Artigos

Conteúdo (article):

ASSOCIAÇÕES ENTRE SAÚDE MENTAL E COMPORTAMENTOS SEXUAIS DE RISCO EM ADOLESCENTES E JOVENS ESCOLARES
ASOCIACIONES ENTRE SALUD MENTAL Y CONDUCTAS SEXUALES DE RIESGO EN ADOLESCENTES Y NIÑOS ESCOLARES
ASSOCIATIONS BETWEEN MENTAL HEALTH FACTORS AND RISKY SEXUAL BEHAVIOR AMONG IN-SCHOOL ADOLESCENTS AND YOUTH

Sofia de Barros Robban. Programa de Pós-graduação em Enfermagem, Instituto Integrado de Saúde, Universidade Federal de Mato Grosso do Sul. E-mail: sofia.robban@ifms.edu.br. ORCID: 0000-0002-9503-7310
Bianca Cristina Ciccone Giacon-Arruda. Programa de Pós-graduação em Enfermagem, Instituto Integrado de Saúde, Universidade Federal de Mato Grosso do Sul. E-mail: biagiacon@gmail.com. ORCID: 0000-0002-8433-6008
Helder de Pádua Lima. Curso de Graduação em Enfermagem, Campus Coxim, Universidade Federal de Mato Grosso do Sul. E-mail: padua_helder@ufms.br. ORCID: 0000-0002-3795-6343
Samira dos Santos Chaves. Curso de Graduação em Enfermagem, Campus Coxim, Universidade Federal de Mato Grosso do Sul. E-mail: chavessamira86@gmail.com. ORCID: 0009-0003-3036-1683
Marcelle Paiano. Programa de Pós-graduação em Enfermagem, Universidade Estadual de Maringá. E-mail: marcellepaiano@hotmail.com. ORCID: 0000-0002-7597-784X
Thaylla Mwryha Maciel Bueno. Programa de Pós-graduação em Enfermagem, Instituto Integrado de Saúde, Universidade Federal de Mato Grosso do Sul. E-mail: thaylla.maciel@ufms.br. ORCID: 0000-0003-2024-6430
Guilherme Oliveira de Arruda. Programa de Pós-graduação em Enfermagem, Instituto Integrado de Saúde, Universidade Federal de Mato Grosso do Sul. E-mail: guilherme.arruda@ufms.br. ORCID: 0000-0003-1690-4808

Resumo
Objetivou-se analisar a associação de saúde mental com comportamentos sexuais de risco entre adolescentes e jovens escolares. Estudo quantitativo, transversal e analítico, com 191 adolescentes e jovens, de 14 e 24 anos, em estado do centro-oeste brasileiro. Foram desfechos o início sexual precoce, múltiplos parceiros, não uso do preservativo no último ano e na última relação, não uso de método contraceptivo (ou uso de método ineficaz) e o risco global para comportamento sexual de risco. Empregou-se Regressão de Poisson com variância robusta para verificar associações e estimar Razões de Prevalências ajustadas (RPaj). Observou-se associação de “comportamento de autolesão no último ano” com “Múltiplos parceiros sexuais” (p=0,024; RPaj=1,071), “não uso de preservativo no último ano” (p=0,022; RPaj=1,098) e “na última relação sexual” (p=0,024; RPaj=1,123), bem como, com o “risco global alto” para comportamentos sexuais de risco (p=0,002; RPaj=1,186). A autoeficácia associou-se ao início sexual precoce (p=0,006; RPaj=1,153) e à satisfação com a vida (p=0,009; RPaj=0,866) e sintomas de estresse, ao “não uso de método anticoncepcional (ou uso de método ineficaz)” (p=0,001; RPaj=1,187). Fatores de saúde mental podem ser considerados como indicadores para a ocorrência de comportamentos sexuais de risco entre adolescentes e jovens.
Palavras chave: Adolescente; Saúde do Adolescente; Comportamento Sexual de Risco; Saúde Mental; Autolesão.

