Condom availability programs in Massachusetts high schools: relationships with condom use and sexual behavior

Recording harms in randomized controlled trials of behavior change interventions: a scoping review and map of the evidence

OBJECTIVES

Randomized controlled trials evaluate diverse interventions. This can include medical interventions such as drugs or surgical procedures, or behavior change interventions (BCIs) that aim to change a habit, belief, or attitude to improve health, for example, healthy eating, psychological wellbeing. Harms are often recorded poorly or inconsistently within randomized controlled trials of BCIs. This scoping review aimed to collate and describe literature on categories, definitions, and mechanisms of harms from BCIs; methods of identifying plausible harms; and recommendations for recording harms.

STUDY DESIGN AND SETTING

A scoping review was conducted. Three databases (MEDLINE, PsycINFO, and CINAHL) were searched. Reference list checking and citation searching were performed. Articles were included if they discussed (1) interventions that aimed to modify behavior, (2) categories or mechanisms of harms, and (3) methods or recommendations for recording harms. All research designs were included. One reviewer reviewed titles, abstracts, and full texts; queries were checked with another reviewer. Data were extracted and synthesized descriptively by one reviewer and checked by another reviewer. A thematic map was constructed to summarize the review findings. Harms described from specific BCIs were identified, and examples were selected and summarized.

RESULTS

The review included 37 articles. Nineteen of 37 articles contributed to a thematic review. Three articles described categories of harms; categories of harm included physical, psychological, group and social interactions, cultural, equity, opportunity cost, environmental, and economic. Seven articles included mechanisms or underlying factors for harms including feelings of failure leading to shame or stigma, and group interventions enabling knowledge exchange on unhealthy behaviors. Twelve articles provided recommendations for recording harms, including taking a proportionate approach by focusing on the most plausible and important harms, collecting different perspectives on whether harms had occurred (eg, caregivers and family members), and using qualitative research methods to identify harms. One article described a three-step method to identify plausible harms from an intervention, and six articles supported aspects of the method. Eighteen of 37 articles contributed to a review which collated harms arising from specific interventions, for example, a peer support intervention in inflammatory bowel disease caused distressing conversations which might lead to anxiety and confrontation with a possible negative future.

CONCLUSION

BCIs can cause harm. This review identified categories and proposed mechanisms of harms, as well as methods and recommendations for identifying and recording harms in BCIs for inclusion in forthcoming recommendations.

Addressing HIV/Sexually Transmitted Diseases and Pregnancy Prevention Through Schools: An Approach for Strengthening Education, Health Services, and School Environments That Promote Adolescent Sexual Health and Well-Being

Adolescents' health behaviors and experiences contribute to many outcomes, including risks for HIV, other sexually transmitted diseases, and unintended pregnancy. Public health interventions and approaches addressing risk behaviors or experiences in adolescence have the potential for wide-reaching impacts on sexual health and other related outcomes across the lifespan, and schools are a critical venue for such interventions. This paper describes a school-based program model developed by the Centers for Disease Control and Prevention's Division of Adolescent and School Health for preventing HIV/sexually transmitted diseases, unintended pregnancy, and related health risk behaviors and experiences among middle and high school students. This includes a summary of the theoretical and evidence base that inform the model, and a description of the model's activities, organized into three key strategies (sexual health education, sexual health services, and safe and supportive environments) and across three cross-cutting domains (strengthening staff capacity, increasing student access to programs and services, and engaging parent and community partners). The paper also outlines implications for adolescent health professionals and organizations working across schools, clinics, and communities, to address and promote adolescent sexual health and well-being.

Giving condoms to school children: educators' views on making condoms available in South African schools

One of the policy goals of the South African Department of Basic Education's National Policy on HIV, STIs and TB of 2017 is to reduce the incidence of HIV and pregnancy among learners. This is expected to be achieved by improving access to prevention services, including the provision of condoms in schools. This study uses street- level bureaucracy theory to explain how educators can play a more productive role in ensuring that policy goals are achieved. Educators provide their views on their role as condom promotion agents, their perception of demand and utilisation among learners, as well as their insights on suitable distribution mechanisms in the school setting. Trepidation exists among educators about their roles in the promotion and education of condoms. Educator statements suggest that they see the value in their policy-ascribed role to deliver sexual health messages and are also open to performing a role in the distribution of condoms at schools. However, our findings reveal that their role as policy communicators or "street-level bureaucrats" is complicated by inadequate policy guidance. We therefore conclude that to achieve optimal outcomes in terms of safer sexual practices among learners, condom messaging and distribution mechanisms in school settings require evidence-informed implementation strategies.

Barrier Protection Use by Adolescents During Sexual Activity

Rates of sexual activity, pregnancies, and births among adolescents have continued to decline during the past decade to historic lows. Despite these positive trends, many adolescents remain at risk for unintended pregnancy and sexually transmitted infections (STIs). This technical report discusses the new data and trends in adolescent sexual behavior and barrier protection use. Since 2017, STI rates have increased and use of barrier methods, specifically external condom use, has declined among adolescents and young adults. Interventions that increase availability of or accessibility to barrier methods are most efficacious when combined with additional individual, small-group, or community-level activities that include messages about safer sex. Continued research informs public health interventions for adolescents that increase the consistent and correct use of barrier methods and promote dual protection of barrier methods for STI prevention together with other effective methods of contraception.

Condom Availability Programs in Schools: A Review of the Literature

OBJECTIVE

This review synthesizes findings from the peer-reviewed evaluation literature on condom availability programs (CAPs) in secondary schools.

DATA SOURCE

Peer-reviewed evaluation literature indexed in MEDLINE, EMBASE, PsychINFO, ERIC, CINAHL, Sociological Abstracts, SCOPUS, and POPLINE.

