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Deborah E. Sellers, PhD, Sarah A. McGraw, PhD, and John B. McKinlay, PhD
Introduction
Proponents of contraception education and condom availability programs
argue that teenagers are sexually active
and must be provided with the means to
protect themselves against pregnancy and
sexually transmitted diseases. Figures for
1988 indicated that about 50% of female
adolescents and 60% of male adolescents
15 to 19 years of age had engaged in
sexual intercourse,1-3 more than 1 in 10
teenage girls was pregnant,2'4 and 1 in 6
sexually experienced teens had a sexually
transmitted disease.5'6 The long incubation period of the human immunodeficiency virus (HIV) and the number of
cases of acquired immunodeficiency syndrome (AIDS) among adults in their 20s
have also raised concern about the rate of
HIV infection among adolescents, even
though relatively few cases of AIDS have
occurred among teens.7 Opponents of
condom availability programs maintain
that the provision of condoms endorses
and thus promotes sexual activity.5'>'2
This issue was raised in the confirmation
hearings for Dr Joycelyn Elders as surgeon general of the United States when
Sen Dan Coates (R, Ind) expressed
concem that "just promoting condoms as
a solution to the problem can promote
Methods
Study Design
In 1990 in Boston, Mass, an 18month community-based AIDS prevention program was initiated among Latino
youth,27 a group at high risk of HIV
infection.28 The multifaceted community
intervention, which was designed to increase HIV/AIDS awareness and to
reduce the risk of HIV infection by
increasing the use of condoms among
sexually active teens, included both the
promotion and distribution of condoms.
Intervention activities, which were conducted by specially trained peer leaders,
included workshops in schools, community organizations, and health centers;
group discussions in the homes of youth;
December 1994, Vol. 84, No. 12
Analysis
To assess whether this HIV prevention program that included the promotion
and distribution of condoms increased the
level of sexual activity in the target
population of Latino adolescents, the
intervention and comparison samples were
compared on three outcomes: the percentage experiencing the onset of sexual
activity between the baseline and follow-up interviews, the change in the
percentage with multiple partners between the baseline and follow-up interviews, and the change in the mean
frequency of sex between the baseline and
follow-up interviews. If the intervention
increased adolescent sexual activity, then
the rate of onset of sexual activity, the
change in the percentage with multiple
partners, and/or the change in the frequency of sex between the baseline and
follow-up interviews in the intervention
group would be greater than that in the
comparison group.
Sexual activity was defined as vaginal
or anal intercourse. Muliple partners was
defined as two or more sex partners in the
6 months prior to the interview. Frequency
ofse was the respondents' estimate of the
number of times they had had sex in the
previous 6 months.
The onset of sexual activity analysis
included only respondents who were not
sexually active at the baseline interview.
The multiple partner and frequency of sex
analyses included only respondents who
were sexually active by the follow-up
interview.
The comparison of unadjusted rates,
however, did not take into account any
baseline differences between the comparison and intervention samples. The quasiexperimental design of the evaluation
required that baseline differences between the intervention and comparison
groups on factors related to the outcome
American Journal of Public Health 1953
Sellers et al.
Girls
Boys
80
70 _
Percent Sexually Active
60 _
Among Respondents
Who were Not Sexually Active 50 -
Percent with
Multiple (2+) Sex Partners
in the Six Months Prior
to the Follow-up Interview
Among Respondents
Who were Sexually Active
by the Follow-up Interview
40
30
20
10
0
80
70
60
50
40
30
20
10
0
#
,/
,
_
Baseline
Follow-up
Baseline Follow-up
80
70
60
50
40
30
20
10
0
Intervention
CComparison
Baseline
Follow-up
Baseline Follow-up
40
40
35
30
25
20
15
n
B .o
10
5
0
80
70
60
50
40
30
20
10
0
Bascline Follow-up
35
30
25
20
15
10
5
0
Baseline Follow-up
the study design, competing HIV prevention activities, and factors related to
adolescent sexual activity, as well as an
indicator for intervention city. The multiple partners and frequency of sex analyses also included the baseline level of the
outcome and thus constituted an analysis
of change between baseline and followup.32 The appendix provides a complete
description of the covariates and their
operationalization. Factors related to adolescent sexual activity were culled from
previous research.33-50 Male respondents
and female respondents were analyzed
separately since previous research indicates that different factors influence the
sexual activity of young men and young
women.33,34,4l
The measures of participation in
HIV prevention activities similar to those
of the intervention were included to
control for the effect of prevention activi-
The influence of sampling procedures on the survey estimates was assessed by calculating sample weights and
design effects.53 The sample weights varied little across respondents (2.79 to 3.67),
and the distributions of weighted and
unweighted outcome variables were essentially the same. Design effects, which
incorporated the influence of clustering of
respondents within households, were close
to one (0.96 to 1.06). Consequently,
unweighted results involving standard
variance estimates are reported.