Resumen
El objetivo fue analizar la asociación entre la salud mental y las conductas sexuales de riesgo entre adolescentes y jóvenes estudiantes. Estudio cuantitativo, transversal y analítico, con 191 adolescentes y jóvenes, de 14 y 24 años, de un estado del centro-oeste de Brasil. Los resultados fueron iniciación sexual temprana, múltiples parejas, no usar condón en el último año y durante la última relación sexual, no usar un método anticonceptivo (o usar un método ineficaz) y riesgo general de conducta sexual de riesgo. Se utilizó la regresión de Poisson con varianza robusta para verificar las asociaciones y estimar las razones de prevalencia ajustadas (RPaj). Se observó una asociación entre “conducta autolesiva en el último año” y “múltiples parejas sexuales” (p=0,024; RPaj=1,071), “no uso de condón en el último año” (p=0,022; RPaj=1,098) y “última relación sexual” (p=0,024; RPaj=1,123), así como con “alto riesgo general” de conducta sexual de riesgo (p=0,002; RPaj=1,186). La autoeficacia se asoció con la iniciación sexual temprana (p=0,006; RPaj=1,153) y la satisfacción con la vida (p=0,009; RPaj=0,866) y los síntomas de estrés, con el “no usar un método anticonceptivo (o usar un método ineficaz)” (p=0,001; RPaj=1,187). Los factores de salud mental pueden considerarse indicadores de la aparición de conductas sexuales de riesgo entre adolescentes y jóvenes.
Palabras clave: Adolescente; Salud del Adolescente; Comportamiento sexual riesgoso; Salud mental; Autolesión.

Abstract
The aim of this study was to analyze the association between mental health and risky sexual behaviors among in-school adolescents and youth. We conducted an analytical cross-sectional study with 191 adolescents and youth aged 14-24 living in a state in the Midwest region of Brazil. The outcomes were early sexual debut, multiple partners, condom non-use in the past year and at last sexual intercourse, non-use of contraception and use of ineffective methods and overall risk of sexual behavior. Poisson regression with robust variance was used to determine associations and calculate adjusted prevalence ratios (adjPR). “Self-injurious behavior in the last year” was associated with having “multiple sexual partners” (p=0.024; adjPR=1.071), “non-use of condoms in the past year” (p=0.022; adjPR=1.098), “non-use of a condom at last sexual intercourse” (p=0.024; adjPR=1.123) and “high-risk sexual behavior” (p=0.002; adjPR=1.186). Self-efficacy was associated with early sexual debut (p=0.006; adjPR=1.153), life satisfaction (p=0.009; adjPR=0.866), symptoms of stress, and “non-use of contraception (or use of ineffective methods)” (p=0.001; adjPR=1.187). Mental health factors may be considered indicators of risky sexual behavior among adolescents and youth.
Keywords: Adolescent; Adolescent Health; Unsafe Sex; Mental health; Self-Injurious Behavior.