STUDY INCLUSION AND EXCLUSION CRITERIA

Manuscripts had to be, written in English, and report evaluation data from a US school-based CAP.

DATA EXTRACTION

Articles were coded independently by 2 authors. Discrepancies were resolved through open discussion.

DATA SYNTHESIS

We grouped findings into outcome evaluation and process evaluation findings. Outcome evaluation findings included sexually transmitted infections (STIs), pregnancy rates, condom use, contraception use, sexual risk, and substance use. Process evaluation findings included awareness of CAPs, attitudes toward CAPs, attitudes toward condoms, and receipt of education and instruction.

RESULTS

Of the 138 citations reviewed, 12 articles published between 1995 and 2012 met the inclusion criteria, representing 8 programs. Evaluations indicate CAPs yield condom acquisition rates between 23% and 48%, have mixed results related to condom use, and are not associated with increases in sexual and other risk behaviors. One program found CAPs were associated with a decrease in a combined rate of chlamydia and gonorrhea. One program found no association between CAPs and unintended pregnancy. Students' attitudes toward CAPs were favorable and awareness was high.

CONCLUSIONS

Condom availability programs are accepted by students and can be an appropriate and relevant school-based intervention for teens. Condom availability programs can increase condom use, but more evaluations are needed on CAP impact on rates of HIV, STIs, and unintended pregnancy.

A Systematic Global Review of Condom Availability Programs in High Schools

PURPOSE

High levels of HIV, sexually transmitted infections (STIs), and pregnancy among adolescents has motivated some countries to consider the implementation of condom availability programs (CAPs) in high schools. In this present study, we analyzed the impact of CAP on students' sexual behaviors and health outcomes.

METHODS

We conducted a systematic literature review of peer-reviewed articles published between 1990 and 2017.

RESULTS

Twenty-nine articles from seven countries were included in this review. We found that CAP does not increase sexual activity nor lead to a greater number of sexual partners. It also does not lower the age of sexual initiation. A majority of the studies reported an increase in condom uptake and use at last sex among students with CAP. All the studies that examined STI found a decrease of STI symptoms and rates for students with CAP compared with the control group. The data on HIV rates was inconclusive. There was no difference in pregnancy rates associated with participation in CAP programs.

CONCLUSION

This global literature review showed that the fears surrounding CAP and promiscuity are unfounded. Once CAP is in place, students utilize it, and condom use increases, which translates to improved sexual health outcomes.

A State-Level Examination of School Nurses' Perceptions of Condom Availability Accompanied by Sex Education

School nurses are often sources of health-care support for teens with sexually transmitted infections (STIs) and unintended pregnancies. However, providing prevention (e.g., condoms) and teaching technical skills (e.g., condom use) needed to reduce high-risk sexual behavior may require a change in perceptions and policies. This study used a cross-sectional study design to assess nurses' perceptions of condom availability accompanied by sex education programs among high school nurses (n = 87) in Kansas. Results showed that school nurses in this study supported condom availability, were comfortable providing condoms, and felt condom availability was within the scope of their job but were less likely to provide condoms because of external barriers. Common barriers include administration, parents, cost, community support, and policies. School nurses, by virtue of their access to the majority of Kansas' adolescents, have the potential to provide sex education and tools such as condoms, so young people can prevent STIs and unintended pregnancies.

Should condoms be available in secondary schools? Discourse and policy dilemma for safeguarding adolescent reproductive and sexual health in Rwanda

Introduction

As a response to challenges associated with adolescent reproductive and sexual health, policy makers in Rwanda have instituted preventive measures against risky sexual behaviours among adolescents. There is an ongoing debate on whether condoms should be made available in secondary schools to minimise risks related to unprotected sex in the context of a growing number of unintended pregnancies among school girls. This paper aims to examine the proposal of condom provision in Rwandan secondary schools through the analysis of policy narratives and the claims-making process.

Methods

A narrative policy analysis was used to understand the claims and counter claims surrounding the debate on the provision of condoms in secondary schools. Documents that were consulted include: the national reproductive health policy, the girls' education policy, the national behaviour change and communication policy for the health sector, the Rwanda national policy on condoms, the adolescent sexual reproductive health and rights policy and the Rwanda family planning policy.

Results

Social and cultural norms in the Rwandan context consider adolescent sexual practices as immoral and thus reject the idea of providing condoms in secondary schools. However, some stakeholders promoting reproductive health suggest that ignoring that some adolescents are sexually active will prevent them from accessing appropriate reproductive and sexual health protective programmes. Consequently, adolescents will be exposed to risky sexual behaviours, a situation which may be counter productive to the overarching goal of safeguarding adolescent sexual health which might impact their long-term education goals.

Conclusion

Making condoms available in secondary schools evokes different meanings among the debaters, underscoring the complex nature of the condom provision debate in Rwanda. This paper calls for a revision of policies related to adolescent reproductive and sexual health in order to answer to the issues of risky sexual behaviours among secondary school students.

Theory-Based Behavioral Intervention Increases Mother-Son Communication About Sexual Risk Reduction Among Inner-City African-Americans

PURPOSE

African-American adolescent males are at increased risk for HIV, yet there are few sexual risk-reduction interventions targeting this population. Interventions that include mothers can influence parentingbehaviors and in turn, reduce risky behaviors in adolescents. This study tests the efficacy of the Mother-Son Health Promotion Project at increasing mother-son communication about sexual risk reduction.

