Objectives. To determine what students know about a condom availability program in their high school, how they react to the program, whether they obtain condoms from it, and what they do with these condoms.
Design. Self-administered anonymous survey conducted 1 year after the program began.
Setting. An urban California school district.
Participants. A total of 1112 students, 9th through 12th grade, 59% of eligible students present on the survey day.
Main Outcome Measures. History of obtaining condoms from the program, use of these condoms, knowledge about the program, and attitudes toward the program.
Results. Forty-eight percent of students had personally taken school condoms, and another 5% had gotten them from someone else, for a total of 53% who had obtained school condoms. Seventy percent of nonvirgins and 38% of virgins obtained condoms. Males were more likely than females to have obtained condoms (60% vs 45%). Fifty-four percent of students who had obtained school condoms had used them for sexual activity: 52% had used them for vaginal intercourse, 7% for anal intercourse, and 4% for fellatio. Students also explored school condoms without having sex, eg, removing them from the packet, putting them on fingers, or putting them on their penis or a partner's penis. Thirty-four percent of students who had used a condom for vaginal intercourse during the previous year had obtained the condom they last used from school, with more males than females reporting the school as their source (41% vs 26%).
Eighty-eight percent of students knew that all students were allowed to obtain condoms, and 74% knew that parental permission was not required. Students generally supported the condom program: 88% thought the school should give out condoms, and 79% thought that if the school were to require parental permission for students to get condoms, students would get them less often than with the present system (which does not require permission). Thirteen percent agreed and 71% disagreed that “having condoms available at school makes it harder for someone who doesn't want to have sex to say no.”
Conclusions. Providing high school students with direct access to condoms leads to widespread use of school condoms, both for sexual activity and for exploratory activities that familiarize students with condoms. Condoms are of interest to both students who have and students who have not engaged in sexual activities for which condoms are recommended.
During the past several years, school districts have been establishing condom availability programs to prevent the spread of human immunodeficiency virus and other sexually transmitted diseases and to reduce the number of unintended pregnancies among their students.
In contrast to programs that provide various forms of contraception at school-based clinics, condom programs provide only condoms and generally make them available at sites other than (or in addition to) clinics. The American Academy of Pediatrics,1 the American College of Obstetricians and Gynecologists,2 and the American School Health Association3 have stated that schools are an appropriate site for condom availability programs, and the American Academy of Pediatrics has called for research on the subject.1
As of June 1995, at least 37 school districts or individual schools in the United States had approved condom availability programs, and schools in at least 19 districts (but probably many more) were making condoms available through school-based health clinics. At least 55 other school districts had rejected condom programs.4
Condom availability programs differ in ways that can greatly influence how community members react to them and whether students use them. Some require written parental permission to participate (active consent), some allow all students to participate unless parents sign a written refusal (passive consent), and others do not offer parents the option to refuse (no consent). Schools that require active or passive consent must authorize an adult (eg, teacher, school nurse) to check a list or card before giving out condoms. Schools without consent requirements have more flexibility. They can make condoms available in unattended sites, let staff provide them without checking names, and sell them through vending machines. Some schools require staff to provide counseling to students who ask for condoms, and some institute formal educational programs.5
Because of the variety of approaches used in implementing condom availability programs, it is necessary to study different types of programs to gain a full appreciation of their potential impact. In particular, it is important to study programs that do not restrict access to condoms so that we can gain an understanding of what the maximal impact is likely to be. A study that measured the number of condoms distributed per student in schools across the United States found that programs with easier access (eg, condoms available in bowls) distributed the largest number of condoms.6 Although there have been some preliminary studies of programs that require students to obtain condoms from staff7-9 and some studies of students' attitudes toward condom programs in schools without a program,10,11 we have found no published studies that have been conducted in programs with unrestricted access or that have reported data on multiple aspects of program impact.
We studied a high school condom program that makes male condoms available to all students; no parental consent is required, and no gatekeepers check identification cards or dispense condoms. In this article, we report on what students know about the condom program, how they react to it, and which students make use of it.
The condom availability program is located in an urban high school that serves a racially and socioeconomically diverse community in Los Angeles County.
The school district put together plastic packets containing two male condoms, an instruction sheet, and a card printed with the following message: “Condoms are not 100% effective in preventing AIDS/HIV, sexually transmitted diseases or pregnancy during sexual intercourse. Abstinence is! Not all teenagers are sexually active. THINK BEFORE YOU ACT! The consequences may be for a lifetime.”
