Assessment of university condom distribution programs: results of a national study.
Butler, Scott M. ; Procopio, Mikella ; Ragan, Kathleen 等
Introduction
Male latex condoms have been found to significantly reduce the risk
of sexually transmitted infections (STIs; Ahmed et al., 2001; Bleeker et
al., 2003; CDC, 2012; Hogewoning et al., 2003; Holmes, Levine, &
Weaver, 2004; Sanchez et al., 2003; Winer, 2006) and unintended
pregnancy (Trussell, 2007). Results of the spring 2012 American College
Health Association (ACHA): National College Health Assessment II survey
revealed that 59.6% of sexually active college students used a male
condom the last time they had vaginal intercourse, .6% a female condom,
and 45.3% report using a male condom in addition to another method
(ACHA, 2013). Lack of availability of condoms has been reported as a
barrier to condom use among college students (Crosby et al, 2003; Crosby
et al., 2002). Condom distribution programs are one form of public
health structural interventions designed to reduce STIs and unintended
pregnancy. According to the CDC (2010) condom distribution programs are
a useful HIV reduction intervention strategy because they address
"external factors that impact personal risk for HIV." Recent
epidemiological investigations indicated condom distribution programs
are effective in increasing condom use and decreasing STI incidence
among preferred populations (Charania et al., 2011).
Despite the role of condoms in reducing STIs and unintended
pregnancy, few studies have assessed condom distribution programs and
sexual health interventions among colleges and universities. A recent
study by Butler and colleagues (2011a) evaluated condom and safer sex
product availability among 358 student health service departments
nationwide. Results indicated that 84.9% of all schools distribute
condoms to their students. The M number of condoms distributed/year was
9,414 (Mdn = 3,000 and Mo = 0). The most common method of distribution
was educational outreach on campus (67.0%), followed by events on campus
(61.7%), and the least common method was outreach conducted at local
bars and restaurants (7.5%). Less than half of participating schools
offered products other than male latex condoms such as sexual
lubricants, latex dams, female condoms, and condoms above/below typical
size. School demographics were found to correlate to condom availability
with public schools more likely to sponsor a condom distribution program
and significantly distribute more condoms/year than private schools.
Similarly, faith-based schools were less likely to offer condoms to
students and the overall number of condoms given to students/year was
significantly lower.
The recent investigation by Butler and colleagues (2011a) was the
first empirical study to assess the mean number of condoms distributed
to students/year nationally. The finding provides unique insight into
the prevalence of condom distribution programs within schools as well as
their utilization by student populations. Additional large-scale
investigations with similar recruitment and sampling methodologies are
needed to corroborate this finding and increase the reliability of the
results. More extensive evaluations of condom and safer sex product
availability are needed including assessments of the relationship
between various products and college/university demographics. In
addition, while the study by Butler and colleagues (2011a) evaluated
distribution methods sponsored by college health centers, future
research is needed to assesses methods used to distribute condoms campus
wide. Finally, in addition to information related to product
distribution, more comprehensive assessments are needed to assess
institutional policies and procedures related to condom distribution
programs including strategies for advertising availability on campus.
The purpose of the present study was to assess the prevalence of
condom and safer sex product distribution programs, condom distribution
procedures, typical number of condoms given to students/year,
demographic correlates of condom availability, and condom publicizing
methods among U.S. colleges and universities.
Method
Participants
Four hundred thirty-eight participants (39.8% response rate) who
served as their campus ACHA representative or the director of student
health services department completed questionnaires regarding their
institution's condom and safer sex product-related services.
Institutionally, the participants resided in 47 U.S. states and
Washington D.C. The sum student population of participating institutions
was 4.8 million. The M student population was 11,126 (SD = 12,680, Mdn =
6,000, and Mo = 12,000). Additional regional, institutional, and student
population demographics are contained in Table 1.
Procedures
Data were collected as part of a large national assessment of
condom and safer sex product availability among U.S. colleges and
universities [see Butler, Procopio, Ragan, Funke, and Black (2011) for
an additional report on schools in rural areas]. All recruitment
procedures were approved by the campus Institutional Review Board at
Georgia College. A previous statistical power assessment by Butler and
colleagues (2011a) conducted on colleges and universities nationally
indicated a sample size of [greater than or equal to] 358 would be
necessary for the present investigation. To meet this minimum
requirement a sampling frame of 1,101 colleges and universities was
identified. To be consistent with the previous investigation conducted
by Butler and colleagues (2011a), a list of 759 institutional members of
the American College Health Association (ACHA) was procured. This list
was supplemented with 342 schools that were randomly stratified from the
Peterson's Guide to Four-Year Colleges (2006). Initially, consent
forms and a copy of the ICAQ were mailed to each of the 1,101 selected
institutions. An additional reminder card was mailed and email was sent
to those who had not responded to previous recruitment efforts.