METHODS

African-American mothers with their sons (ages 10-15 years) residing in public housing in Philadelphia, Pennsylvania were randomized into a HIV/sexually transmitted infections risk-reduction intervention consisting of 16 1-hour modules or an attention-matched health-promotion control intervention.Mothers and sons completed surveys pre-intervention, immediately postintervention, and at 3-, 6-, 12-, 18- and 24-months postintervention.

RESULTS

Of 525 mother-son dyads, 366 (69.7%) completed the 24-months postintervention follow-up survey. Generalized-estimating-equations models using both mothers' and sons' reports revealed that over 24 months, mothers and sons in the HIV/sexually transmitted infections risk-reduction intervention were more likely to communicate about sexual health, including sexual intercourse, birth control, HIV/AIDS prevention, and condoms. Intervention efficacy was found to weaken over time.

CONCLUSIONS

This culturally grounded, theory-based intervention was efficacious in increasing mother-son communication about sexual risk reduction. The work highlights the value of the intervention toincrease parental protective factors, including communication by mothers, to decrease HIV risk behaviors of African-American adolescent males.

"Be Straight Up and So Will He": Evaluation of a Novel HIV Prevention Condom Distribution and Health Communication Intervention Targeting Young African American Females

This study evaluated a novel 3-month campus-based HIV prevention condom distribution and health communication intervention for African American females attending a historically Black college in North Carolina. The theoretical framework for study incorporated the integrative model of behavioral prediction and the theory of gender and power. The intervention provided free condoms via condom dispensers with point-of-access messaging on the dispensers. We assessed 195 individuals before and 118 three months after the intervention. Almost 90% of participants were exposed to the intervention. Forty-four percent used the dispensers, 70% of whom reported using the condoms for sexual intercourse. Perceptions of condom availability and accessibility increased significantly after the intervention. In a multiple regression analysis controlling for covariates, dispenser use was significantly associated with greater condom use. These findings show the promise of a low-cost, broad-reach HIV/STI prevention intervention for young African American women.

The Effects of School-Based Condom Availability Programs (CAPs) on Condom Acquisition, Use and Sexual Behavior: A Systematic Review

We conducted a systematic review to assess the impact of school-based condom availability programs (CAPs) on condom acquisition, use and sexual behavior. We searched PubMed to identify English-language studies evaluating school-based CAPs that reported process (i.e. number of condoms distributed or used) and sexual behavior measures. We identified nine studies that met our inclusion criteria, with the majority conducted in the United States of America. We judged most studies to have medium risk of bias. Most studies showed that school-based CAPs increased the odds of students obtaining condoms (odds ratios (ORs) for individual studies ranged between 1.81 and 20.28), and reporting condom use (OR 1.36-3.2). Three studies showed that school-based CAPs positively influenced sexual behavior, while no studies reported increase in sexual activity. Findings suggest that school-based CAPs may be an effective strategy for improving condom coverage and promoting positive sexual behaviors.

Structural Interventions in HIV Prevention: A Taxonomy and Descriptive Systematic Review

One of the four national HIV prevention goals is to incorporate combinations of effective, evidence-based approaches to prevent HIV infection. In fields of public health, techniques that alter environment and affect choice options are effective. Structural approaches may be effective in preventing HIV infection. Existing frameworks for structural interventions were lacking in breadth and/or depth. We conducted a systematic review and searched CDC's HIV/AIDS Prevention Research Synthesis Project's database for relevant interventions during 1988-2013. We used an iterative process to develop the taxonomy. We identified 213 structural interventions: Access (65%), Policy/Procedure (32%), Mass Media (29%), Physical Structure (27%), Capacity Building (24%), Community Mobilization (9%), and Social Determinants of Health (8%). Forty percent targeted high-risk populations (e.g., people who inject drugs [12%]). This paper describes a comprehensive, well-defined taxonomy of structural interventions with 7 categories and 20 subcategories. The taxonomy accommodated all interventions identified.

Condom Availability in Schools: A Practical Approach to the Prevention of Sexually Transmitted Infection/HIV and Unintended Pregnancy

Adolescents and young adults are highly impacted by sexually transmitted infections (STIs) and unplanned pregnancy in the United States and globally. Consistent and correct use of male latex condoms is associated with protection against both STIs and pregnancy. Providing adolescents and young adults with access to free condoms in schools may increase the use of condoms by improving condom availability, eliminating cost, and decreasing embarrassment associated with purchasing condoms. Studies demonstrate that condom availability in schools is associated with the increased use of condoms and improved overall sexual health. The Society for Adolescent Health and Medicine encourages schools to make condoms available to students as part of efforts to decrease rates of STIs and unplanned pregnancy in adolescents and young adults. The Society for Adolescent Health and Medicine also encourages health care providers to advocate for and support the availability of condoms in local schools.

Parents' knowledge, attitudes, behaviors, and barriers to promoting condom use among their adolescent sons

Human immunodeficiency virus (HIV) is increasing in Thai youth. Consequently, a school-based National Condom Strategy program was launched in 2015 to reduce the rate of HIV and sexually transmitted infections. We conducted in-depth interviews of 31 parents/adoptive guardians of high-school age Thai boys to explore parents' knowledge, attitudes, behaviors, and barriers to promoting condom use and its role in preventing HIV/sexually transmitted infections. A descriptive phenomenological approach and thematic analysis was used. Most participants had knowledge and positive attitudes about condom use. Half disagreed with the National Condom Strategy of placing condom vending machines in schools. More than half did not initiate teaching male youth about condom use until the youth had broached the question or only intended to do so when the youths were older. Barriers included parents' lack of condom experience and knowledge, embarrassment/discomfort when talking about condoms, and belief that youth were not sexually active. Parents are a key factor for supporting condom use in Thailand. This study supports the need for education programs for parents.