Packets were available in baskets in four classrooms and outside the nurse's office; some of these sites were accessible at times when other people generally would not be around. A sign asked students to leave a quarter for each packet in a can next to the basket of packets. During the first year of the program, between 1800 and 2000 packets were taken per school month and almost no money was collected.
The district had a 9th grade health curriculum that already covered sexual behaviors and risk prevention and an annual AIDS Awareness Week with assemblies and other educational programs. No new educational programs were added.
The program began in April 1992. The data for this article come from a survey of students in grades 9 through 12, conducted 1 year after the program was initiated.
This article covers knowledge, perceptions, and use of the condom availability program; history of sexual activities; and demographics. All terms and concepts used in the survey were part of the district's 9th grade health curriculum.
Items covering attitudes and other nonbehavioral questions generally had Likert scale response alternatives. For the response alternatives that included “strongly agree,” “sort of agree,” “uncertain,” “sort of disagree,” and “strongly disagree,” we generally combined “strongly” and “sort of” when reporting results for “agree” and “disagree.” For a question on the potential impact of requiring parental permission to obtain school condoms, answer options included “more often,” “the same as before,” “less often,” and “uncertain.”
The survey covered history of various sexual activities during the previous year. It also covered lifetime history of vaginal intercourse (nonvirginity) but not lifetime history for other activities. For analytic purposes, we divide the students into virgins and nonvirgins, but of course, virgins can engage in other sexual activities for which condoms are generally recommended.12
Administration and Survey Response Rates
Respondents completed the 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. RAND's Human Subjects Protection Committee approved consent and administration procedures.
Parents were required to sign a form providing permission for their children to participate (active consent), and this was explained in letters and information sheets for parents and students. Respondents supplied oral assent, and the names of respondents completing the survey were not recorded. Respondents were instructed to skip questions they preferred not to answer.
A group of parents contended that specific questions about students' sexual activities were inappropriate and that the informed-consent process was inadequate. They sought a temporary restraining order against the survey. The controversy also prompted news media attention about the study. After hearing the case, the court ruled that the informed-consent and privacy procedures offered appropriate protection for the rights of parents and students, and the survey was administered as planned.
Approximately 2500 students were enrolled in the school. Students in classes teaching English as a second language (∼16% of the student body) and students in intensive special education classes were excluded from the study at the request of the principal. An alternative school for ∼125 students considered at high risk for dropping out of school was not included in the evaluation.
Fifteen percent of eligible students were absent. Of 1878 eligible students present, 1112 (59%) turned in usable surveys, 764 (41%) did not take the survey, and 2 turned in unusable surveys. Although the controversy 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.13-15
In addition to the 1-year follow-up survey covered by this article, we had conducted a survey just before the condom availability program was introduced. The same eligibility criteria were used for both surveys; however, the consent procedures were different. For the baseline survey, parents received a letter from the school district informing them of the study and giving them the opportunity to sign a form withholding permission for their children to participate (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. At follow-up, after discussions with parents who preferred active consent, the research team modified the consent procedures with approval from the superintendent.)
The baseline survey achieved a response rate of 98% of eligible students present on survey day. Therefore, we were able to use data from the two surveys to construct weights to adjust for the effects of selective participation resulting from the active consent procedures and local controversy. We developed analysis weights so that the weighted follow-up sample would represent the baseline sample in terms of several characteristics that should not have been affected by the program but may have been related to nonresponse at follow-up: gender, race/ethnicity, mother's education, father's education, grade, age relative to grade, educational expectations, self-reported grades, importance of religion in the respondent's life, and presence of two parents in the household. Characteristics that could have been affected by the condom program (eg, sexual history) were not used for creating weights.
We used logistic regression to generate the weights. The sample consisted of all surveys collected at baseline or follow-up, the dependent variable identified the survey wave, and the predictor variables were ones collected at each wave. We imputed wave-specific means for all missing values. The logistic regression produced predicted probabilities P̂i that an observation was obtained at follow-up as opposed to baseline. We transformed the predicted probabilities P̂ifrom the logistic regression into predicted response ratesr̂i = P̂i/(1 − P̂i) that measured the probability that a student would respond at follow-up. The follow-up weights are reciprocals of the predicted follow-up response rates–that is,wi = 1/r̂i. Because most analyses are performed separately for males and females, the weights were computed separately by gender.
