Poly-substance use and sexual risk behaviours: a cross-sectional comparison of adolescents in mainstream and alternative education settings

Although health inequalities among adolescents have been reported to be smaller than those observed for younger or older age groups [1, 2], it is known that health inequalities among adolescents are widening [3]. Health risk behaviours that are adopted during adolescence are known to track strongly into adulthood [4‐6]. These behaviours, which include smoking, heavy alcohol consumption and drug use, have all been shown to contribute to excess morbidity and mortality during adulthood [7]. Furthermore, it has been identified that tobacco, alcohol and drug use [8, 9] and sexual risk taking behaviour [9, 10] are two of the major causes of death and illness among adolescents and young adults. It is thus important to understand trends in health inequalities and the underlying social determinants of these in order to develop interventions and policies to reduce the effects of these upon population health [11, 12].

In order to understand factors exacerbating ill-health and perpetuating inequalities, calls have been made for more research focused upon the experience of vulnerable and socially excluded populations [13]. One population that is currently under-represented within the UK literature is adolescents attending Alternative Education Settings (AES). This is because most large scale population surveys of adolescent health in the UK are conducted in mainstream schools, thus excluding AES pupils [14]. AES are defined by the UK Department of Health as education arranged by local authorities for “permanently excluded pupils” and “other children who, because of exclusion, illness or other reasons”, for instance behavioural problems, learning disabilities and developmental delays, “would not receive suitable education”. AES are also attended by pupils “subject to a fixed-period exclusion of more than five days” [15]. The most common reasons for referral to AES in the UK are: physical assault of teaching staff and pupils; persistently disruptive behaviour in the classroom; risk taking behaviours such as youth offending, substance use and high risk sexual behaviour; and teenage pregnancy [16‐18]. Around 6500–7000 pupils in Scotland attend these settings each year, with published statistics aggregated to include both primary and secondary schools pupils [19].

Young people in AES, particularly those who are attending due to behavioural problems, disengagement from education and repeat exclusions from mainstream education settings (MES), may be particularly susceptible to adopting health risk behaviours. This is because health risk behaviours such as sexual risk-taking and substance use, which often start during adolescence, are associated with deprivation and social exclusion [20‐24]. For example, in a representative sample of 15–16 year olds in Scotland, higher sexual risk was associated with deprivation, living in a lone-parent household, low levels of parental monitoring, living in a care/foster home and having limited educational/career aspirations [25, 26]. These factors are also associated with school exclusion [27], which in turn can increase the likelihood of antisocial and risky behaviours [28]. Where this includes being exposed to and using substances, evidence from adolescent cohort studies suggests that this is associated with poorer sexual health outcomes for adolescents, including earlier sex, higher numbers of sexual partners, earlier pregnancies and risk of contracting sexually transmitted infections (STIs) [29‐32].

Although little is known about the health risk behaviours of AES in the UK, evidence utilising cross-sectional, self-reported data from young people in the USA, the Netherlands and New Zealand reveal high rates of health risk behaviours among AES pupils, including cigarette smoking [33‐36], alcohol consumption [33‐35], drug use [33‐37] and sexual risk behaviour (e.g. early sexual initiation, poor contraceptive use and increased levels of teenage pregnancy) [35, 38‐42]. The most rigorously conducted of these, the 1998 National Alternative High School Youth Risk Behaviour Survey (ALT-YRBS), used probability sampling techniques to create a nationally representative sample of pupils attending AES (mean age 16.8 years) in the United States [33]. The authors reported that: 64.1% of AES pupils smoked cigarettes; 64.5% consumed alcohol; 49.8% engaged in episodic heavy drinking (i.e. they had consumed 5+ drinks on two or more days in the preceding month); 84.5% had tried marijuana; and 53% reported being current users of marijuana. In all cases, males were significantly more likely than females to use substances [33]. Looking specifically at sexual behaviour, the ALT-YRBS study reported that: 87.8% of AES pupils were sexually active; 22% had been under the age of 13 at sexual initiation; and 50.4% had had four or more sexual partners. Around half (45.6%) of male AES and two thirds (63.9%) of female AES reported that they had not used condoms at last sexual intercourse [33]. Similar prevalence rates were reported in a New Zealand study of AES pupils [43].