Improving Adolescent Sexual and Reproductive Health: A Systematic Review of Potential Interventions

Adolescents have special sexual and reproductive health needs (whether or not they are sexually active or married). This review assesses the impact of interventions to improve adolescent sexual and reproductive health (including the interventions to prevent female genital mutilation/cutting [FGM/C]) and to prevent intimate violence. Our review findings suggest that sexual and reproductive health education, counseling, and contraceptive provision are effective in increasing sexual knowledge, contraceptive use, and decreasing adolescent pregnancy. Among interventions to prevent FGM/C, community mobilization and female empowerment strategies have the potential to raise awareness of the adverse health consequences of FGM/C and reduce its prevalence; however, there is a need to conduct methodologically rigorous intervention evaluations. There was limited and inconclusive evidence for the effectiveness of interventions to prevent intimate partner violence. Further studies with rigorous designs, longer term follow-up, and standardized and validated measurement instruments are required to maximize comparability of results. Future efforts should be directed toward scaling-up evidence-based interventions to improve adolescent sexual and reproductive health in low- and middle-income countries, sustain the impacts over time, and ensure equitable outcomes.

Implementation of Sexually Transmitted Infection Interventions

Although community-wide, multilevel interventions are widely regarded as the most effective method for addressing complex health issues such as sexually transmitted infections (STIs), there is a dearth of research about the implementation of interventions of this nature. The aim of this study was to determine the implementation of locally developed and evidence-based STI interventions across an urban community using the Institute of Medicine's intervention spectrum as a framework, to highlight collaborations, and to identify barriers to the implementation of community-wide, multilevel interventions. Semistructured interviews were conducted ( N = 20) with staff from schools, after-school programs, community organizations, and clinics in a Midwestern metropolitan area. Results indicate that interventions were implemented at all levels of the Institute of Medicine's intervention spectrum, although selective interventions that served a small number of youth were most common. Most interventions were locally developed or adapted from evidence-based programs. Despite reported collaboration between agencies, there was relatively little community-wide coordination of STI interventions due to factors such as community norms and competition for limited funding. These findings offer further insight into the gap between best practice recommendations and the implementation of community-wide, multilevel interventions. Implications for intervention development and implementation are discussed.

Sexual Violence Against Adolescent Girls

This study investigates associations between immigration and acculturation with sexual assault among a large, representative sample of high school girls. The analysis utilized data from the Massachusetts Youth Risk Behavior Surveys conducted in 1999, 2001, and 2003 ( N = 5,919). Adjusted logistic regression analyses were conducted among the full sample and a sexually active subsample. Being an immigrant was associated with recurring sexual assault victimization; this effect was not consistent across age and racial/ethnic groups. Immigrant status conferred risk among adolescent girls aged 15 and younger, Black adolescent girls, and sexually active Hispanic girls. No differences were detected in sexual assault victimization based on acculturation.

Psychosocial Predictors for Cancer Prevention Behaviors in Workplace Using Protection Motivation Theory

Backgrounds. The aim of this study was to describe the preventive behaviors of industrial workers and factors influencing occupational cancer prevention behaviors using protection motivation theory. Methods. A self-administered questionnaire was completed by 161 petrochemical workers in Iran in 2014 which consisted of three sections: background information, protection motivation theory measures, and occupational cancers preventive behaviors. Results. A statistically significant positive correlation was found between PM and self-efficacy, response efficacy, and the cancer preventive behaviors. Meanwhile, statistically significant negative correlations were found between PM, cost, and reward. Conclusions. Among available PMT constructs, only self-efficacy and cost were significant predictors of preventive behaviors. Protection motivation model based health promotion interventions with focus on self-efficacy and cost would be desirable in the case of occupational cancers prevention.

Impact of community-based interventions on HIV knowledge, attitudes, and transmission

In 2012, an estimated 35.3 million people lived with HIV, while approximately two million new HIV infections were reported. Community-based interventions (CBIs) for the prevention and control of HIV allow increased access and ease availability of medical care to population at risk, or already infected with, HIV. This paper evaluates the impact of CBIs on HIV knowledge, attitudes, and transmission. We included 39 studies on educational activities, counseling sessions, home visits, mentoring, women's groups, peer leadership, and street outreach activities in community settings that aimed to increase awareness on HIV/AIDS risk factors and ensure treatment adherence. Our review findings suggest that CBIs to increase HIV awareness and risk reduction are effective in improving knowledge, attitudes, and practice outcomes as evidenced by the increased knowledge scores for HIV/AIDS (SMD: 0.66, 95% CI: 0.25, 1.07), protected sexual encounters (RR: 1.19, 95% CI: 1.13, 1.25), condom use (SMD: 0.96, 95% CI: 0.03, 1.58), and decreased frequency of sexual intercourse (RR: 0.76, 95% CI: 0.61, 0.96). Analysis shows that CBIs did not have any significant impact on scores for self-efficacy and communication. We found very limited evidence on community-based management for HIV infected population and prevention of mother- to-child transmission (MTCT) for HIV-infected pregnant women. Qualitative synthesis suggests that establishment of community support at the onset of HIV prevention programs leads to community acceptance and engagement. School-based delivery of HIV prevention education and contraceptive distribution have also been advocated as potential strategies to target high-risk youth group. Future studies should focus on evaluating the effectiveness of community delivery platforms for prevention of MTCT, and various emerging models of care to improve morbidity and mortality outcomes.

A scoping review of unintended harm associated with public health interventions: towards a typology and an understanding of underlying factors

OBJECTIVES

Unintended harm theory as related to public health interventions (PHI) is under developed, with harm evaluation and reporting often absent or incomplete. This review presents a typology for, and underlying factors linked to, PHI-associated unintended harm.

