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The importance of condom distribution in schools to prevent the rise of teenage pregnancy

  1. Survey items covering attitudes, knowledge and perceptions generally used Likert-scale response alternatives.
  2. In 10 percent, students have access only with written permission of their parents "opt-in". Bell is a senior statistician, Sandra H.
  3. To understand the decline in condom use, the authors conducted focus groups with groups of students and examined schoolwide survey data.

March 29, 1998 DOI: Results There was no significant change over time in the percentage of males or females who had ever had vaginal intercourse or who had had vaginal intercourse during the year prior to the survey. On the other hand, female respondents showed no significant change in their condom use. The self-reported likelihood of using a condom for vaginal intercourse during the following year did not change significantly for students who had had vaginal intercourse, but it increased dramatically for those who had never had vaginal intercourse.

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The students' attitudes toward sex and condom use either remained the same between surveys or changed in a direction favoring less sexual behavior and greater risk prevention.

Conclusions The condom availability program appears not to have produced an increase in sexual activity among high school students, and it appears to have led to improved condom use among males. The apparent strong effect on students' intention to use condoms and on males' use at first vaginal intercourse suggests that such programs may have a particular impact on the least sexually experienced adolescents.

Family Planning Perspectives, 1998, 30 2: While some districts have considered such programs and decided against them, 1 by early 1995, at least 431 schools in 50 school districts had established programs making condoms available to students.

Opponents, however, argue that such programs lead students to believe that schools condone their engaging in sexual activity, and thus encourage students to have sex.

These opposing, but not mutually exclusive, views raise important questions about program impact.


The American Academy of Pediatrics, in addition to stating that schools are an appropriate site for condom availability programs, has called for research to evaluate such programs. We report on changes in sexual behavior and condom use, and on changes in knowledge, attitudes and perceptions related to sexual activity. Methods Program Description We examined the condom availability program in an urban high school that serves a racially and socioeconomically diverse community in Los Angeles County.

Not all teenagers are sexually active. The consequences may be for a lifetime. A can was placed next to each basket with a sign requesting that students leave a quarter for each packet they took. Implementation of the program was publicized within the school. The district had an existing ninth-grade health curriculum that covered sexual behavior and risk prevention and an AIDS Awareness Week that included assemblies and other educational programs.

No new curricula were added to supplement the condom program. Unlike many condom availability programs, this one did not require parental consent, so all students were allowed to take condoms. During the first year of the program, between 1,800 and 2,000 condom packets were taken each month, and almost no money was collected. Respondents completed an anonymous, self-administered survey during a regular class period and sealed it in an opaque envelope.

Survey administrators unaffiliated with the school district proctored the classes. Consent and administration procedures received Human Subjects Protection Committee approval. The baseline and follow-up surveys covered demographic information; knowledge, attitudes and beliefs about sex, HIV and other STDs, pregnancy and contraception; specific sexual behaviors; and condom use.

Separate versions of the survey for males and females were identical except for appropriate differences in pronouns and in sexual behaviors.

To minimize confusion about types of sexual behaviors, we used both precise technical language and anatomic descriptions, and we avoided euphemistic language. For example, the male version of the survey included the question, "How old were you the first time you had vaginal intercourse put your penis in a girl's vagina?

Making condoms available in schools

The survey covered lifetime history of vaginal intercourse, as well as history of vaginal intercourse during the prior year; for other sexual activity, questions covered experiences during the prior year. For some statistical analyses, we divided students into those who had ever had vaginal intercourse and those who had not.

Although students who had never had vaginal intercourse may have engaged in other sexual activities, 11 we were unable to divide the students into those who had or had not engaged in any activities for which condoms are generally recommended including anal intercourse and fellatio because the survey did not cover lifetime history of all such sexual activities.

For an analysis of those students who had recently initiated vaginal intercourse, we included students whose current age and age at first vaginal intercourse were the same or one year apart. Survey items covering attitudes, knowledge and perceptions generally used Likert-scale response alternatives. Response alternatives for attitude items included "strongly agree," "sort of agree," "uncertain," "sort of disagree" and "strongly disagree.

Prior to administration of the baseline survey, the school district sent parents a letter informing them of the study and giving them the opportunity to withhold permission for their children to participate by signing a form passive consent.

This procedure was selected by the school district superintendent, in consultation with the school board, because it was the standard approach to school surveys in the district.

For the follow-up survey, the research team used active consent parents signed a form to allow their children to participateafter discussions with some parents in the district who the importance of condom distribution in schools to prevent the rise of teenage pregnancy active consent and with the approval of the superintendent.

This procedure was explained in letters and information sheets sent to parents and distributed to students. For both the baseline and follow-up surveys, students gave oral consent to participate, and their names were not recorded.

Respondents were instructed to skip questions they preferred not to answer. In addition, the section covering respondents' own sexual behavior began with instructions telling them what page to turn to if they preferred to skip the entire section. Shortly before the follow-up survey was administered, a group of parents contended that specific questions about students' sexual activities were inappropriate and threatened the welfare of students exposed to the survey, and also argued that the active consent process was inadequate.

These parents sought a temporary restraining order against the survey, and the controversy prompted media attention about the study. After hearing the case, the court ruled that active consent and the privacy procedures implemented offered appropriate protection for the rights of parents and students, and the survey was administered as planned.

The switch to an active consent procedure and the local controversy may have led to selective participation in the follow-up survey; as a result, the follow-up sample may have differed from the baseline sample in terms of characteristics that should not have been affected by the program, but that may have been related to outcomes of interest.

Thus, to adjust for differences in response, we developed analysis weights that assumed the distribution of certain demographic and other characteristics of students in the school was the same for both years. We also assumed that given the extremely high response rate at baseline, the baseline respondents provided an adequate approximation of the true distribution of characteristics among students attending the school.

