Does the Promotion and Distribution

of Condoms Increase Teen Sexual

Activity? Evidence from an HIV
Prevention Program for Latino Youth

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

promiscuity."'3 An even stronger position

was expressed by Phyllis Schlafly during
the debate over the distribution of condoms in the New York City public
schools: "condom distribution programs
produce an increase in teen-age sexual
activity."'14 The goal of this study was to
empirically evaluate the assertion that the
promotion and distribution of condoms
increases adolescent sexual activity.
Since the consistent and correct use
of condoms reduces the risk of HIV

infection,1"'15"16 HIV/AIDS prevention

programs often include the promotion

and distribution of condoms.'7'18 In developing countries, these programs target

both the general adult population and
high-risk populations such as prostitutes.19'20 In the United States, such
programs are more likely to target highrisk populations such as homosexual men,
intravenous drug users, and prostitutes,
although in some areas condoms are
distributed to a broader adult population.2122 The controversy over condom
distribution arises primarily when general
adolescent populations are targeted."
The first school-based condom availability program in the United States was
implemented in a school district in Commerce City, Colo, in 1988.10 In 1991, the
New York City school board adopted a
condom availability program after a nationally publicized debate.1023 Since that
time, similar programs have been implemented or approved in at least 45 other
cities and towns throughout the United
States.24 In some of these programs,
access to condoms is provided in schoolbased health clinics; in other programs,
specially trained faculty, staff, and/or
volunteers provide condoms at designated
times and places. Under both methods of
distribution, however, students who want
condoms must make some effort to
acquire them. Condoms are not automatically given to every student. In addition,
most condom availability programs represent one component of a more comprehensive HIV prevention or sexuality education program.8
To date, little research has focused
on the question of whether programs that
The authors are with the New England
Research Institute, Watertown, Mass.
Requests for reprints should be sent to
John B. McKinlay, PhD, New England Research Institute, 9 Galen St, Watertown, MA
02172.
This paper was accepted June 22, 1994.

December 1994, Vol. 84, No. 12

Condoms and Teen Sex

include the promotion and distribution of
condoms increase adolescent sexual activity. One study of three school-based
health clinics that dispensed contraceptives found that the percentage of students who had ever had sex, the mean age
at first intercourse, and the frequency of
sex in the previous 4 weeks were no higher
among students in schools with clinics
than among students in matched comparison schools.25 Another study 'evaluated
the effect of a direct mailing about
condoms, including coupons for free
condoms, to 16- and 17-year-old lowincome boys.26 This study found no difference between the experimental and control groups in the percentage who had
ever had sex or the mean number of acts
of coitus; however, the method of intervention, the short time period between the
intervention and follow-up, and the focus
on lifetime sexual activity limit the utility
of this study.
A recent evaluation of an HIV
prevention program among Latino teenagers in two northeastern cities provides
data with which to empirically examine
the question of whether the promotion
and distribution of condoms increases
sexual activity in a population-based
sample of adolescents. Three specific
questions were addressed: (1) Were adolescents who had not initiated sexual
activity prior to the prevention program
more likely to initiate activity as a result of
the intervention? (2) Were adolescents
who were sexually active by the end of the
intervention more likely to have multiple
partners as a result of the intervention?
and (3) Were adolescents who were
sexually active by the end of the intervention having sex more frequently as a result
of the intervention?