METHODS

This scoping review was conducted electronically and includes articles from 1992 to June of 2013. Out of 2,490 originally identified titles, 26 full-text articles were included that discussed unintended harm associated with PHI. An iterative data analysis process was utilized to identify both a typology and underlying factors associated with unintended harm.

RESULTS

A typology of PHI-associated unintended harm was identified: (1) physical; (2) psychosocial; (3) economic; (4) cultural and (5) environmental. Five underlying factors associated with PHI unintended harm emerged: (1) limited and/or poor quality evidence; (2) prevention of one extreme leads to another (boomerang effects); (3) lack of community engagement; (4) ignoring root causes; and (5) higher-income country PHI implementation in a lower- or middle-income country.

CONCLUSIONS

PHI planning and evaluation frameworks may benefit from the consideration and potential incorporation of the unintended harm typology and underlying factors.

Condom Use by Adolescents

Rates of sexual activity, pregnancies, and births among adolescents have continued to decline during the past decade to historic lows. Despite these positive trends, many adolescents remain at risk for unintended pregnancy and sexually transmitted infections (STIs). This policy statement has been developed to assist the pediatrician in understanding and supporting the use of condoms by their patients to prevent unintended pregnancies and STIs and address barriers to their use. When used consistently and correctly, male latex condoms reduce the risk of pregnancy and many STIs, including HIV. Since the last policy statement published 12 years ago, there is an increased evidence base supporting the protection provided by condoms against STIs. Rates of acquisition of STIs/HIV among adolescents remain unacceptably high. Interventions that increase availability or accessibility to condoms are most efficacious when combined with additional individual, small-group, or community-level activities that include messages about safer sex. Continued research is needed to inform public health interventions for adolescents that increase the consistent and correct use of condoms and promote dual protection of condoms for STI prevention with other effective methods of contraception.

Factors Associated With Parent Support for Condom Education and Availability

Expanding condom-related knowledge and skills and reducing barriers to condom use have the potential to help reduce pregnancies and sexually transmitted infections among youth. These goals are sometimes addressed through condom education and availability (CEA) programs as part of sexuality education in school. Parents are a key constituency in efforts to implement such programs. A representative statewide sample of households with children ( N = 1,093) in California was employed to examine parent support for CEA and the potential influences of demographics (gender, age, and Hispanic ethnicity), sociodemographics (education, religious affiliation, religious service attendance, and political ideology), and condom-related beliefs (belief in condom effectiveness and belief that teens who use condoms during sex are being responsible) on parent support for CEA. The parents in our sample reported a high level of support for CEA ( M = 3.23 on a 4-point scale) and believing in a high level of condom effectiveness ( M = 3.36 on a 4-point scale). In addition, 84% of the parents agreed that teens who use condoms during sex are being responsible. Hierarchical regression analyses showed that parents who were younger, Hispanic, with a lower educational attainment, without a religious affiliation, less religiously observant, and politically liberal were more supportive of CEA. After controlling for these demographic and sociodemographic factors, condom effectiveness and responsibility beliefs each added independently to the predictability of parent support for CEA. These findings suggest that parent education related to condom effectiveness could help increase support for school-based CEA programs.

Macro-level approaches to HIV prevention among ethnic minority youth: state of the science, opportunities, and challenges

The HIV epidemic continues to disproportionately affect ethnic minority youth. These disconcerting health disparities indicate that although existing HIV preventive strategies for ethnic minority youth have been efficacious, they have not significantly reduced the impact of the epidemic in this population. Macro-level interventions, such as structural or policy interventions, have the potential to impact the HIV epidemic at a population level, and thus reduce the HIV health disparities that exist among ethnic minority youth and other segments of the U.S. population. This article calls for a paradigm shift to develop, evaluate, and disseminate interventions that target upstream/macro-level factors or that, at a minimum, integrate both a macro and individual level perspective. The article also discusses the challenges in developing and evaluating such interventions. Psychologists and other behavioral scientists can play a critical role in reducing the impact of HIV on ethnic minority youth by integrating macro-level approaches to future HIV prevention strategies.

Condom use among sexually active rural high school adolescents personal, environmental, and behavioral predictors

Adolescents who engage in unprotected intercourse are at risk of pregnancy and sexually transmitted infection (STI). Although adolescents in rural areas participate in levels of sexual risk taking similar to that of nonrural youth, few data are available identifying factors that influence condom use among rural adolescents. The purpose of this study is to determine the predictive value of selected personal, environmental, and behavioral factors for condom use among rural adolescents in grades 9-12. A cross-sectional survey was conducted among sexually active youth (N = 613), ages 14-19, in three rural school districts in the Northeast. Using logistic regression, identified predictors for condom use include personal standards (odds ratio [OR] = 2.45; confidence interval [CI]: [2.39, 6.47]), condom use goals (OR = 1.32; CI [1.21, 1.45]), condom use at first intercourse (OR = 3.93; CI [2.39, 6.47]) and male gender. School nurses are encouraged to incorporate identified predictors of condom use when considering interventions promoting safer sexual behaviors among rural youth.