Analysis of multiple questions about experience with certain sexual behaviors indicated that inconsistencies were rare. For example, among adolescents who indicated that they had engaged in vaginal intercourse one or more times during the previous year, <2% of respondents reported that they had never had vaginal intercourse (more than 10 items earlier).
We report results of weighted cross-tabulations (including φ coefficients) and weighted logistic regression. All statistical inference accounts for the weights through the use of linearization methods that produce asymptotically consistent standard errors.16 Computations were performed by the hreg and hlogit commands in Stata, version 3.1.17
Fifty-one percent of respondents were male. The sample was distributed evenly by grade: 9th grade, 25%; 10th, 27%; 11th, 25%; 12th, 23%. Eight percent described themselves as African-American, 10% Asian and Pacific Islander, 27% Latino, 48% white, and 7% Other. Fifty-six percent had at least one parent who was a college graduate; 71% reported that English was the language most often spoken at home; 47% were living in a two-parent household; 18% expected not to graduate from college, 31% expected to graduate from college, and an additional 51% expected to attend graduate or professional school. Fifty-one percent had had vaginal intercourse (were nonvirgins). Forty-nine percent had had vaginal or anal intercourse during the previous year.
Awareness of the School's Condom Availability Program
Respondents had an accurate perception of the school's condom availability program. Eighty-eight percent agreed that “students of all ages and in all grades are allowed to get condoms at my school.” Seventy-four percent knew that the school does not require parents' permission to take condoms, and most of the rest (19%) were uncertain.
Experience With School Condoms
Forty-eight percent of the students had personally taken school condoms during the school year, and another 5% had not personally taken them but had obtained them from someone else, for a total of 53% who had obtained school condoms (Table1). Males were more likely than females to have obtained condoms, and the likelihood of obtaining them increased with grade. Among racial/ethnic groups, African-Americans were the most likely to have obtained school condoms and Asians and Pacific Islanders were the least likely. Nonvirgins were much more likely to have obtained condoms than virgins (70% vs 38%,P < .001, φ = −.32). Students who had had vaginal or anal intercourse during the previous year were much more likely to have obtained condoms than those who had not (71% vs 37%,P < .001, φ = −.34).
Among adolescents who had personally picked up school condoms during the school year, 31% had taken 1 packet (each packet contained 2 condoms), 40% had taken 2 to 5, 13% had taken 6 to 10, 9% had taken 11 to 19, and 7% had taken 20 or more. Most students who had not had vaginal or anal intercourse during the previous year took only 1 condom packet (49%) or 2 to 5 packets (43%).
Fifty-seven percent agreed that “it's fairly easy to take condoms at school without someone seeing you.” Adolescents who had personally taken condoms were more likely to consider it easy than those who had not taken them (71% vs 44%, P < .001, φ = −.28). (Fourteen percent of the former group were uncertain, compared with 33% of the latter group.)
Forty-six percent “would be embarrassed if someone saw me taking condoms at school.” Potential embarrassment was more likely to be reported by virgins than by nonvirgins (53% vs 38%, P< .001, φ = −.15) and by adolescents who had not taken school condoms than by those who had (55% vs 36%, P < .001, φ = .19). Females also were more likely to be embarrassed than males (51% vs 42%, P = .020, φ = −.08).
Seventy-nine percent agreed that “it's OK to take them without paying if you don't have the money.”
Among students who had obtained condoms, 77% had read the accompanying information sheets. Among students who had read the sheets, 17% “didn't learn anything,” 46% “learned a little,” 23% “learned a lot,” and 14% did not “remember much about what they [the information sheets] say.” Thirty-three percent of students who had not gotten condoms had also read the information sheets. Eighteen percent of these students “didn't learn anything,” 46% “learned a little,” 14% “learned a lot,” and 22% did not “remember much.”
Use of School Condoms
Thirty percent of all students (Table 1), 54% of students who had obtained school condoms, and 78% of nonvirgins who had obtained school condoms had used them for sexual activity. Specifically, among students who had obtained condoms, 52% had used them for vaginal intercourse, 7% for anal intercourse, and 4% for fellatio.
Among students who had used school condoms for sexual activity, 31% had used a school condom 1 time, 37% 2 to 5 times, 16% 6 to 9 times, 10% 10 to 19 times, and 6% 20 or more times.
Students also used condoms for other activities, with virgins reporting more exploratory use than nonvirgins (Table2).