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

presentations at large community events;

and door-to-door and street corner canvassing. This canvassing included distribution of a kit that provided condoms and
pamphlets on how to use them. Condoms
were also freely available at the intervention office and at all intervention activities. Project messages promoting the use
of condoms were disseminated throughout the intervention neighborhood via
radio and television public service announcements, posters in local businesses
and public transit facilities, and a quarterly newsletter produced by the peer
leaders. Use of a variety of channels for
the distribution and promotion of condoms, as well as other project messages,
ensured relatively easy access to condoms
and rather pervasive saturation of the
project message in the target neighborhood. A more comprehensive description
of the intervention is available elsewhere.27
Evaluation of the intervention consisted of a longitudinal comparison of
probability samples of Latino youth from
the intervention city (Boston) and a
comparison city (Hartford, Conn). Hartford was selected as the comparison city
because it provided a comparable innercity Latino population and because its
160-km (100-mile) distance from Boston
minimized the possibility of intervention
activities affecting the comparison site.
Areal probability samples, rather than
school- or participant-based samples, were
used because the intervention targeted
the general adolescent population. To
draw a representative, probability sample
of Hispanic adolescents in each city,
census blocks in which at least 20% of the
population was of Spanish origin were
selected as target neighborhoods. In these
target neighborhoods, standard block sampling and household enumeration procedures were used to identify eligible Hispanic adolescents. A detailed description
of the enumeration and sampling procedures has been provided elsewhere.27 29
Trained, bilingual staff completed
baseline interviews before and follow-up
interviews after the intervention activities,
which took place between June 1990 and
December 1991. Interviewers, who were
paired with respondents of the same sex,
protected confidentiality in both interviews by conducting them in private
places. Interviews covered sociodemographic information, AIDS knowledge
and attitudes, and sexual activity and
condom use.
The HIV prevention program increased the likelihood that a teen would

have a condom in his or her possession.27

After adjustment for covariates, the odds
of possessing a condom at the time of the
follow-up interview were 2.3 (P < .01)
and 2.0 (P = .07) times greater for boys
and girls, respectively, in the intervention
city. The intervention also lowered the
risk of HIV infection in males and females
by 9% and 15%, respectively, after adjustment for baseline risk and other covariates; however, these differences did not
achieve statistical significance (Ps = .20
and' .15, respectively).27 More details
about the measurement of HIV risk and
the effects of the intervention are available elsewhere.27'29

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 -

by the Baseline Interview

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

Mean Frequency of Sex

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

FIGURE 1-Unadjusted value of outcome measures for intervention and

comparison groups, by gender and time of interview.

of interest be statistically controlled.30

Consequently, multivariate regression
methods were used to determine the
effect of the intervention on each outcome after any differences between the
intervention and comparison samples on
factors related to that outcome had been
controlled. Logistic regression was used
for the onset of sexual activity and
multiple partner analyses. Ordinary least
squares regression analysis was used for
frequency of sex. In 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.
The onset of sexual activity, multiple
partners at follow-up, and frequency of
sex at follow-up were each regressed on a
1954 American Journal of Public Health

set of covariates that included artifacts of

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-

ties in the comparison city, which took

place because of the general attention to
HIV education and prevention during the
period under study. The percentage of
respondents who reported participating
in AIDS programs and workshops was
similar in both cities, but a significantly
larger proportion of the intervention
group reported receiving either a condom
kit or free condoms (62% vs 42% of
females and 90% vs 73% of males). In the
intervention city, 75% of respondents
responded positively to one or more of
three questions during the follow-up interview that inquired about exposure to items
(posters, newsletter, condom kit) specifically associated with the intervention program, indicating that exposure to the
intervention activities was rather extensive.
In evaluations of the effects of the
intervention, analytic attention focused
on residence in the intervention city
rather than documented participation in
specific activities because the goal was to
reach the entire population of Latino
adolescents in the target neighborhoods
of the intervention city. The intervention
included some formally organized presentations and workshops that teens could
attend, but much of the activity involved
more diffuse efforts-including public
service announcements on local radio
stations, posters in businesses and public
transit facilities, and outreach workers on
street corners and at community
events-to expose the target population
to project messages. Thus, similar to
intention-to-treat analyses in clinical trials, residence in the intervention city
constituted exposure to the intervention,
and the effect of the intervention on
sexual behavior was captured via an
indicator for such residence.
For all three outcomes, the regression analysis was completed in three steps.
First, respondent's age and the study
design covariates were forced into the
model. Second, a backward stepwise
procedure including all other covariates
(except the intervention indicator) was
completed. The backward procedure, with
a conservative criterion for removal
(P = .2), permitted control of influential
covariates, even if not strictly statistically
significant. Finally, the indicator for intervention city was forced into the model to
assess-the effect of the intervention after
other covariates had been controlled.
Model fit was checked with the HosmerLemeshow goodness-of-fit statistic for
logistic regressions51 and residual analysis
for linear regressions.52
December 1994, Vol. 84, No. 12