Same-Sex Sexual Behaviors Among Male Migrants in a Context of Male “Marriage Squeeze”

The male marriage squeeze in China may increase the prevalence of male same-sex sexual behaviors among unmarried male migrants who lack stable female sexual partners. The same-sex sexual behaviors among unmarried male migrants appear to be at high risk of transmission of human immunodeficiency virus (HIV) and sexually transmitted infections (STIs), mainly because of a lack of knowledge of these diseases. Using data from the “Survey on Reproductive Health and Family Life of Migrant Male Bachelors in Urban Areas” conducted in Xi’an City, Shaanxi Province, in December 2009 and January 2010, this study compares same-sex sexual behaviors of unmarried with that of married male migrants (including married but separated men who are migrating without their spouse or partner and cohabitating men who are migrating with their spouse or partner). It is reported that the prevalence of same-sex sexual behaviors among unmarried males reaches 11%, more than twice the 5.1% reported by married but separated men and thrice the 3.8% reported by cohabitating men. It also appears that the same-sex sexual behaviors is significantly associated with men’s attitudes toward same-sex sexual behaviors (odds ratio = 1.59, p < .001), toward life-long bachelorhood (odds ratio = 1.35, p < .01), and with marital status (odds ratio = 0.37, p < .01). The frequency of condom use appears to be higher among unmarried men than among men who are married, whether or not they migrated with their wives, and is significantly associated with scores on knowledge about HIV/AIDS (estimated coefficient = .12, p < .001) and STIs (estimated coefficient = .22, p < .01). It is also associated with the likelihood of same-sex sexual behaviors (estimated coefficients = .83, p < .01) and marital status (estimated coefficients for married but separated = −.50, p < .05; estimated coefficients for cohabitating = −.77, p < .001).

Children, adolescents, and the media: health effects

The media can be a powerful teacher of children and adolescents and have a profound impact on their health. The media are not the leading cause of any major health problem in the United States, but they do contribute to a variety of pediatric and adolescent health problems. Given that children and teens spend >7 hours a day with media, one would think that adult society would recognize its impact on young people's attitudes and behaviors. Too little has been done to protect children and adolescents from harmful media effects and to maximize the powerfully prosocial aspects of modern media.

Condom access in San Antonio, Texas: the "three A's" and HIV/STI incidence

Condoms are highly effective at reducing STI transmission. Access is a critical precursor to use. This socio-ecologic study operationalizes the concept of condom access by defining it in terms of availability, affordability, and affect, and explores the relationship between these and STI incidence. Three pairs of zip codes, each with similar demographics but different Chlamydia and HIV incidence rates, were identified. Supermarkets, convenience stores, and pharmacies (N = 102) were evaluated for the three A's. Nonparametric methods were used to compare the moderate-Chlamydia areas to the high-incidence areas. High-Chlamydia areas were significantly less likely to have 12-packs available compared to moderate-Chlamydia areas. Prices averaged over $1 per condom and did not vary by incidence. High-incidence areas were significantly less likely to allow patrons to select condoms unassisted. High-HIV areas placed more positively-connoted items near condoms. Improving these factors may improve condom acquisition and in turn reduce STI and HIV incidence rates.

Efficacy of structural-level condom distribution interventions: a meta-analysis of U.S. and international studies, 1998-2007

This systematic review examines the overall efficacy of U.S. and international-based structural-level condom distribution interventions (SLCDIs) on HIV risk behaviors and STIs and identifies factors associated with intervention efficacy. A comprehensive literature search of studies published from January 1988 through September 2007 yielded 21 relevant studies. Significant intervention effects were found for the following outcomes: condom use, condom acquisition/condom carrying, delayed sexual initiation among youth, and reduced incident STIs. The stratified analyses for condom use indicated that interventions were efficacious for various groups (e.g., youth, adults, males, commercial sex workers, clinic populations, and populations in areas with high STI incidence). Interventions increasing the availability of or accessibility to condoms or including additional individual, small-group or community-level components along with condom distribution were shown to be efficacious in increasing condom use behaviors. This review suggests that SLCDIs provide an efficacious means of HIV/STI prevention.

Condom availability program in an inner city public school: effect on the rates of gonorrhea and chlamydia infection

PURPOSE

Sexual activity and sexually transmitted infection (STI) rates are high in adolescents. In this study, we sought to determine whether the initiation of a school-based condom availability program was associated with a decrease in STI rates.

METHODS

We compared the rates of STIs in 15-19-yr-olds reported to the Massachusetts Department of Public Health for the 3 years before and after a condom availability program was introduced in Holyoke, MA, as compared with a similar city, Springfield, MA, which did not have such a program.

RESULTS

Holyoke males, aged 15-19 years, showed a 47% decrease in the rates of gonorrhea and chlamydia infection combined over the 3 years after the implementation of the condom availability program, whereas similar aged males in Springfield had a 23% increase in the rates of gonorrhea and chlamydia infection. The difference in regression slopes in this period was significant (p < .01). Females, aged 15-19 years, from either Holyoke or Springfield, showed moderate, variable changes in rates of STIs after 2005; there was no significant difference in the regression slopes of STIs between Holyoke and Springfield.

CONCLUSIONS

Initiating a condom availability program in a city's high school was associated with a decrease in STI rates for 15-19-yr-old males but not females.

Systematic review and narrative synthesis of the effectiveness of contraceptive service interventions for young people, delivered in educational settings

STUDY OBJECTIVE

This review was undertaken to determine the effectiveness of contraception service interventions for young people that were delivered in educational settings.

DESIGN

We conducted a systematic review and narrative synthesis.

SETTING

Interventions were included where they were delivered in educational institutions, including schools, colleges, and pupil referral units.

PARTICIPANTS

Young people aged 19 and under. Studies of wider age groups were included if the majority of participants were aged under 19 years.

INTERVENTIONS

We included interventions which consisted of contraceptive service provision, and also interventions to encourage young people to use existing contraceptive services.

MAIN OUTCOME MEASURES

The main outcome measures used in the studies were: rate of teenage pregnancy, rate of contraceptive use, and sexual behavior. Many outcome measures were self reported.