Introduction
Brazil has more than 30 million people aged 10-19 years and almost 48 million people aged 10-24¹. The level of risky sexual behavior (RSB) is worryingly high among adolescents and youth, including condom non-use, associated with multiple sexual partners or not², and early sexual debut (prior to age 13)³, which can lead to adverse health outcomes.
RSB can be defined as engaging in sexual practices that can be harmful to health, especially sexual and reproductive health, as they increase the risk of sexually transmitted infections (STIs) and unwanted pregnancy5. A study in Brazil4 found that 18% of the 2,369 adolescents and youth surveyed did not use contraception at first sexual intercourse. Of these, 83.5% were aged 14-19 and 70% considered contraception unnecessary. Other RSBs included unprotected sex, concomitant use of alcohol or drugs, unplanned intercourse and increased use of emergency contraception4.
Studies have investigated the relationship between mental health and RSB6,7,8, showing that the latter was associated with suicidal ideation9. High levels of anxiety, depression and stress were related to lower frequency of condom use among Spanish adolescents6. A study in South Korea with students aged 12-18 reported an association between depression and pregnancy experiences in girls, with some sexually risky behaviors being associated with depression7. Research in Brazil with adolescents aged 12-17 found that one of the predictors of early sexual debut (ESD) in girls was having three or more common mental disorders8.
However, it is important to address other aspects of adolescent mental health when investigating factors related to RBS, including positive experiences, perceptions of life, self-perception and perceived self-efficacy. Along these lines, research assessing the subjective well-being (SWB) of adolescents can help understand the relationship between mental health and different outcomes. SWB represents the perception of happiness, life satisfaction and the synthesis between pleasant and unpleasant emotions10. However, while SWB is a priority area in epidemiological surveys of adolescent health indicators12, few studies have focused on this aspect among adolescents11.
Self-esteem among adolescents can help explain and represent the mental health and social skills of this group and, consequently, be included as a factor that potentially influences RSB. Self-esteem is also commonly associated with life satisfaction, level of depression, emotional adjustment and use of coping strategies13. It is also important to include overall self-efficacy in the analysis of factors associated with RSB, because this aspect encompasses the ability to handle stressful situations and affects one’s general motivational state, which can help explain certain health behaviors14.
It is also important to assess the association between mental health and RSB adjusted for other variables that may influence potential relationships, such as sociodemographic aspects and health and behavioral profiles15.
However, few studies have taken an integrated approach to investigating the relationships between different mental health factors and different RSBs among adolescents, resulting in a gap in knowledge. A recent national study analyzed mental health variables as potential factors associated with RSB but focused on aspects such as bullying and body image16. The relationship between self-mutilation and sexual onset and unsafe sexual behavior has already been studied17. This study therefore proposes to advance research in this area by investigating more mental health factors such as subjective well-being, self-esteem and self-efficacy, as well as self-harm, mental disorders, depression, anxiety, stress, attempted suicide and suicidal ideation.
The objective of this study was therefore to analyze the association between mental health and RSB among in-school adolescents and youth.

Method
Study design and location
We conducted an analytical cross-sectional study in two technical colleges in Coxim and Corumbá, in the north and northeast of the state of Mato Grosso do Sul, in Brazil’s Midwest region.

Participants
The study population consisted of 1,330 in-school adolescents and youth selected by convenience sampling. The following inclusion criteria were used: adolescents and youth aged 14-24 enrolled in one of the courses provided by the two colleges, regardless of study period (morning, afternoon or evening). The exclusion criterion was being absent on the days set aside for data collection.
Minimum sample size was estimated based on the following parameters: probability of event of interest occurring in the presence of an exposure factor of 55%, probability of event of interest occurring in the absence of an exposure factor of 30%, type 1 error of 5%, power of 80%, R-Squared of 0.25 and proportion of occurrence of the exposure factor in the sample of 40%. The minimum sample size was calculated to be 171 participants using G*Power version 3.1.9.7. The final sample was increased by 11.69%, totaling 191 participants.