Condoms and Teen Sex

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.

Unadjusted Intervention Effects

Figure 1 illustrates the unadjusted
intervention effects for both males and
females by presenting the outcome measures for the intervention and comparison
groups. The top panel provides the rate of
onset of sexual activity; the middle and
lower panels provide the change between
the baseline and follow-up interview in
the proportion with multiple partners and
in the frequency of sex, respectively, in the
6 months prior to the interview.
For female respondents, the rate of
onset of sexual activity was the same in the
intervention group as in the comparison
group. Similarly, the increase in the
frequency of sex between baseline and
December 1994, Vol. 84, No. 12

TABLE 1-Effect of the Intervention on the Level of Sexual Activity after

Adjustment for Covariates Related to Adolescent Sexual Activity,
Competing HIV Prevention Activities, and Artifacts of the Study
Design

Outcome

Onset of sexual activity between baseline and

follow-up interviewsa (logistic regressionb)
Odds ratio
95% confidence interval
Hosmer-Lemeshow goodness of fit (P level)
No.
Multiple (2+) sexual partners in the 6 months
prior to the follow-up interviewc (logistic

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.

follow-up was the same for females in

both groups, even though the frequency
was slightly higher in the comparison
group. In addition, for females, the increase in the percentage with multiple
partners in the 6 months prior to the
interview between the baseline and follow-up interviews was lower in the intervention group than in the comparison
group. For male respondents, the onset of
sexual activity between the baseline and
follow-up interviews and the increase in
the frequency of sex between baseline and
follow-up were lower in the intervention
than in the comparison group. However,
the increase in the percentage with multiple partners was greater in the intervention group than in the comparison group.
Thus, with the exception of the proportion of males with multiple partners, the
intervention did not accelerate the naturally occurring increase in the level of
sexual activity among either males or
females.

Adjusted Intervention Effects

The unadjusted results presented in
Figure 1 do not control for baseline
differences between the intervention and
comparison samples. As mentioned earlier, the lack of experimental control in
the quasi-experimental evaluation design
required that any differences between the
intervention and comparison groups on
factors related to the outcome of interest
be statistically controlled.30 Table 1 and
Figure 2 present the results of the
multivariate regression analysis applied to
each outcome to provide this statistical
control. Since the covariate results were
not central to the question of interest,
only the results obtained from forcing the
intervention indicator into the model (the
last step in each regression analysis) are
reported.
After control for the influence of
other covariates, males in the intervention
city were less likely to become sexually

American Journal of Public Health 1955

Sellers et al.

*ODDS RATIO (Intervention:Comparison)

0.01 0.02

0.05 0.1 0.2

ONSET OF SEXUAL ACTIVITY*

I
BOYS

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.

FIGURE 2-Effect of HIV prevention program, which includes the promotion

and distribution of condoms, on the sexual behavior of Latino
adolescents after adjustment for differences between the
intervention and comparison groups.