RESULTS

Twenty-nine papers were included which reported on interventions to prevent adolescent pregnancy (and repeat pregnancy), school-based health centers, contraceptive use in college students, and multicomponent interventions. Intensive case management intervention conducted by a culturally matched school-based social worker (along with other components including peer education) were shown to be effective in preventing repeat adolescent pregnancy, at least for the duration of the intervention. Also, school-based health centers appear to be most effective when contraception provision is made available on site.

CONCLUSIONS

The evidence from these papers is limited, in terms of both quality and quantity, along with consistency of findings, but some recommendations in relation to effective interventions can be made.

Household-level correlates of condom use among a representative sample of Canadian adolescents

BACKGROUND

The relationship between an adolescent's micro-environment (e.g. the home) and the likelihood of engagement in sexual risk behaviour is poorly understood. Therefore, we sought to examine the household-level correlates of condom use at last intercourse among a nationally representative sample of Canadian adolescents aged 15 to 19.

METHODS

Using data from the 2005 Canadian Community Health Survey, we conducted logistic regression analyses to determine whether factors related to characteristics of the household environment were associated with self-reported condom use at last intercourse.

RESULTS

Among 3974 sexually active adolescents, condom use at last intercourse was reported by 74.8%. After adjusting for household education and income, participants who reported living in larger dwellings were less likely to report condom non-use, while those reporting greater numbers of persons in the household were more likely to report condom non-use. Other significant correlates of condom non-use included older age, female sex, alternative birth control methods and having a weak sense of community belonging.

CONCLUSION

Our results demonstrate that factors related to the household environment are independently associated with condom use among adolescents. Policies and programs that aim to promote condom use should seek to address issues such as privacy, which may limit adolescents' ability to engage in safer sexual practices.

American Academy of Pediatrics. Policy statement--sexuality, contraception, and the media

From a health viewpoint, early sexual activity among US adolescents is a potential problem because of the risk of pregnancy and sexually transmitted infections. New evidence points to the media adolescents use frequently (television, music, movies, magazines, and the Internet) as important factors in the initiation of sexual intercourse. There is a major disconnect between what mainstream media portray-casual sex and sexuality with no consequences-and what children and teenagers need-straightforward information about human sexuality and the need for contraception when having sex. Television, film, music, and the Internet are all becoming increasingly sexually explicit, yet information on abstinence, sexual responsibility, and birth control remains rare. It is unwise to promote "abstinence-only" sex education when it has been shown to be ineffective and when the media have become such an important source of information about "nonabstinence." Recommendations are presented to help pediatricians address this important issue.

Parental support for the human papillomavirus vaccine

This study examined support for the human papillomavirus (HPV) vaccine among a representative sample of Minnesota parents after approval from the U.S. Food and Drug Administration. Support for the vaccine was high; 87% supported its use. Although individual characteristics predicted support, support was high across subgroups with two-thirds or more of parents supporting the vaccine.

Ethical dilemmas and great expectations for human papilloma virus vaccination

When the first preventive HPV vaccine became available in 2006, it drew both enthusiasm and multiple ethical problems. In the case of HPV vaccination, there is a clear conflict between the scientific data that claim a definitive advantage for preventing HPV infection in the exposed population and the ethical and moral issues resulting from a compulsory program. Despite the evident success of routine and compulsory vaccination in young women, there is increasing concern about safety, efficacy, and equity of the vaccine and to close the knowledge "gaps" about HPV infection and consequent health outcomes. Some of these fears are expressed particularly in conservative groups that link these arguments to those of religious and moral issues contending that HPV vaccination is an indirect license for liberal sexual activity in youths, resulting in promiscuity and/or less participation in cervical cancer screening. It has been well demonstrated that HPV infection can lead to harm through the induction of premalignant and cancerous lesions. Therefore, any proven method for preventing infection, such as HPV vaccines, should be used in persons at risk. These policies, however, should be strictly linked to cervical cancer screening programs.

Condom provision and education in Minnesota public schools: a telephone survey of parents

BACKGROUND

Increasing correct and consistent condom use among sexually active adolescents continues to be a critical public health goal, with schools serving as key agents for achieving this goal through sexuality education and condom use provision. This research aims to describe the views of parents regarding school-based condom distribution and education programs, and examines how these views differ across demographic groups.

METHODS

Parents of school-age children in Minnesota were surveyed in telephone interviews (N = 1605; 63% participation) regarding their beliefs about condom availability and education. Chi-square tests of significance were used to detect differences in agreement with each statement for 10 demographic and personal characteristics.

RESULTS

A majority of respondents held supportive views about condom availability and education programs. Strongest support centered on statements in the survey about teenagers needing information about condoms (86%) and showing actual condoms during classroom lessons (77%). Approximately two thirds of the parents agreed that school-based instruction about condoms should be "allowed" at the high school level (65%), and one fifth (21%) believed that this type of education should be "required." Support for condom availability and education programs differed significantly according to certain personal characteristics, with less supportive views from self-identified Born Again Christians and politically conservative parents.

CONCLUSIONS

Public discourse regarding school-based sexuality education should include the viewpoints of parents of school-aged children as key stakeholders. Parents' perspectives provide unique and critical insights that school administrators and educators should consider as they develop educational and programmatic offerings regarding condoms.

HIV testing practices and attitudes on prevention efforts in six diverse Chicago communities

Data describing local level HIV testing practices and attitudes regarding HIV prevention are rarely available, yet would be useful for HIV policy and evaluation. A comprehensive health survey was conducted in six community areas of Chicago (n = 1,699) in 2002-2003. The HIV prevention module of this survey was used for this analysis. The proportion that ever tested for HIV ranged from 40 to 75% and 11 to 38% were tested in the past 12 months. Residents favored: needle exchange programs (59-77%), HIV information in high schools (95-100%) and elementary schools (85-94%), and condom distribution in high schools (74-93%). Attitudes were less favorable regarding pharmacies selling clean needles (37-58%) and condom distribution in elementary schools (22-66%). Adults in these areas are over three times more likely to have been tested recently than adults nationally. Residents strongly favor community based HIV prevention initiatives such as needle exchange programs, condom distribution in high schools, and HIV prevention taught in schools. These evidence-based observations may be valuable in planning HIV prevention programs and in shaping policy.