Instruments and measures
The Brazilian Youth Questionnaire18 consists of 77 objective questions, 35 of which were removed because they are not related to the study topic. Six questions were added to obtain information on clinical variables, sleep and sedentary screen time (computer, tablet, television, videogames, cell phone). The wording of two questions (one about sexual orientation and the other about number of partners) was changed to make them consistent with the study objectives. The final instrument consisted of 49 questions. The questionnaire18 was administered to obtain data on RSB, sexual and reproductive health, sociodemographic characteristics, use of alcohol/drugs, self-esteem and perceived general self-efficacy. The same instrument was also used to obtain information on sex, sexual orientation, gender identity, suicidal thoughts and attempted suicide.
For the purposes of this study, perceived general self-efficacy was taken to be belief in one’s abilities to mobilize the motivation, cognitive, behavioral and affective resources needed to achieve a goal, handle specific situations or complete a task19. Data on perceived general self-efficacy were obtained from the original question 75 of the Brazilian Youth Questionnaire20 using the perceived general self-efficacy scale21, which has good internal consistency (α = 0.81)14.
Self-esteem was defined as how you perceive yourself, representing self-concept and self-worth based on positive (self-approval) and negative (self-deprecation) perceptions13. Data on self-esteem were taken from the original question 74 of the Brazilian Youth Questionnaire20 using the Rosenberg Self-Esteem Scale, which has good internal consistency (α=0.80)22.
The other sociodemographic variables were assessed using a questionnaire prepared by the researchers including questions about the following: work, children, physical and leisure activities, eating habits, COVID-19 and difficulty sleeping.
Sexuality was assessed using the Adolescent Student Attitudes to Sexuality Scale (E3AS), which was developed and validated in Portugal23. The E3AS consists of 34 items answered using a five-point Likert scale (ranging from “strongly disagree” to ”strongly agree”), with a total score of 170. The scale has good internal consistency (Cronbach’s alfa = 0.766). The E3AS scores were categorized based on the 25th and 75th percentiles: < 109.00 (up to 25th percentile) for “low”; ≥ 109.00 to < 124.00 (between the 25th and 75th percentiles) for “intermediary”; and ≥ 124.00 (75th percentile and above) for “high”.
Mental health was assessed using three scales. The first was the Subjective Well-Being Scale (SWBS). The version adapted for use in Brazil assesses how individuals rate their lives. At the time of validation, the scale obtained an overall reliability index of 0.86 and specific Cronbach\'s alpha values of 0.95, 0.95 and 0.90 for positive affect, negative affect and satisfaction with life, respectively. The total score is divided by the number of items, with a score of ≥ 4 in the three sub-scales being deemed high and < 4 being deemed low.
The second scale was the Depression, Anxiety and Stress Scale (DASS-21), adapted and validated for Brazilian Portuguese. The scale consists of 21 items (short form), distributed across three seven-item subscales used to assess symptoms of depression, anxiety and stress. The scores were categorized into five groups: normal, mild, moderate, severe and extremely severe. The exposure variables were dichotomized into “present” (mild to extremely severe) and “absent” (normal)24. The adequacy of the scale is high, with Cronbach\'s alpha values of 0.92, 0.90 and 0.86 for depression, stress and anxiety, respectively, indicating good internal consistency24.
The third scale was the Self-Injurious Behavior Scale (SIS), which was translated and adapted for use in Brazil25 and assesses the forms, means, frequency and reasons for self-harm. The criterion for self-injurious behavior was engagement in behavior that caused physical harm in the past year.

Variables
The outcome variables were: ESD (“yes” for onset at age 14 or younger and “no or has not initiated sexual intercourse” for those who initiated sexual intercourse at age 15 or older); multiple partners (“two or more partners” the last three months and “up to one partner or has not initiated sexual intercourse”); condom non-use in the past year (“never/few times” and “always/many times/has not initiated sexual intercourse”); condom non-use at last sexual intercourse (“did not use a condom/doesn’t recall” and “used a condom/has not initiated sexual intercourse”); and non-use of contraception (grouped into “use of ineffective contraception/does not use contraception” and “use of effective contraception/has not initiated sexual intercourse”). The data for these five variables were cross-referenced to create the variable “overall risk of sexual behavior” (“high risk”, when any of the five RSBs were present; and “low risk”, when RSBs were absent). The analysis included all respondents, including those who reported having not had sex, who were grouped into the absence of RSB and low overall risk categories.
The following mental health exposure variables were analyzed: positive affect (“high” and “low”), negative affect (“high” and “low”) and life satisfaction (“high” and “low”); perceived general self-efficacy (“high” – score of 33 or more, and “low” - score of less than 33, where the cut-off point was based on the median/50th percentile = score of 33); self-esteem (“high” – score of 30 or more, and “low” – score of less than 30, where the cut-off point was based on the median/50th percentile = score of 33); mental disorder (“yes” and “no”); symptoms of depression, anxiety and stress, treated separately (“present” and “absent”); suicidal thoughts (“yes” and “no”); attempted suicide (“yes” and “no”); and self-harm in the past year (“yes” for any type of self-harm and “no”).
The sociodemographic, clinical and behavioral/attitudinal variables were considered to have a potential influence on the relationship between mental health factors and RSB.
The sociodemographic variables were sex, age group, skin color, sexual orientation, religion, religiosity, family income, work and maternal and paternal education level. The clinical and sexual and reproductive health variables were chronic diseases, sexually transmitted infections, and history of pregnancy. The behavioral/attitudinal variables were leisure activities, physical activity, hours of sleep per night, difficulty sleeping, drug use in the past year and last month, attitude towards sexuality, future expectations and bad experiences.