active than were males in the comparison

city (odds ratio [OR] = 0.08, P = .011).
For females, the intervention did not
significantly increase or decrease the
chances of becoming sexually active
(OR= 1.24, P = .692). Hosmer-Lemeshow statistics of 6.08 (P = .638) and
4.95 (P = .763) for males and females,
respectively, indicate that the fit of both
models was very good.
In terms of multiple partners, the
indicator for the intervention had an odds
ratio of 0.902 (P = .790) for males and an
odds ratio of 0.06 (P = .005) for females,
after the influence of the covariates had
been controlled. For both males and
females, the fit of the model was good,
with Hosmer-Lemeshow statistics of 5.51
(P = .702) and 4.60 (P = .800), respectively. Thus, female respondents in the
intervention city were significantly less
likely to have multiple partners at the
follow-up interview than were their counterparts in the comparison city. In addition, the apparently greater increase in
the propensity to have multiple partners

1956 American Journal of Public Health

among male respondents in the intervention group based on the unadjusted

results was insignificant after adjustment
for differences between the intervention
and comparison groups.
The intervention did not significantly
affect the frequency of sex for either male
or female respondents. Residual analysis
indicated no problems with the fit of
either model. About 28% and 38% of the
variance was explained by the covariates
in the model for males and females,
respectively.

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

than those in the comparison city. In fact,

male respondents in the intervention city
were less likely than those in the comparison city to experience the onset of sexual
activity. Among teens who were sexually
active by the end of the intervention, the
number of sexual partners and the frequency of sex in the previous 6 months
were no higher in the intervention city
than in the comparison city. Indeed,
female respondents in the intervention
city were less likely than those in the
comparison city to have had multiple sex
This lack of an increase in sexual
activity as a result of promoting and
distributing condoms is consistent with
previous research. Generally, providing
adolescents with information about reproduction and contraception has not increased sexual activity.54 60 Instead, recent
programs that have combined reproductive and contraceptive information with a
message to delay early sexual involvement
and the skills with which to achieve that
goal have documented a decrease in
sexual involvement and activity.6063 An
evaluation of school-based health clinics
that distributed contraceptives found no
increase in sexual activity.25
The lack of an increase in sexual
activity as a result of providing adolescents with access to contraceptives is also
consistent with the experience in other
developed nations. In countries such as
Sweden, the Netherlands, and England,
easy, confidential access to contraceptives
for adolescents has been institutionalized.
Yet levels of sexual activity among adolescents in those countries are similar to
those in the United States, and, despite
the similarity in the level of sexual activity,
the teen pregnancy rate in those countries
is generally considerably lower than that
in the United States.64
This investigation was limited in
several ways. First, the power to detect
differences between the comparison and
intervention cities was limited by the
sample sizes available. For the onset of
sexual activity analysis for females and the
multiple partner analysis for males, the
minimum detectable differences in the
unadjusted rates for the available sample
sizes (in a one-sided test with an alpha
level of .10 and a power of .80) were about
18 and 15 percentage points, respectively.65 For both males and females, the
minimum detectable difference in the
unadjusted frequency of sex in the previous 6 months was 13 contacts for a similar
test. However, the multivariate analysis
improved the power to detect differences
December 1994, Vol. 84, No. 12

Condoms and Teen Sex

by reducing within-group variances.32 In

addition to this limitation due to the
number of individuals, the study was also
limited by the use of only one intervention
and one comparison site.
Second, since this AIDS prevention
program focused on Latino adolescents,
the results cannot be immediately extrapolated to non-Hispanic Whites or AfricanAmerican teenagers. Unique cultural factors that vary with education, socioeconomic status, and acculturation may influence the effect of messages promoting the
use of condoms on Latino adolescents.4950'66 However, attention to the
effects of HIV prevention programs among
Latino adolescents is important because
the cumulative incidence of AIDS among
15- to 24-year-old Latinos is at least twice
as high as it is for other groups.28
In summary, the results of this
investigation, as well as previous research
and the experience with providing contraceptives to adolescents in other developed
nations, suggest that the concern that
providing adolescents with condoms and
information about condoms promotes
promiscuity and increases sexual activity
is not justified. Although additional research efforts should include attention to
this question, particularly in instances in
which data are readily available as part of
other investigations, the magnitude of the
crisis presented for adolescents and society by both teen pregnancy and the HIV
epidemic dictate that we provide adolescents with the information, skills, and
material goods required to combat these
problems. O