High-risk behaviours among juvenile prison inmates in Pakistan

OBJECTIVES

To assess the sexual- and drug-use-related risk behaviours of male juvenile detainees in Karachi, Pakistan.

DESIGN

Cross-sectional study.

METHODS

A cross-sectional study was conducted of prison inmates aged 15-21 years in Karachi Juvenile Prison in 2002. In total, 321 inmates were interviewed about sexual orientation and behaviours, and knowledge about human immunodeficiency virus (HIV) and sexually transmitted infections (STIs). Urine specimens were collected and tested for Chlamydia trachomatis and Neisseria gonorrhoeae using ligase chain reaction.

RESULTS

A substantial proportion (n=111, 34.6%) of the participants were sexually active. Sixty-two (19%) and 67 (21%) had had sex with a male or female before incarceration, respectively. Twenty-seven (8.4%) participants had an STI, and 50% of the 109 sexually active participants had had multiple sexual partners. Use of addictive substances was associated with sexual activity. The mean knowledge score computed from the sum of 16 items was 4.7, with a median of 2.9. A large proportion (40%) of participants knew about condoms, but very few (3.4%) had ever used one. The mean+/-standard deviation risk score from nine items was 2.4+/-1.7. On the basis of behavioural and biological markers, 117 (36.4%) participants had high-risk behaviour. In multivariate logistic regression analysis, knowledge, risk perception and age were predictive of higher risk.

CONCLUSIONS

HIV risk behaviours are common among adolescent inmates. Although inmates do have knowledge about modes of transmission and condom use, the use of condoms is significantly low. Interventions are needed for behavioural change among this group.

The moral justification for a compulsory human papillomavirus vaccination program

Compulsory human papillomavirus (HPV) vaccination of young girls has been proposed as a public health intervention to reduce the threat of the disease. Such a program would entail a symbiotic relationship between scientific interests in reducing mortality and morbidity and philosophical interests in promoting morality. This proposal raises the issue of whether government should use its police powers to restrict liberty and parental autonomy for the purpose of preventing harm to young people. I reviewed the scientific literature that questions the value of a HPV vaccination. Applying a principle-based approach to moral reasoning, I concluded that compulsory HPV vaccinations can be justified on moral, scientific, and public health grounds.

Condom access in South African schools: law, policy, and practice

Juliana Han and Michael L. Bennish discuss their experience developing a policy on condom distribution for Mpilonhle, a South African nongovernmental organization involved in HIV prevention in schools.

Sexual activity and teenage females taking hormonal therapy for medical indications

The objective of this study was to compare the rates of initiating sexual activity between a group of 13- through 18-year-old females placed on hormonal therapy for medical indications and a group of 13- through 18-year-old females not on hormonal therapy for medical indications. Although the number of participants was low, there was no statistically significant difference in the rates of sexual debut between the groups.

Effects of a televised two-city safer sex mass media campaign targeting high-sensation-seeking and impulsive-decision-making young adults

This study evaluates the ability of a safer sex televised public service announcement (PSA) campaign to increase safer sexual behavior among at-risk young adults. Independent, monthly random samples of 100 individuals were surveyed in each city for 21 months as part of an interrupted-time-series design with a control community. The 3-month high-audience-saturation campaign took place in Lexington, KY, with Knoxville, TN, as a comparison city. Messages were especially designed and selected for the target audience (those above the median on a composite sensation-seeking/impulsive-decision-making scale). Data indicate high campaign exposure among the target audience, with 85%-96% reporting viewing one or more PSAs. Analyses indicate significant 5-month increases in condom use, condom-use self-efficacy, and behavioral intentions among the target group in the campaign city with no changes in the comparison city. The results suggest that a carefully targeted, intensive mass media campaign using televised PSAs can change safer sexual behaviors.

A quantitative study on the condom-use behaviors of eighteen- to twenty-four-year-old urban African American males

This research study sought to develop, pilot test, and assess a brief male-centered condom promotion program for urban young adult African American males. For study implementation, both qualitative and quantitative research methods were used, and the project was guided by tenets of two common but integrated theoretical frameworks in HIV/sexually transmitted disease (STD) prevention research: the social cognitive theory and the stages of change model. The purpose of the qualitative component was to identify and explore condom-use barriers and facilitators while that of the quantitative component was to identify the prevalence of condom-related behaviors and the feasibility of program administration. After recruitment of study participants from hang-out spots and street intercepts, study participants were self-administered a baseline survey regarding their perceived condom-use behaviors prior to random assignment to program conditions (a condom promotion program and an attention-matched comparison condition). In this paper, we report the findings from the analyses of the quantitative baseline survey data. While the occurrence of HIV/STD-related risk behavIors were highly prevalent among this population; importantly, regression analyses revealed that sexual debut, favorable attitudes toward condom use, social or personal connectedness to HIV/STDs, health beliefs, perceived susceptibility, unprotected sexual encounters, and refusal skills were predictive of retrospective (i.e., prior 30 days) condom use while positive reasons (pros) to use condoms, condom-use beliefs, condom-carrying, health belief, unprotected sexual encounters and refusal skills were also predictive of prospective (i.e., future 30 days) condom-use intentions. The implications and limitations of this study are described and recommendations provided for program development.