Data collection
Meetings organized by the college principals were held to explain the study objectives, ethical issues and data collection procedures to the adolescents and youth. After the meeting, the adolescents and youth were invited to participate in the study. Informed assent and consent forms were handed out in-person in the classroom to all students who agreed to participate in the study. The latter were asked to give the informed assent form to their parents/guardians or sign the informed consent form, as appropriate.
After receiving the signed forms, an in-person meeting was scheduled with the participants in the college computer labs to complete the electronic questionnaire in the presence of the researchers. Average completion time was 40 minutes. Where it was not possible to complete an electronic version of the questionnaire, printed copies were made available.
Data analysis
A descriptive analysis of the data was performed using measures of central tendency and dispersion and absolute and relative frequencies to characterize the sample and present the frequency with which the events of interest occurred.
Bivariate analysis (Pearson\'s chi-squared test) was performed to identify the sociodemographic, clinical and behavioral variables that could potentially influence the relationship between mental health and RSB. Associations with a p-value ≤ 0.05 indicated potentially intervening variables.
Pearson’s chi-squared test and Poisson regression with robust variance estimates were used to identify the variables eligible for multiple analysis (those with a p-value ≤ 0.20).
Association was assessed using multiple Poisson regression with robust variance estimates. This method provides a more accurate estimate of prevalence ratios in cross-sectional studies with binary outcomes and minimizes the risk of overestimating the magnitude of associations, especially when the frequency of the event of interest is greater than 10%26. We chose to apply Poisson regression to outcomes with a prevalence of higher or lower than 10%.
P-values from the omnibus test and the Akaike information criterion were used along with the p-values for each variable to determine whether variables should be retained or removed. Adjusted prevalence ratios and respective 95% confidence intervals were calculated to determine the magnitude of association.
The data were coded in an Excel spreadsheet, recategorized and analyzed using SPSS version 20.