Acknowledgments

This research was supported by grant RO1

HD25026 from the National Institute of Child
Health and Development.
We would like to acknowledge the important work of Jose Duran, Heriberto Crespo,
Haner Jemandez, Antonieta Gimeno, the
Poder Latino peer leaders, and other staff at
the Hispanic Office for Planning and Evaluation. We would like to thank Eleanor Weber,
MA, Peter H. Rossi, PhD, Sybil L. Crawford,
PhD, and Kevin W. Smith, MA, for their
helpful comments on earlier versions of this
manuscript and Henry Feldman, PhD, for his
assistance with Figure 2.

References

1. Sonenstein F, Pleck JH, Ku LC. Sexual

activity, condom use and AIDS awareness
among adolescent males. Fam Plann Perspect. 1989;21:152-158.

2. Forrest JD, Singh S. The sexual and

reproductive behavior of American women,
1982-1988. Earn Plann Perspect. 1990;22:

206-214.

3. Centers for Disease Control. Sexual behavDecember 1994, Vol. 84, No. 12

ior among high school students-United

States, 1990. MMWR 1992;40:885-888.
4. Henshaw SK, Van Vort J. Teenage abortion, birth and pregnancy statistics: an
update. Fam Plann Perspect. 1989;21:8588.
5. Besharov DJ. Teen sex: truth and consequences. TheAmerican Enteiprise. January/
February 1993:53-59.
6. Annual Report. Atlanta, Ga: Division of
STD/HIV Prevention, Centers for Disease
Control; 1990.
7. Boyer C, Kegeles SM. AIDS risk and
prevention among adolescents. Soc Sci
Med. 1991;33:11-23.
8. Briefing Paper on Condom Availability in
Schools. Washington, DC: Center for Population Options; 1991.
9. Flax E. Condom policies move up school
boards' agenda. Education Week December 11, 1991:8.
10. Kerr DL. Condom availability in New York
City schools. J Sch Health 1991;61:279-280.
11. Roper WL, Peterson HB, Curran JW.
Commentary: condoms and HIV/STD prevention-clarifying the message. Am J

Public Health. 1993;83:501-503.

12. Tapia A. Abstinence: the radical choice for
sex ed. Chrislaniy Today. 1993;37(2):24-29.
13. Hearings Before the Senate Labor and
Human Resources Committee, 103rd Cong,
1st Sess (1993).
14. Schlafly P. Leading students into early sex?
The Washington Times. January 17, 1994:
G4.
15. Francis DP, Chin J. The prevention of
acquired immunodeficiency syndrome in
the United States. JAMA. 1987;257:13571366.
16. Weller SC. A meta-analysis of condom
effectiveness in reducing sexually transmitted HIV. Soc Sci MedL 1993;36:1635-1644.
17. Turner CH, Miller HG, Moses LE. AIDS
Sexual Behavior and Intravenous Dnrg Use.
Washington, DC: National Academy Press;
1989.
18. Coates T. Strategies for modifying sexual
behavior for primary and secondary prevention of HIV disease. J Consult Clin Psychol.
1990;58:57-69.
19. Coates TJ. Prevention of HIV-1 infection:
accomplishments and priorities. JNIHRes.
1993;5:73-76.
20. Tchupo JP, Manchester T, Monny LM,
Buschel R. The importance of peer distribution of condoms to prostitutes. Presented at the International Conference on
AIDS; June 16-21,1991; Florence, Italy.
21. Wunderlich G, Hannon A, Clark S, Goldman J, Johnston P, Wiley A. The 'Threefor-Free' Program: a statewide condom
distribution program. Presented at the
International Conference on AIDS; June
4-9,1989; Ottawa, Canada.
22. Calsyn DA, Meinecke C, Saxon AJ, Stanton V. Risk reduction in sexual behavior: a
condom giveaway program in a drug abuse
treatment clinic. Am J Public Health.