Results
Baseline interviews were completed
with 586 Latino adolescents who were 14
to 20 years of age and were primarily
Puerto Rican (94%). The baseline response rate was 84.4%. Follow-up interviews were completed with 536 of these
respondents, for a follow-up response rate
of 91.5%. The attrition rates (7.2% and
9.3% in the intervention and comparison
cities, respectively) were minimized by
contacting each respondent at 3-month
intervals between baseline and follow-up
to obtain current address and telephone
information.
Of the 536 respondents who responded to both the baseline and the
follow-up interviews, 256 (47.8%) reported no sexual activity prior to the
baseline interview. Of these, 227 (88.7%)
provided responses to all covariates in the
model for onset of sexual activity and thus
constituted the analytic sample for that
analysis. By the follow-up interview, 433
respondents (80.8%) reported sexual activity. Of these, 403 (93.1%) provided
valid responses to all covariates and thus
constituted the analytic sample for the
frequency of sex and multiple partner
analyses.
Outcome
Males
Females
0.08*
0.01, 0.57
6.08 (.638)
89
1.24
0.44, 3.46
4.95 (.763)
138
0.90
0.43,1.91
5.51 (.702)
211
0.06**
0.01, 0.43
4.60 (.800)
192
.21
-0.20, 0.62
.276
211
-.11
-1.74, 4.26
.380
192
regressionb)
Odds ratio
95% confidence interval
Hosmer-Lemeshow goodness of fit (P level)
No.
Frequency of sexd in the 6 months prior to the
follow-up interviewc (ordinary least
squares regressionb)
Regression coefficient
95% confidence interval
Adjusted R2
No.
Note. See Appendix for a description of the covariates and their operationalization.
aAmong respondents who were not sexually active at baseline.
bThe regression analysis was completed in three steps. First, respondent's age and two covariates
measuring artifacts of the study design were forced into the equation. Second, a backward
stepwise procedure with a conservative criterion for removal (P = .20) was applied to all other
covariates. Finally, the intervention indicator was forced into the equation. The resuits for this final
step are reported.
CAmong respondents who were sexually active by the follow-up interview.
din order to satisfy the assumption of homoscedasticity in ordinary least squares regression, a
natural log transformation was applied to frequency of sex in the previous 6 months.31 To permit
retention of respondents who reported no sex in the previous 6 months, a constant (1) was added
to each score prior to this transformation.
*P < .05; **P < .01.
Sellers et al.
0.5
10
GIRLS
MULTIPLE PARTNERS*
BOYS
I
GIRLS
partners.
FREQUENCY OF SEX**
BOYS
GIRLS
-2.0
0.5
**REGRESSION COEFFICIENT
-1.5
-1.0
-0.5
0.0
1.0
Note. The estimated effect of the intervention is shown after adjustment for differences between the
intervention and comparison groups. Error limits indicate 95% confidence intervals. The onset of
sexual activity analyses used logistic regression and were restricted to those not sexually active
before the baseline interview. The multiple partner analyses used logistic regression and were
restricted to those who were sexually active by the follow-up interview. The frequency of sex
analyses, which were also restricted to those sexually active by the follow-up interview, used
ordinary least squares linear regression. A natural log transformation was applied to frequency of
sex after adding a constant (1) to each score.
Discussion
Evaluation of an HIV prevention
that included the promotion and
distribution of condoms provided no
evidence to suggest that the availability of
condoms increased sexual activity or promoted promiscuity in the target population of Latino adolescents. Adolescents in
the intervention city who were not sexually active prior to the intervention were
no more likely to become sexually active
program
Acknowledgments
References
206-214.