Ethical aspects
The study was approved by the human research ethics committee (reference code 5.941.387).
Results
The participants were predominantly female (n=117; 61.6%), aged 14-16 (n=87; 45.5%) and 17-20 (n=87; 45.5%), brown (n=91; 47.9%) and heterosexual (n=126; 67.0%). Around one-fifth of the sample (n=40; 21.2%) had a family income of between one and two minimum wages, 59.7% (n=114) had a religion, 50.3% had never or almost never sought a religion, 87.4% (n=166) did not work and 40.2% (n=72) and 41.0% (n=77), respectively, reported that their father and mother had completed secondary education. The average age of the participants was 17.17 years (minimum = 14; maximum = 24; SD = 2.12).
With regard to mental health, 39.3% (n=75) of the participants reported low self-esteem, 59.7% (n=114) had low self-efficacy, 60.2% (n=115) and 51% (n=98), respectively, showed high levels of positive and negative affect, 44.0% (n=84) reported low levels of life satisfaction, 68.6% (n=131), 63.9% (n=122) and 68.6% (n=131), respectively, had symptoms of depression, anxiety and stress, and 18.4% (n=34) reported having a mental disorder.
With regard to sexual behavior, 40.7% (n=77) of the sample reported having had sexual intercourse; of these, 79.2% (n=61) reported RSB. Overall, 13.8% (n=26) of the respondents reported ESD, 5.8% (n=11) had had two or more sexual partners in the last three months, 14.3% (n=27) had never used a condom or used one only a few times in the past year, 22.2% (n=42) did not use or could not remember if they used a condom at last sexual intercourse, 19.4% (n=36) had never used contraception or used ineffective contraceptive methods and 32.3% (n=61) reported having engaged in high-risk sexual behavior.
Self-efficacy and attempted suicide were included in the multiple analysis of ESD. In the table including multiple partners, self-esteem and self-harm during the past year were eligible for multiple analysis (Table 1).
(Table 1 here)
The variables self-harm during the past year and attempted suicide were included in the adjusted analysis of condom non-use during the past year and at last sexual intercourse. Negative affect was included in the analysis of condom non-use at last sexual intercourse (Table 2).
(Table 2 here)
Based on the results of the bivariate analysis of non-use of contraception, the variables life satisfaction, symptoms of anxiety and stress, self-harm during the past year and attempted suicide were included in the multiple analysis (Table 3).
Based on the results of the analysis of overall risk of sexual behavior, the variables positive affect, symptoms of stress, self-harm during the past year and attempted suicide were also included in the multiple analysis (Table 3).
(Table 3 here)
The results of the multiple analysis showed that self-harm during the past year was the only mental health variable linked to sexual behavior, being associated with the following RSBs: multiple sexual partners, condom non-use during the past year and at last sexual intercourse, and high-risk sexual behavior. The findings show that the adjusted prevalence of high-risk sexual behavior was 18.6% higher among individuals who reported self-harm during the past year than in those who did not (Table 4). Perceived general self-efficacy was associated with sexual debut, with adjusted prevalence of ESD being 15.3% higher among individuals who reported high self-efficacy than in those who had low self-efficacy (Table 4).
The adjusted prevalence of use of ineffective contraception methods was 18.7% higher among respondents who reported feeling symptoms of stress than in those who did not. It was also found that the prevalence of this outcome was significantly lower (13.4%) in participants who reported low levels of life satisfaction when compared to those with high life satisfaction.
(Table 4 here)
Discussion
In previous studies, samples were made up predominantly of girls27, 28, and the average age of participants was 1627,29. Most respondents were brown/black27,29, did not work27,30, had a family income of up to 2 minimum wages27, and had parents who had completed between 10 and 12 years of education31. In other studies, most of the sample were heterosexual5 and had some form of religion30,31.
A nationwide study16 with students from the seventh year of elementary school to third year of high school in public and private schools in Brazil’s regions and state capitals reported that RSB prevalence was 40.3%, which is higher than in the present study. It is important to mention however that prevalence of RSB (condom non-use at last sexual intercourse) was calculated based on the adolescents who reported having had a sexual debut (33.8%)16. In our study, 40.7% of the participants had initiated sexual intercourse. Of these, 79.2% reported engaging in RSB.
Our findings reveal a relationship between high perceived general self-efficacy and ESD, corroborating the results of a study28 with participants aged 13-19, which showed that adolescents with higher levels of self-efficacy were more likely to report having had sex. In contrast, another study with adolescents aged 14-1835 found that self-efficacy was a protective factor for health risk behaviors such as ESD.
Given that causality cannot be inferred from the research design used in this study, it is not possible to confirm whether adolescents who have had sex have greater perceived self-efficacy because they are more sexually experienced36 or if sexual debut occurred partly due to greater perceived self-efficacy and feeling confident and secure to start their sexual life28.
The variable most associated with RSB was self-harm, with magnitudes of association ranging from 7.1% (95%CI = 0.9% - 13.7%) for multiple sexual partners to 18.6% (95%CI = 6.7% - 31.9%) for overall risk of sexual behavior. Self-harm is a type of self-inflicted violence with or without the intention of suicide that consists of self-directed aggression, and is considered a public health problem17. It is believed that the associations with RSB shown by this study are permeated by determinants of self-injurious behavior, such as negative emotions and difficulties in regulating emotions, self-deprecation and high levels of impulsivity. Self-injurious behavior can be driven by social relationships and is often practiced in response to suffering.