Few studies have compared the health risk behaviours of AES and MES pupils [34, 36, 44]. Comparing the prevalence of health risk behaviours found within the 1998 ALT-YRSB with an age- and ethnicity- matched sample from the 1997 Youth Risk Behaviour Survey (YRBS), Grunbaum et al. [34] concluded that AES pupils were significantly more likely than MES pupils to smoke cigarettes (70.1% vs. 36.3%), consume alcohol (64.9% vs. 50.8%), use marijuana (53.9% vs. 26.2%), and be sexually active (85.5% vs. 48.3%). Sexually active AES pupils were also significantly more likely to report that they had had 4+ sexual partners (48.0% vs. 16%) and that they had not used a condom at last sexual intercourse (52.5% vs. 43.1%). The same pattern of significantly elevated risk has been reported in comparative studies of AES and MES pupils conducted in New Zealand [36] and Hong Kong [44].

The high levels of risk taking behaviours observed among AES pupils has resulted in their being described by society as ‘marginalised’, ‘disenfranchised’, ‘troubled’, ‘problem’, ‘bad’ and ‘failing’ youth [45‐50]. These descriptions not only stigmatise young people in AES, but act as a barrier to understanding the wider socio-environmental and cultural factors that may perpetuate health inequalities by placing the onus for poor health outcomes upon individual choices and behaviours [50]. However, both quantitative and qualitative evidence suggests that the socioeconomic and familial characteristics of pupils within AES may increase their propensity to display increased levels of health risk-taking behaviours. Young people attending AES disproportionately come from low-income and lone-parent households. They are also more likely to have been exposed to social and familial adversity (e.g. parental mental ill-health, parental substance use and domestic violence), been maltreated as a child and be known to social work and criminal justice systems [16, 51‐54]. These same factors have been identified by the UK Government as key drivers of social exclusion, and can increase the health risks of young people over time in the UK and beyond [55‐58]. Thus, it is likely that in addition to familial factors, school exclusion contributes to health inequalities for AES pupils by acting as a barrier to young people being exposed to prosocial peers and adults, resulting in them receiving less monitoring and supervision, spending more time with other disadvantaged pupils, and being at increased risk of exposure to risky behaviours, including sexual risk-taking behaviours [59].

Although the literature suggests that disadvantage across multiple social contexts may underpin the increased levels of health risk behaviour observed among AES, to date, studies exploring the antecedents of substance use and sexual risk taking behaviours among AES have focussed mainly upon exploring associations between interpersonal factors and health risk behaviours. Looking first at family factors, it has been reported that AES pupils who perceive greater family connectedness or caring have lower levels of marijuana and cocaine use [60], are less likely to be sexually active [40] and are more likely to use condoms during intercourse [40]. Beyond familial factors, several studies have identified the associations between peers, educational aspirations and substance use. For instance, alcohol and drug use among peers has been found to be associated with substance use among AES, and also contributed significantly to the experience of negative consequences associated with substance use in adulthood [61]. Social isolation (e.g. having fewer friends) was associated with an increase in the number of monthly substances used among AES [62], while having lower educational aspirations was associated with increased cocaine use [60].

While these findings provide valuable insight into the factors associated with elevated levels of risk-taking among AES they are limited by the fact that they focus solely upon explaining how single risk factors, for instance lack of parent-child connectedness, explain the increased levels of risk observed among samples of AES pupils. Within the public health literature it has been identified that the most effective behaviour change interventions are based upon understanding behaviours and the settings in which they occur [63]. The social ecological model (SEM) is a theoretical framework that can be used to demonstrate that human health is shaped through the complex interaction of individual- (e.g. sex, economic status, knowledge, attitudes and behaviour), interpersonal- (e.g. social networks, social and familial support), organisational- (e.g. polices within organisations that affect how services are delivered to individuals), community- (e.g. relationships between organisations and institutions) and policy- (e.g. local and national laws) factors [64]. In order to reduce risk taking among vulnerable and socially excluded groups such as AES pupils, the framework of the SEM can be used to help understand how factors operating at multiple levels contribute to health risk behaviours [65].

Drawing upon the SEM, this study aims to build upon existing research by using multivariable regression models to explore, for the first time, how individual (socioeconomic status, age and gender) and interpersonal (familial, educational and peer) factors contribute to substance use behaviours and sexual risk taking among AES and MES pupils. We also aim to explore whether differences in the underlying socio-economic, familial, educational and peer factors of AES and MES pupils can help to explain why AES have significantly higher rates of health risk behaviours when compared with their contemporaries in MES [50]. Other studies have not compared AES and MES across school settings in this way. In order to meet these aims, three research questions (RQ) will be addressed:

In answering these questions, we provide the first UK based estimates of substance use and sexual risk taking behaviour among AES pupils.