Measures
The participants completed the Institutional Condom Assessment
Questionnaire (ICAQ) developed by Butler and colleagues (2011b). The
ICAQ is a valid and reliable instrument designed to evaluate condom and
safer sex product availability (15 items), condom distribution methods
(20 items), use of peer helpers to distribute condoms and conduct condom
outreach (7 items), and condom publicizing methods (26 items) on college
and university campuses. In addition, the ICAQ contains 21 items
assessing college/university demographics. Previous psychometric
analyses of the ICAQ by Butler and colleagues (2011b) indicated the
overall internal consistency of the instrument was .93 with individual
section reliabilities from .60-.93. Split-half reliability analyses were
conducted on the ICAQ by dividing the instrument into two parts
(Cronbach alphas of .78 and .92, respectively). The correlation between
the two parts was .66, the Spearman-Brown Coefficient value was .79 for
both equal and unequal lengths, and the Guttman Split-Half Coefficient
value was .72. A test-retest consistency assessment was conducted on the
ICAQ by having a subsample of 32 university student health service
department employees complete the questionnaire on two occasions.
Results indicated the test-retest consistency across all service-related
items was 89.6%. For additional information regarding the validity and
reliability of the ICAQ see Butler and colleagues (2011b).
Data Analyses
Descriptive statistics and measures of central tendency were used
to assess demographic variables, rate of condom and safer sex
product-related services, and the M, Mdn, and Mo of the condoms
distributed to students/year. Simple Pearson Chi Squared tests were used
to assess statistical differences among product availability across the
six demographic variables contained in Table 1. The Mann-Whitney U test
and Kruskall-Wallis H tests assessed condom rank differences across the
six demographic variables. Bonferoni corrections were used to avoid Type
1 errors for the Simple Pearson Chi Squared tests as well as the
Mann-Whitney U and Kruskall-Wallis H tests. For these computations,
alpha levels for tests of significance were adjusted by dividing .05 by
5 (the number of comparisons for each variable) and alpha was set at
.01. A Spearman Rank Correlation Coefficient was used to assess the
relationship between the condoms distributed to students /year variable
and the college/university population variable.
Results
Condom and Safer Sex Product Availability
Nationally, 86.3% (n = 378) of all colleges and universities
distribute male latex condoms to their students. Results regarding the
rate of condom and safer sex product availability, as well as their
distribution procedures are contained in Tables 2-3. Among the 378
institutions that sponsor a condom distribution program, 95 (25.1%) were
unable to report data regarding the number of condoms typically given to
students/year. Among those reporting data, the M was 9,999 (95% CI =
7,702 - 12,298, Mdn = 3,000, and Mo = 0). Significant differences were
observed in the number of male latex condoms given to students/year in
the student population variable, H(3) = 75.10, p < .001. Post hoc
comparisons indicated that schools with populations < 5,000
distributed less condoms than schools with populations of 5,000 - 9,999,
U = 2994, p = .035, as well as schools with 10,000 - 24,999, U = 3526, p
< .001, and schools with populations of > 25,000, U = 1064, p <
.001. When compared to private schools, public institutions distributed
more condoms, U = 9017, p < .001, as did non-faith-based schools when
compared to faith-based schools, U = 3041, p < .001. There were no
statistically significant differences among geographic region, H(3) =
7.570, p = .056, or residential characteristic, H(2) = 1.505, p = .471.
Additional data assessing the number of condoms distributed to students
and condom/safer sex product program comparisons across demographic
characteristic are contained in Tables 4-6.
Policies and Procedures for Condom Distribution
Additional data regarding condom publicity methods are contained in
Table 7. More than three-quarters (77.5%) of institutions with a condom
program host a condom-related campus event such as World AIDS Day or
Safe Spring Break Week in which condoms are given to students.
Similarly, 61.6% host a student group or organization that distributes
condoms to their peers. Among the institutions that sponsor a condom
program, 52.4% offer condoms to students without charge, 3.7% require
students to purchase condoms, 42.3% offer them for free and charge their
students, and 1.6% did not report whether or not they required their
institution to charge for condoms. Only 2.6% required students to
undergo a counseling session with a healthcare provider or prevention
specialist when acquiring condoms on campus. Approximately one third
(32.8%), received their condoms from an outside source for free such as
a state/local public health institution, condom company, or other
organization. Similarly, nearly 20% of schools included an outside
agency such as Planned Parenthood as part of their program. More than
half (55%) refer students to these organizations and/or agencies for
condom acquisition and/or condom-related concerns.