1992;82:1536-1538.

23. Blair JF. HIV/AIDS education including

condom availability in New York City
public schools. SIECUS Rep. 1992;20:8-11.
24. Cities with Schools Offering Condom Availability Programs. Washington, DC: Center
for Population Options; 1993.
25. Kirby D, Waszak C, Ziegler J. Six schoolbased clinics: their reproductive health

services and impact on sexual behavior.

Fam Plann Perspect. 1991;23:6-16.
26. Kirby D, Harvey PD, Claussenius D, Novar
M. A direct mailing to teenage males about
condom use: its impact on knowledge,
attitudes and sexual behavior. Fam Plann

Perspect. 1989;21:12-18.

27. McGraw SA, Smith KW, Crawford SL,

Costa LA, McKinlay JB. The effectiveness
of a community-based AIDS prevention
program for inner-city Latino youth. Manuscript under review (available from Dr

McKinlay).

28. Castro KG, Manoff SB. The epidemiology

of AIDS in Hispanic adolescents. In:
Quackenbush M, Nelson A, Clark K, eds.
The AIDS Challenge: Prevention Education
for Young People. Santa Cruz, Calif: Network Publications; 1988.
29. Smith KW, McGraw SA, Crawford SL,
Costa LA, McKinlay JB. HIV risk among
Latino adolescents in two New England
cities. Am J Public Health. 1993;83:13951399.
30. Rossi PH, Freeman HE. Evaluation: A

Systematic Approach. Beverly Hills, Calif:

Sage Publications; 1985.
31. Kleinbaum DG, Kupper LL, Muller KE.
Applied RegressionAnalysis and OtherMultivariate Methods. Boston, Mass: PWS-Kent
Publishing Co; 1988.
32. Fleiss JL. The Design and Analysis of
Clinical Experimnents. New York, NY: John
Wiley & Sons Inc; 1986.
33. Hofferth SL, Hayes CD, eds. Risking the
Future:Adolescent Sexualt, Pregnancy, and
Childbearing. Washington, DC: National
Academy Press; 1987.
34. Brooks-Gunn J, Furstenberg FF Jr. Adolescent sexual behavior. Am Psychol 1989;44:
249-257.
35. White SD, DeBlassie RR. Adolescent
sexual behavior. Adolescence. 1992;27:183191.
36. Moore KA, Peterson JL, Furstenberg FF.
Parental attitudes and the occurrence of
early sexual activity. J Mamage Fam.

1986;48:777-782.

37. Miller BC, McCoy JK, Olson TD, Wallace

CM. Parental discipline and control attempts in relation to adolescent sexual
attitudes and behavior. J Marriage Fam.

1986;48:503-512.

38. Shah F, Zelnick M. Parent and peer

influence on sexual behavior, contraceptive
use, and pregnancy experience of young
women. J Mamage Fam. 1981;43:339-348.
39. Jessor R, Costa F, Jessor L, Donovan JE.
Time of first intercourse: a prospective
study. J Pers Soc PsychoL 1983;44:608-626.
40. Thornton A, Camburn D. Religious participation and adolescent sexual behavior and
attitudes. J Mariage Fam. 1989;51:641653.
41. Day RD. The transition to first intercourse
among racially and culturally diverse youth.
JMarriage Fam. 1992;54:749-762.
42. Durbin M, DiClemente RJ, Siegel D,
Krasnovsky F, Lazarus N, Camacho T.
Factors associated with multiple sex partners among junior high school students. J
Adolesc Health. 1993;14:202-207.
43. Richter DL, Valois RF, McKeown RE,
Vincent ML. Correlates of condom use
and number of sexual partners among high
school adolescents. J Sch Health. 1993;63:
91-96.

American Joumal of Public Health

1957

Sellers et al.