Many self-injurious behaviors begin during adolescence, between age 12 and 1437. Self-harm among teenagers may be related to the stage of life they are going through, marked by feelings of vulnerability, discovery and conflict, which are part of the biopsychosocial development process and constitute a well-delineated phase with its own specificities31.
A systematic review17 revealed that self-harm is common among teenagers, with rates varying from 1% in Argentina and Portugal to 85% in the United States. Socioeconomic, family-related, behavioral and school factors influence self-harm, including sex, age group, income, parental education level and substance use. Some of these factors were analyzed in the current study as variables that influence the relationship between self-harm and RSB. The review also suggested that sexual debut (irrespective of earliness) and forced or unsafe sexual behavior were associated with self-harm. In line with these findings, a study of Australian adolescents found that self-harm was associated with initiation of sexual intercourse before age 15 among females (odds ratio = 2.39)38. In contrast, another systematic review did not report sexual factors as proximal predictors of self-harm39.
The fact that self-injurious behavior was the mental health factor most associated with RSB and high-risk sexual behavior means it is important to consider the publication of documents that act as guidelines on reporting self-harm, such as Law 13.819. Created in April 201940, this law provides for the mandatory reporting of all suspected and confirmed cases of self-harm by health and educational facilities.
A systematic review of cohort studies found an indirect association between SWB and ESD in adolescents, with factors such as family living arrangements potentially leading to more stable lives, improving SWB and, consequently, sexual behavior41. In contrast, another study that investigated “psychological well-being” in adolescents participating in a British birth cohort found that the association between “well-being” and sexual behaviors became non-significant when early life adversities were included in the analysis42.
Life satisfaction in the context of SWB refers to a judgmental process in which individuals assess their life on the basis of their own unique criteria, resulting in a comparison of perceived life circumstances with a self-imposed set of standards43. Our findings show that prevalence of contraception non-use or use of ineffective methods was lower among adolescents who had low levels of life satisfaction. While the data suggest that low life satisfaction may be a protective factor, we believe that other aspects should be considered.
Perception of life satisfaction may have been influenced by mood and level of self-esteem or self-efficacy at the time of self-assessment, or by reverse causality.
An integrative literature review15 found that the mental health factors depression, sadness and suicidal ideation were associated with RSB (condom non-use, ESD and multiple sexual partners) among adolescents. This contrasts with the current study, which found a relationship between symptoms of stress and self-harm and contraception non-use or use of ineffective methods.
The association between symptoms of stress and contraception non-use or use of ineffective methods is consistent with the findings of a previous study with adolescents aged 14-1844, which found that the non-adjusted prevalence of stress was 95.1% higher in respondents who did not use a condom at last sexual intercourse than in those who did. This effect value is considerably higher than the rate observed in the present study (18.7%); however, this rate was adjusted for life satisfaction (associated factor) and other intervening variables.
It is important to mention that the construct of stress adopted by the present study refers to a non-specific ongoing state of arousal, whose features include being tense or unable to relax, easily upset or irritable, easily startled, nervy, jumpy or fidgety, impatient, and intolerant of interruption or delay45. It can therefore be inferred that the presence of stress can increase predisposition to engaging in RSB, based on the relationship with attitudes and behaviors that are driven mainly by agitation and impatience.
Although the current study found no relationship between depression and RSB, a previous study7 found an association between these two variables.
This study has the following limitations: use of non-probabilistic sampling and the fact that the research design is limited in its ability to determine the direction of causality, given that relationships observed by this study may be bidirectional; and information bias may have occurred due to the length of the data collection instruments and the consequent waste of energy by participants. However, the use of self-administered questionnaires facilitated administration and ensured greater participant privacy.
The study findings highlight the importance of considering not only isolated behaviors, but also the broader contexts in which adolescents find themselves. The relationship between mental health and RSB demonstrates the need for integrated, multidisciplinary and intersectoral approaches to health promotion and prevention during this crucial stage of development. Further in-depth study using representative samples should be undertaken to obtain a more accurate understanding of these interactions. Our findings provide valuable insights for the development of intervention strategies and public policies aimed at promoting the health and well-being of adolescents and youth.
Acknowledgements
This work was undertaken with the support of the Federal University of Mato Grosso do Sul (UFMS/MEC), Coordination for the Development of Higher Education Personnel (CAPES – senior fellowship, funding code 001) and the Mato Grosso do Sul State Foundation for the Development of Education, Science and Technology’s (Fundect - Science Internship Program grant).

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