To calculate the actual weights, we analyzed all responses from the baseline and follow-up surveys combined. Characteristics that could have been affected by the condom program e.

Because most analyses were done separately for males and females, the weights were computed separately by sex. The weighting strategy assumes that once we control for the predictors in the logistic regression model, responses occur at random. Table 1 indicates that the weighted follow-up data match the baseline data for key sample characteristics. We compare distributions of outcomes at follow-up with distributions at baseline.

We report percentages for binary outcomes and means for nonbinary outcomes. All results from the follow-up survey are based on the weighted data. Because two-sample t-tests and chi-square tests do not work properly for weighted data they are generally too liberalwe used corrections based on the linearization method. This method produces asymptotically consistent standard errors that serve as the basis for all inferences reported in this article. Consequently, our statistical tests, which do not account for overlap, would tend to be conservative.

Impact of a High School Condom Availability Program on Sexual Attitudes and Behaviors

Analysis of multiple questions about experience with specific sexual behaviors indicated that response inconsistencies were rare. Sample Approximately 2,500 students were enrolled in the school at the time of the survey. An alternative school for about 125 students considered at high risk for dropping out of school was not included in the evaluation. Fifteen percent of eligible students were absent on the day of the follow-up survey.

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While the controversy over the survey undoubtedly influenced some parents' and students' decisions about participation, the magnitude of influence is not clear, given that comparable response rates have been reported for other school surveys on sensitive topics primarily drug use behaviors conducted with active consent.

Students participating at follow-up were more likely to have parents who were college graduates and were more likely to expect to attend graduate or professional school than were those surveyed at baseline. Results Sexual Behavior There was no significant change between the baseline and the follow-up surveys in the percentage of males or females who had ever had vaginal intercourse or who had had vaginal intercourse during the prior year Table 2. There was also no significant change in the percentage of males who reported engaging in each of the remaining sexual activities during the prior year.

The percentage of females reporting fellatio with ejaculation, cunnilingus with a male partner and anal intercourse increased significantly, generally moving closer to percentages reported by males. Among students who had engaged in vaginal intercourse at least once, there was no significant change in the reported number of times that either males or females had done so during the prior year Table 3.

There were also no significant changes in the number of times respondents had engaged in any other opposite-sex sexual activities for the prior year among respondents who had engaged in them at least once.

Frequencies of same-sex sexual activities were not analyzed because reported prevalence was too low to obtain meaningful results. In addition, no significant changes in sexual behavior were found by grade not shown.

There was no significant change in any of these measures of condom use for vaginal intercourse among females. There also was no significant change in either males' or females' condom use during male-female fellatio with ejaculation.

Condom use among males who reported engaging in same-sex fellatio with ejaculation and same-sex anal intercourse was not analyzed because of small sample sizes. Among students who had ever had vaginal intercourse, the expected likelihood of using a condom for vaginal intercourse during the following year did not change significantly: Attitudes, Self-Efficacy and Knowledge Males agreed more at follow-up than at baseline with the statement "People my age should not be having vaginal intercourse," while females did not change their level of agreement Table 5.

Both males and females were more likely at follow-up than at baseline to disagree that having condoms makes one more likely to have vaginal intercourse. In response to the item "Imagine you and your partner both want to have vaginal intercourse. You really want to use a condom but your partner doesn't want to. What do you think would happen? The importance of condom distribution in schools to prevent the rise of teenage pregnancy knowledge increased over time for two of the three true-false items, and there was a corresponding reduction in responses of "don't know" Table 6.

Notably, the only item that showed an increase in incorrect answers between the baseline and the follow-up surveys concerning the permeability of natural and latex condoms to HIV was a topic not addressed on the information sheet included in the condom packets. The measure of the perceived percentage of students in the respondents' grade who used condoms every time during vaginal intercourse increased from 2.

Measures of perceptions of the proportion of friends of either sex who had ever had vaginal intercourse remained the same 2. Discussion Our results show a substantial increase in the percentage of males who reported that they used condoms every time they had vaginal intercourse in the year following the introduction of a school-based condom availability program. This finding is reinforced by evidence that at follow-up, males who recently had initiated vaginal intercourse were more likely to have used a condom at their first intercourse than were males who recently had initiated intercourse at baseline.

However, there was no similar increase in condom use among females. One reason for this difference between males and females may be that the types of sexual activity assessed in this study did not necessarily take place with partners from the same school.

Our findings suggest that interventions aimed at increasing condom use may be effectively targeted at males. This is not to say that such interventions cannot successfully be targeted at females, but greater effort may be necessary to address issues that may influence females more than males, such as embarrassment when obtaining condoms, 17 discomfort when proposing condom use to partners and a particular interest in contraceptive methods that are most effective in preventing pregnancy e.

In assessing changes in sexual behavior associated with condom availability programs, the question often arises whether condom availability programs encourage some students to engage in sexual activities from which they might otherwise refrain.

Another important question is whether the ready availability of condoms encourages those who are engaging in a sexual activity to do so more often or with more partners. With regard to vaginal intercourse, we found neither to be the case for males and females. Among males we found no evidence of either outcome for the other sexual behaviors covered in the study i. However, at follow-up, a higher percentage of females reported having engaged with male partners in sexual activities other than vaginal intercourse.

These increases could reflect changes in behavior associated with the program or with some other factor. However, if a condom program were to increase the number of students engaging in sexual activity, one might expect it to have its biggest impact on activities most associated with condom use—namely, vaginal intercourse. These findings could also reflect a greater willingness among females to report these activities at the follow-up survey, perhaps because of the schoolwide experience from the baseline survey that answers did in fact remain anonymous and confidential.