Discussion
The results of this national investigation indicate that the vast
majority of U.S. colleges and universities (86.3%) distribute condoms to
their students. Assessment of the number of condoms distributed to
students/year variable revealed that the M value was 9,999, the Mdn
3,000, and the Mo 0. When factoring in student population, the adjusted
number of condoms given to students per year is 1.00 condoms/student
among institutions that provide a condom distribution program and .90
condoms/student among all institutions. Overall, when taking these
assessments into consideration, results of the present study suggest
that condom availability among colleges and universities nationally may
not be adequate to significantly reduce risk of STIs and unintended
pregnancy among students.
Results are consistent with previous assessments of sexual
health-care availability among U.S. colleges and universities, which
indicated that demographic variables significantly predict service
availability (Butler et al, 2011a; Butler, Black, & Avery, 2012;
Koumans et al., 2005; McCarthy, 2002; Miller, 2011). Demographic
assessments conducted by the Pearson Chi Squared tests indicate that
student population is the most common statistically significant
correlate. On 11 of the 14 comparisons (78.6%) colleges and universities
with larger student populations were significantly more likely to
distribute condom and safer sex products to their students. On each of
these occasions a linear relationship was observed between the reported
number of students within the college or university and proportion of
institutions which offer products to their students. In addition,
according to post hoc comparisons the number of condoms distributed to
students significantly increased as student population increased.
Overall, these results are consistent with previous assessments of
sexual health care on college campuses (Butler et al, 2011a; Butler et
al, 2012; Koumans et al., 2005) and indicate schools with larger student
populations may have more resources and/or greater infrastructure for
sexual health care delivery. Future research is needed to assess the
relationship between student population and allocated funds for
prevention programs on college and university campuses.
Private institutions were less likely to offer condoms and safer
sex products on the majority of occasions when compared to public as
were faith-based when compared to non-faith-based. Overall, on 11 of the
14 comparisons (78.6%) faith-based colleges and universities were
significantly less likely to offer condom and safer sex products to
their students. In addition, faith-based institutions distributed 1,446
condoms to students on a typical year (Mdn = 0) whereas non-faith-based
schools distributed 12,353 (Mdn = 4,025). Findings suggest faith-based
institutions may have unique barriers to condom and safer sex product
distribution such as institutional ideology and/or restrictions based
upon religiosity. Future research is needed to assess the sexual
behaviors and condom use among students attending faith-based schools
and whether this population faces significant sexual health care-related
disparities.
It is noteworthy that of the 14 condom and safer sex products
assessed only male latex condoms, male latex condoms without spermicide,
and sexual lubricants were reported by at least 50% of all institutions.
Less than 40% of all colleges and universities offer key safer sex
products, which may be useful in the prevention of STIs such as latex
dams, specialty condoms, and latex gloves. Of the 18 distribution
methods assessed, half were found in 10% or less of all colleges and
universities nationwide. With regard to publicizing condom availability
on campuses, only two strategies (advertising through peer
educator/helper outreach and advisers in residential halls) were
reported by 50% or more of all institutions. Similarly, only 27.2% of
schools advertise condom availability through campus fliers and 13.8%
through social networking. These findings suggest more comprehensive and
innovative strategies are needed to ensure that the environments where
students live are adequately reached in structural condom distribution
programs. In addition to traditional dissemination efforts, more
comprehensive publicizing strategies are needed that are wide-ranging
and focus upon technological innovations such as incorporating social
media.
The present study provides unique insight into condom and safer sex
product distribution methods and as well as policies and procedures
within colleges and universities. Findings provide the largest national
assessment of the number of condoms given to students/year and
corroborate the previous finding by Butler and colleagues (2011a). While
the previous investigation by Butler and colleagues (2011a) was limited
to distribution methods sponsored by student health service departments,
the present study included campus-wide initiatives. In addition, the
present study included unique insight into the prevalence of condom
advertising on college and universities and the collaboration of schools
with outside agencies such as public health departments and Planned
Parenthood. Finally, while the previous study by Butler and colleagues
(2011a) assessed male condom availability across demographic
characteristics, the present investigation conducted demographic
assessments of 14 condom and safer sex products.