Among students who had had vaginal intercourse in the previous year, 55% had used school condoms for vaginal intercourse. For male–female fellatio with ejaculation and male–female anal intercourse, the comparable percentages were 5% and 25%, respectively.
Adolescents who had used a condom for vaginal intercourse during the previous year obtained them from a variety of sources. Thirty-five percent of students who had used a condom for vaginal intercourse during the previous year had obtained the condom they last used for vaginal intercourse from school, with more males than females reporting the school as their source (42% vs 26%, P = .006, φ = −.17). Thirty-three percent had obtained the condom from a store, 14% from a friend, 4% from a parent, and the remaining 14% from other sources.
For the subsample that had used a condom for vaginal intercourse during the previous year, male gender was the only characteristic in a logistic regression that significantly predicted that the student had obtained the condom last used for vaginal intercourse from school (odds ratio: 2.56, 95% confidence interval: 1.53–4.29, P < .001). The other variables in the regression, including grade, race/ethnicity, number of parents in the household, language spoken at home, and parental education, were also not significant in bivariate analyses.
Attitudes About the Condom Program
Students generally supported the condom program. Eighty-eight percent of the students thought the school should give out condoms, with 75% of these students reporting they liked the way the school organized its program. Sixty-five percent would like condoms to be available in more locations at school, such as in the gym and in more classrooms, and 68% thought they should be available through vending machines in restrooms.
Students strongly opposed the idea that parental permission be required to obtain condoms. In response to the question, “Do you think that a parent's permission should be required for a student to get condoms at school?,” 75% answered “definitely not” and another 10% answered “probably not.” The rest were evenly split between those who had “no opinion” and those who “definitely” or “probably” supported a requirement for parental permission. This finding varied somewhat by whether the students had or had not gotten school condoms (probably or definitely not: 90% vs 81%,P = .002, φ = −.12) or whether they were virgins (82% vs 90%, P = .005, φ = .11). However, high percentages opposed parental permission in all subgroups.
If the school were to require parental permission for students to get condoms, 79% thought students would get them less often than with the present system (which does not require permission). There were no statistically significant differences based on whether students had obtained school condoms (78% vs 80%, P = .436, φ = .03) or were virgins (78% vs 81%, P = .391, φ = .03). Fifty-seven percent of respondents thought that students would use condoms less often if parental permission were required, 21% thought condom use would be unchanged, 9% thought they would use condoms more often, and the rest were uncertain. Seventy-four percent believed that there would not be a change in how often students would have vaginal intercourse, 9% thought the frequency would increase, and 7% thought it would decrease. Thirty-five percent thought there would be no change in the frequency with which students would discuss sexual issues with their parents, 28% thought they would discuss sexual issues less often, and 15% thought they would discuss sexual issues more often.
Perceived Impact of Program on Peer Environment
Thirteen percent agreed and 71% disagreed that “having condoms available at school makes it harder for someone who doesn't want to have sex to say no.” Seventy-six percent of students who had obtained school condoms and 79% of those who had used them for sexual activity disagreed as well. Females were more likely to disagree than males (77% vs 66%, P = .002, φ = .12). Sixty-two percent agreed and 13% disagreed that “having condoms available at school makes it easier to talk with your sex partner about using them.” There were no significant differences in the percentage of males and females who agreed (63% vs 61%, P = .598, φ = .02). Seventy percent of students who had obtained school condoms and 76% of those who had used them for sexual activity agreed.
High school condom availability programs were introduced only recently into schools in the United States. Despite much controversy and debate over these programs,5,18-23 little scientific information is available about them. In particular, little is known about how students react to these programs and the extent to which they make use of condoms.
Our study demonstrates widespread use of the program. Students knew the program existed and had an accurate view of how it functions. Approximately half had taken school condoms, and many were using them for sexual activities. Approximately half of nonvirgins had used school condoms for vaginal intercourse, indicating broad impact of the intervention.
However, school condoms were not being used for all forms of intercourse. Among students who had engaged in fellatio with ejaculation and anal intercourse during the previous year, very few had used school condoms for these activities. School condoms were lubricated, making it unlikely that they would be used for fellatio. (If schools want to encourage use of school condoms for fellatio, they may need to provide unlubricated condoms in addition to or instead of lubricated condoms, along with education about their proper use.)
Results from this study reinforce previous findings suggesting that condom availability programs receive high levels of support from students.7,10,11 However, the students would have preferred condoms to be available in more places, such as bathroom vending machines. Embarrassment and concern about being seen obtaining condoms (whether from a store or school program) have been noted in other studies as one reason adolescents do not obtain them.7,24-26 Our study supported these findings, with many of the students reporting that they would be embarrassed if they were seen taking condoms. This suggests that programs would reach more students if condoms were made available in a discreet manner.