44. Tli sinton A, Camburn D. The influence of

the family on premarital sexual attitudes and
behavior. Demography. 1987;24:323-340.
45. Newcomer S, Udry JR. Parental marital
status effects on adolescent sexual behavior. JMamage Fam. 1987;49:235-240.
46. Flewelling RL, Bauman KE. Family structure as a predictor of initial substance use
and sexual intercourse in early adolescence.JMarriageFam. 1990;52:171-181.
47. Miller BC, Bingham CR. Family configuration in relation to the sexual behavior of
female adolescents. J Marriage Fam. 1989;
51:499-506.
48. Ajzen I, Fishbein M. Understanding Attitudes and Predicting Social Behavior. Englewood Cliffs, NJ: Prentice-Hall; 1980.
49. Negy C, Woods DJ. A note on the
relationship between acculturation and
socioeconomic status. Hispanic JBehav Sci
1992;14:248-251.
50. Rogler LH, Cortes DE, Malgady RG.
Acculturation and mental health status
among Hispanics: convergence and new
directions for research. Am Psychol. 1991;
46:585-597.
51. Hosmer DW, Lemeshow S. Appled Logistic Regression. New York, NY: John Wiley
& Sons Inc; 1989.
52. Weisberg S.AppliedLinearRegression. New
York, NY: John Wiley & Sons Inc; 1980.

1958 American Journal of Public Health

53. Kish L. Survey Sampling. New York, NY:

John Wiley & Sons Inc; 1965.
54. Zelnick M, Kim YJ. Sex education and its
association with teenage sexual activity,
pregnancy and contraceptive use. Fam
Plann Perspect. 1982;14:117-126.
55. Furstenberg FF Jr, Moore KA, Peterson
JL. Sex education and sexual experience
among adolescents. Am J Public Health.
1985;75:1331-1332.
56. Dawson DA. The effects of sex education
on adolescent behavior. Fam Plann Perspect. 1986;18:162-170.
57. Marsiglio W, Mott FL. The impact of sex
education on sexual activity, contraceptive
use and premarital pregnancy among
American teenagers. Fam Plann Perspect.
1986;18:151-162.
58. Stout JW, Rivera FP. Schools and sex
education: does it work? Pediat,ics. 1989;83:
375-379.
59. Ku LC, Sonenstein FL, Pleck JH. The
association of AIDS education and sex
education with sexual behavior and condom use among teenage men. Fam Plann
Perspect. 1992;24:100-106.
60. Stout JW, Kirby D. The effects of sexuality
education on adolescent sexual activity.

PediatnicAnn. 1993;22:120-126.
61. Kirby D, Barth RP, Leland N, Fetro JV.

62.
63.

64.

65.
66.

Reducing the risk: impact of a new

curriculum on sexual risk-taking. Fam
Plann Perspect. 1991;23:253-263.
Howard M, McCabe JB. Helping teenagers
postpone sexual involvement. Fam Plann
Perspect. 1990;22:21-26.
Eisen M, Zellman GL, McAlister AL.
Evaluating the impact of a theory-based
sexuality and contraceptive education program. Fam Plann Perspect. 1990;22:261271.
Jones EF, Forrest JD, Goldman N, et al.
Teenage pregnancy in developed countries: determinants and policy implications.
Fam Plann Perspect. 1985;17:53-63.
Cohen J. Statistical Power Analysis for the
Behavioral Sciences. 2nd ed. Hillsdale, NJ:
Lawrence Erlbaum Associates; 1988.
Mikawa JK, Morones PA, Gomez A, Case
HL, Olsen D, Gonzales-Huss MJ. Cultural
practices of Hispanics: implications for the
prevention of AIDS. Hispanic J Behav Sci.

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.

December 1994, Vol. 84, No. 12

Condoms and Teen Sex

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.

December 1994, Vol. 84, No. 12

American Journal of Public Health 1959