In order to better understand heath inequalities in the UK this paper drew upon the social ecological model to compare the levels of health risk behaviours exhibited by AES pupils [13] and explore the contexts in which these behaviours occurred [63]. Our results show that AES pupils are consistently more disadvantaged than their contemporaries in MES, and are more likely to: grow up in under-employed households; experience family breakdown; be looked after in residential or foster care and have limited educational aspirations (RQ1). Looking specifically at health risk behaviours, our results demonstrate that, compared with MES pupils, AES pupils have higher rates of PSU and more frequently engage in sexual risk behaviours, including having had penetrative sex, failure to consistently protect against pregnancy and STIs, increased numbers of sexual partners and having sex under the influence of drugs and alcohol (RQ2). These findings are consistent with the existing international literature identifying AES pupils as a vulnerable population of young people [16, 51‐54] who exhibit high levels of health risk behaviours [34, 36, 44].

The absolute rates of health risk behaviours that were seen among our sample are lower than those reported in the USA [34] and New Zealand [36]. Differences in sample characteristics may help to explain this finding. Our sample of AES pupils consisted of pupils who were excluded from MES as a result of SEN and/or SEBD. In contrast, the data that was generated from the USA focussed upon pupils in schools which served as alternatives to expulsion or imprisonment, or provided remediation or rehabilitation for pupils with SEBD [34], while the data from New Zealand focussed specifically upon young people with substantial histories of school refusal or exclusion [36]. It is possible that including SEN pupils within our sample of AES may have diluted the levels of risk taking observed as it is known that while SEN pupils have significantly elevated levels of health risk behaviours compared to MES, the greatest levels of risk are seen for SEBD pupils [14]. However, while we report lower levels of risk among our AES sample, it is important to note that the same pattern of elevated risk is present for AES when compared with MES.

There have been a number of studies which have identified that AES pupils exhibit significantly higher levels of health risk behaviours than MES pupils, however, to our knowledge there have been no studies that have focussed upon identifying why AES pupils are significantly more likely than their contemporaries in MES to use substances and engage in earlier and risky sex [50]. In this study we used multivariable analyses to show for the first time that increased rates of sexual activity and failure to consistently protect against pregnancy and STIs among AES pupils can be fully explained by the combined effects of socioeconomic, familial and educational disadvantage among AES pupils (RQ3). These findings are in line with the extant literature showing that deprivation, living in a lone-parent household, having low levels of parental monitoring, living in a care/foster home and having limited educational/career aspirations are all significantly and independently associated with earlier and riskier sexual behaviour among adolescents [25, 26]. However, where our findings add to the evidence base is by identifying that it is the accumulation of these risk factors that underscores the inequalities in sexual health outcomes observed between AES and MES pupils.

Whereas our results demonstrate that increased levels of sexual risk taking in AES versus MES pupils can be explained by the greater levels of disadvantage among AES pupils, our results demonstrate that the increased risk of PSU in AES versus MES pupils cannot be fully explained by differences in the socio-economic, familial, educational and peer backgrounds of these pupils (RQ3). That increased rates of PSU among AES pupils were only partially explained by the explanatory variables investigated suggests that PSU may be attributable to other unmeasured factors. Evidence from the international literature suggests that substance use amongst AES pupils is associated with mental health difficulties, juvenile offending and childhood abuse histories [37‐39, 60, 77], which were not investigated in our study. For instance, it has been demonstrated that among AES pupils: inhalant use is associated with depression and carrying a weapon during adolescence [37]; alcohol use is associated with a history of coercive sexual experiences [39]; and cannabis, cocaine and codeine use by young women is associated with a history of being sexually abused [77]. Further research should investigate the effects of these socio-environmental factors on AES pupils’ health risk behaviours in order to help feed in to future intervention development. School-effects research is also needed to understand how organisational factors such as learning cultures and peer mix within AES settings may serve to protect against or accentuate exposure to health risk behaviours.

AES pupils are a particularly vulnerable group, and this paper provides the first UK evidence of the substantial health gap between AES and MES pupils. For sexual risk, differences between AES and MES pupils can be explained by the combined effects of socioeconomic, familial and educational disadvantage experienced by AES pupils. Thus, evidence-based interventions to improve the sexual health of AES, especially those related to raising educational aspiration and minimising intentions towards early pregnancy and parenthood, may be particularly beneficial among AES. As an increased risk for PSU remained for AES vs MES pupils after adjusting for these factors and the influence of peer behaviours, further research is needed to explore additional factors that may help attenuate PSU, such as attitudes to risk, mental health difficulties, juvenile offending and abuse histories.

Our findings highlight the need for bespoke intervention development and feasibility work to learn how best to support pupils in AES to reduce health risk behaviours. Beyond this, policy makers should be aware of and act on the evidence that broader social changes are required to reduce the marginalisation and social exclusion of young people excluded from MES.