sutton et al., 2019). Development of effective interventions in rural communities requires research on why contraception use is lower among rural youth, and variation therein. Guided by a social determinants of health (SDoH) framework, this study 1) examined differences in contraception use among subgroups of rural youth, and 2) tested for associations between rural adolescents’ SDoH and contraceptive use outcomes.

Methods: Data come from a state-wide survey of sexually active, rural students in the 8^th, 10^th, and 12^th grades (N=3,757). The sample was ethnoracially diverse, 47% female-assigned-at-birth, 22% gay/lesbian, bisexual, or questioning (LGBQ), and 15 years old on average. Contraception use was measured via two dichotomous indicators: condom use and any form of contraceptive use (condom, hormonal method, multiple methods) at last sex. Chi-square and independent samples t-tests (including effect sizes) assessed differences in contraceptive use across ethnoracial, socioeconomic, gender, and sexual identity subgroups. Logistic regression models examined associations between SDoH factors (economic, social/community, and healthcare access) and contraceptive use outcomes.

Results: Approximately 52% of rural youth reported condom use, and 78% any contraceptive use. Disparities by ethnoracial, socioeconomic, and sexual identity were observed across outcomes. Notably, rural youth identifying as Black, Asian, Indigenous, and Latino/a/x/e, LGBQ, and those experiencing poverty reported significantly lower contraceptive use compared to white and heterosexual youth, and those without poverty. Regression models accounting for youth characteristics found family instability, maltreatment, unsafe neighborhood, sexual coercion, and intimate partner violence—but not healthcare access—significantly reduced the odds of condom use, with family instability and maltreatment significantly reducing odds of any contraceptive use. LGBQ status consistently predicted lower contraceptive use net SDoH factors.

Conclusions and Implications: Contraception use is vital to understand, as it forms part of the pathway linking SDoH with adolescent pregnancy and STIs. Few studies have examined differences in, and drivers of, rural adolescent contraceptive use despite documented disparities in rural teen births and STI risk. We found evidence of disparities in rural contraception use, particularly for marginalized youth. Our findings suggest that these disparities are influenced by a complex interplay of social and economic factors, and existing healthcare resources may not sufficiently mitigate youths’ adverse living conditions. Additionally, this challenge may uniquely affect LGBQ youth. Addressing rural contraceptive use disparities requires comprehensive, multilevel interventions that are relevant and responsive to youths’ identities and social/economic contexts. Strategies for increasing contraceptive use and improving sexual and reproductive health outcomes among rural adolescents will be discussed.