As had been found in previous studies,7,9 male students were more likely than female students to have taken school condoms. Male students were also nearly twice as likely to report having used school condoms for sexual activity, even though they were only ∼20% more likely to report having engaged in vaginal or anal intercourse during the previous year. Consistent with these findings, female students were more likely than male students to report that they would feel embarrassed if seen taking condoms at school. Condoms have been traditionally considered a male form of contraception, and our findings may indicate that condom programs will have more of a direct effect on males in a school. Nonetheless, it may be possible to create an atmosphere in which females who want to use the program will feel more comfortable doing so. Efforts may be necessary to address issues that may inhibit females' use of the program, such as embarrassment, discomfort proposing condom use to sexual partners, and selection of methods that prevent pregnancy rather than pregnancy anddisease.
More than two thirds of 9th graders who had had vaginal or anal intercourse in the previous year had used school condoms for sexual activity, compared with slightly more than half of comparable 12th graders. Although this could indicate less contraceptive use by older students, it could also reflect that 12th graders have greater access to obtaining condoms outside of the school or that they are more likely to use other forms of contraception. Regardless of the reason, our results suggest that a school condom program may be used more by younger students, who have less access to other sources of any form of contraception.
Few previous studies have examined or documented use of condoms (from any source) by students who are virgins. We found that some virgins engaged in exploratory use of school condoms without having intercourse, raising questions about the long-term consequences. Greater familiarity with condoms could lead to greater likelihood of their use by virgins who later engage in intercourse, especially at first intercourse. The opportunity to become familiar with condoms in advance of actual use could also result in more students using condoms properly. These possibilities are worth addressing in prospectively designed studies in the future.
The use of condoms obtained in school was probably higher in the program we studied than it would have been in programs that limit participation or restrict access. Nearly double the percentage of students in our study had taken condoms, compared with students at a school where condoms were made available through faculty members.9 One concern raised about programs that make condoms freely available without adult monitoring is that a few students may empty baskets of all the condoms and leave none for other students. The widespread acquisition and use of school condoms documented in our study suggests otherwise.
Although we weighted the data using demographic and other variables, some other characteristic (eg, sexual history) may have influenced the probability of participating in the survey as well as reactions to the condom program. Variables such as sexual history could not be used for weighting the data, because they could have been changed by the condom program. Local factors and specific program details can affect reactions to any new program, and generalizing to other school districts must always be done with caution.
We report on data collected 1 year after the condom availability program began. Response to any new program may vary from the period of novelty just after implementation until later, when it may become an unremarkable feature of school life. This is particularly true in a high school, where within 4 years there will be almost no students remaining who remember a time when the program did not exist. Additional research is needed to determine how students will react to condom availability programs in the long run.
This study was supported by Grant HS08055-1, Agency for Health Care Policy and Research, Rockville, MD; the American Foundation for AIDS Research, Los Angeles, CA; the Brotman Foundation of California, Encino, CA; the California Wellness Foundation, Woodland Hills, CA; and the Robert Wood Johnson Clinical Scholars Program, Los Angeles, CA.
We thank the students, parents, school and district personnel, and school board members who contributed to this study, and Robert H. Brook, MD, ScD; Rebecca Collins, PhD; Phyllis L. Ellickson, PhD; Arleen Leibowitz, PhD; Linda G. Martin, PhD; Martin F. Shapiro, MD, PhD; and our anonymous reviewers for their comments on drafts of this article. We also thank Jennifer Hawes-Dawson, BA; Ron D. Hays, PhD; Beverly A. Weidmer, MA; and the staff of the RAND Survey Research Group for their assistance with this study.
- Received November 15, 1996.
- Accepted March 17, 1997.
Reprint requests to (M.A.S.) RAND, 1700 Main St, Box 2138, Santa Monica, CA 90407-2138.
The opinions expressed are those of the authors and do not necessarily reflect the opinions of their institutional affiliations or the funding agencies.
- American Academy of Pediatrics, Committee on Adolescence
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- ↵Advocates for Youth. Cities With Schools Offering Condom Availability Programs. Identified as of 7/3/95. Washington, DC: Advocates for Youth; 1995
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- Copyright © 1997 American Academy of Pediatrics