The present study has limitations to consider. Data produced for
the investigation was self-reported by the director of the student
health services department or the ACHA designated representative. It is
possible that this individual could under or over represent the number
of condoms given to students/year. However, it is believed that this
individual was most likely to be informed of condom distribution efforts
campus wide and most willing to provide valid and reliable results.
While the present investigation assessed condom distribution procedures
campus wide, it is noteworthy that all of the participating institutions
house a student health services department. Based upon this, findings
may not generalize to colleges and universities who do not sponsor a
student health services program. Of the 378 institutions that report
distributing condoms to their students, 95 (25.1%) were unable to report
the M number of condoms typically given to students/year. This finding
is consistent with Butler and colleagues (2011a) who found that 22.6% of
participating institutions did not report the activity of their campus
program. Butler and colleagues (2011a) hypothesize that reporting this
statistic in particular may require time and/or effort that may be
deemed excessive. Finally, the present investigation assessed the
availability of condom distribution programs nationally as well as the
number of condoms given to students/year. However, the effect of these
condoms in reducing STIs, unintended pregnancy, or other
health-enhancing outcomes is unknown
Findings from the present study have implications for condom
distribution programs and the development of benchmarks for
condom-related programs on college campuses nationally. Results provide
useful information regarding condom availability, distribution
strategies, demographic comparisons, and condom publicizing strategies
for a large sample of U.S. colleges and universities representing a
significant portion of students nationwide. In addition, the results may
assist in the development of comprehensive health-care implementation
and health policy development within institutions. Future research is
needed to assess the overall prevalence of condom distribution programs
within collegiate settings as well as their impact upon the health of
students.
Scott M. Butler, PhD, MPH
School of Health and Human Performance, Georgia College
Mikella Procopio, BA, BSN, RN
School of Health and Human Performance, Georgia College
Kathleen Ragan, BS, CHES
School of Public Health, Emory University
Barbara Funke, PhD, MCHES
School of Health and Human Performance, Georgia College
David R. Black, PhD, MPH, HSPP, CHES, CPPE, FASHA, FSBM, FAAHB,
FAAHE
Department of Health and Kinesiology, Purdue University
Contact and Additional Information to be addressed to: Scott M.
Butler, PhD, MPH
College of Health and Human Performance
Georgia College, Campus Box 112 Milledgeville, GA 31061
478-445-1218
scott.butler@gcsu.edu
Author Note: This publication was supported in part by a grant
provided by the Georgia College Foundation.
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Table 1
Regional, Institutional, and Setting Demographics of Participant
Institutions (n = 438)
Respondents
Demographic n %
Region
South 123 28.1
Northeast 111 25.3
Midwest 104 23.7
West 88 20.1
Unreported 12 2.7
Type of Institution
Public 235 53.7
Private 190 43.4
Unreported 13 3.0
Student Population Size
<5,000 187 42.7
5,000-9,999 66 15.1
10,000-24,999 119 27.2
[greater than or equal to]25,000 55 16.6
Unreported 11 2.5
Residential Characteristic
Primarily Residential 187 42.7
Primarily Commuter 148 33.8
Equal Residential/Commuter 90 20.5
Unreported 13 3.0
Religious Affiliation
Non-Faith-Based 353 81.1
Faith-Based 83 18.9
Table 2
Prevalence of Condom Safer and Sex Product Availability among Colleges
and Universities (n = 438)
Variable n %
Male latex condoms (of any kind) 378 86.3
Male latex condoms (without spermicide) 324 74.0
Sexual lubricants 221 50.5
Latex dams (i.e., dental dams) 172 39.3
Male flavored condoms 168 38.4