3. Centers for Disease Control. Sexual behavDecember 1994, Vol. 84, No. 12
1992;82:1536-1538.
Perspect. 1989;21:12-18.
McKinlay).
1986;48:777-782.
1986;48:503-512.
1957
Sellers et al.
PediatnicAnn. 1993;22:120-126.
61. Kirby D, Barth RP, Leland N, Fetro JV.
62.
63.
64.
65.
66.
1992il4:421-433.
67. Green LW. Manual for scoring socioeconomic status for research on health behavior. Public Health Rep. 1970;85:815-827.
68. Rossenberg M, Schooler C, Schoenbach C.
Self-esteem and adolescent problems: modeling reciprocal effects. Am Sociol Rev.
1989;54:1004-1008.
APPENDIX-Description of Covarlates
Factors related to adolescent sexual activity
Parental supervision: 1 = parents always "know where you are and what you are doing"; 0 = otherwise.
Parental attachment: Sum of responses (5 categories, never to always, coded so that high score indicates greater attachment) to 4
items: Do parents act fair and reasonable? Do parents act as if they don't care? Do parents blame or criticize you when you don't
deserve it? and Do you respect parents' opinion about important things in life?
Peer influence: 1 = respect friends' opinions more often than parents'; 0 = otherwise.
Importance of friends: 1 = responded very or fairly important to 2 items: importance of friends in life and importance of time spent with
friends: 0 = otherwise.
Normative environment: Product of number of best friends (0-5) who had sex in last 6 months with 5-category response (never = 1,
always = 5) to "How often would you like to be the kind of person your best friends are?"
Family intact: 1 = 2 parents (stepparents or natural parents) living in home at baseline; 0 = otherwise.
Socioeconomic status: Green's 2-factor index. 67
Age: respondent's age in years at baseline.
Changed residence: 1 = moved between baseline and follow-up interviews; 0 = otherwise.
Employment: 1 = employed at baseline; 0 = otherwise.
Dropout-follow-up: 1 = withdrew from school without high school degree by follow-up; 0 = otherwise.
Self-esteem: Rossenberg's 5-item scale.68
Church attendance per month: number of times attending church each month (12 = 12 or more).
Ever smoked: 1 = ever smoked even one puff of a cigarette; 0 = otherwise.
Ever consumed alcohol: 1 = 12 or more drinks of alcohol in lifetime; 0 = otherwise.
Drunk: 1 = 5 or more drinks in 1 day in past 12 months; 0 = otherwise.
Medium and high acculturation: Sample was divided into three levels of acculturation (0-7 = low, 8-9 = medium, and 10-15 = high)
based on the sum of the 5-category responses (1 = Spanish only, 5 = English only) to questions about language use with friends,
language use with family, and the language of the interview; indicators (1 = yes, 0 = no) for the medium and high levels of acculturation were used as covariates.
Medium acculturation-socioeconomic status: Product of indicator for medium level of acculturation and socioeconomic status.
High acculturation-socioeconomic status: product of indicator for high level of acculturation and socioeconomic status.
Worry about AIDS: response (1 = not at all, 4 = a great deal) to "How much do you worry that you could get AIDS?"
AIDS knowledge: scale measuring AIDS knowledge constructed from 13 yes/no items about the mechanisms of transmission, means
of lowering risk of infection, and cure or prevention of the virus.
Living with partner-follow-up: 1 = living with partner at time of follow-up interview; 0 = otherwise.
Multiple partners-baseline: 1 = 2 or more sex partners in 6 months prior to baseline interview; 0 = otherwise.
Frequency of sex-baseline: frequency of sex in 6 months prior to baseline interview.
Intervention activities
AIDS program: 1 = hosted AIDS discussion group in home; 0 = otherwise.
AIDS workshop: 1 = attended AIDS workshop or forum outside of home; 0 = otherwise.
Condom kit: 1 = received condom kit, including condoms and information about how to use them; 0
Free condom: 1 = received free condom in the last 6 months; 0 = otherwise.
otherwise.
Study design
Smoking study participant: 1 = participant in previous smoking study; 0 = otherwise.
Months to follow-up: number of months between the baseline and follow-up interviews.