Female condoms 164 37.4
Condoms above average size 152 34.7
Male latex condoms (with spermicide) 150 34.2
Male non-latex condoms 133 30.4
Flavored latex dams 103 23.5
Condom carriers (i.e., pouches or cases) 81 18.5
Latex gloves 65 14.8
Non-latex gloves 55 12.6
Condoms below average size 43 9.8
Other 23 5.3
Table 3
Prevalence of Condom Distribution Methods among Colleges and
Universities (n = 378)
Variable n %
At the student health services 363 96.0
Through educational outreach 222 58.7
In residential halls 203 53.7
Through appointment with health care provider 199 52.6
At campus events 152 40.2
At student organization office (e.g. Gay-Straight 133 35.1
Alliance)
At the student health center/health services after hours 99 26.2
At counseling services 91 24.1
At the pharmacy 98 23.3
In campus vending machines 49 13.0
In campus restrooms 33 8.7
At campus bookstore 31 8.2
At campus grocery store 21 5.6
In academic department offices/lounges 16 4.2
At bars near or on campus 12 3.2
At campus athletic events 8 2.1
At campus library 8 2.1
Through campus mailings 6 1.6
At restaurants near or on campus 3 .8
Other 38 10.1
Table 4
Comparisons of Condoms Distributed across Campus Demographic
Characteristics (n = 336)
Variable M 95% CI Mdn
Population
<5,000 3,561 2,221-4,900 1,500
5,000-9,999 5,232 2,794-7,668 2,500
10,000-24,999 12,679 8,336-17,023 6,000
>25,000 32,594 19,510-45,679 15,000
Region
West 9,776 5,805-13,746 5,000
Midwest 10,461 4,000-16,923 2,000
Northeast 7,815 4,109-11,521 3,000
South 11,850 7,846-15,853 3,000
Type of Institution
Public 14,763 10,638-18,888 5,000
Private 4,785 3,316-6,255 2,000
Residential Characteristic
Primarily residential 9,371 5,960-12,783 3,000
Commuter 11,569 6,864-16,274 3,000
Equal 7,988 4,610-11,368 2,750
Faith Affiliation
Faith-Based 1,446 630-2,262 0
Non-Faith-Based 12,353 9,491-15,215 4,025
Table 5
Prevalence of Condom Availability Programs across Campus Demographic
Characteristics (n = 438)
Variable a b c d
Population
<5,000 75.9 59.9 23.0 24.6
5,000-9,999 89.4 77.3 36.4 37.9
10,000-24,999 95.0 86.6 53.8 50.4
>25,000 96.4 ** 87.3 ** 61.8 ** 52.7 **
Region
West 92.0 79.5 37.5 27.3
Midwest 79.8 65.4 38.5 34.6
Northeast 83.8 73.0 32.4 45.0
South 89.4 78.0 46.3 40.0
Type of Institution
Public 95.7 83.8 46.4 43.0
Private 74.7 ** 61.6 ** 29.5 ** 30.5 *
Residential Characteristic
Commuter 89.2 78.4 43.9 35.8
Equal 87.8 74.4 38.9 37.8
Primarily Residential 82.4 73.4 34.2 35.8
Non-Faith-Based 96.3 82.8 44.5 44.2
Faith-Based 43.4 ** 36.1 ** 12.0 ** 8.4 **
Variable e f g h
Population
<5,000 19.3 36.4 17.1 2.7
5,000-9,999 34.8 28.8 24.2 6.1
10,000-24,999 49.6 36.1 44.5 17.6
>25,000 52.7 ** 29.1 50.9 ** 21.8 **
Region
West 39.8 36.4 29.5 17.0
Midwest 28.8 29.8 26.9 7.7
Northeast 32.5 39.6 27.0 9.0
South 37.4 30.9 37.4 7.3
Type of Institution
Public 44.7 35.7 35.7 12.3
Private 22.1 ** 32.6 23.2 5.8
Residential Characteristic
Commuter 45.9 32.4 31.8 14.9
Equal 32.2 38.9 30.0 6.7
Primarily Residential 26.7 * 34.2 29.4 7.5
Non-Faith-Based 39.7 38.6 34.6 11.5
Faith-Based 13.3 ** 15.7 ** 12.0 ** 2.4
Note. Assessments were conducted using the Pearson Chi Squared test.
Level of significance set at .01. * p < .01. ** p < .001.
a = Male latex condoms (of any kind), b = Male latex condoms (without
spermicide), c = Male flavored condoms, d = Female condoms, e =
Condoms above average size, f = Condoms (with spermicide), g = Male
non-latex condoms, h = Condoms below average size.
Table 6
Prevalence of Safer Sex Product Availability across Campus Demographic
Characteristics (n = 438)
Variable a b c d e f
Population
<5,000 32.1 27.8 11.8 9.6 11.2 10.7
5,000-9,999 48.5 37.9 25.8 24.2 15.2 13.6
10,000-24,999 69.7 51.3 33.6 26.9 19.3 16.8
>25,000 74.5 ** 60.0 41.8 ** 25.5 ** 20.0 10.9
Region
West 61.4 37.5 26.1 23.9 18.2 10.1
Midwest 48.1 39.4 25.0 18.3 13.5 15.4
Northeast 45.0 44.1 24.3 13.5 15.3 12.6
South 50.4 39.0 21.1 20.3 13.8 11.4
Type of Institution
Public 62.6 43.4 29.8 24.7 17.0 14.0
Private 36.8 ** 35.8 16.3 * 11.6 * 13.2 11.6
Residential Characteristic
Commuter 57.4 41.9 27.0 25.0 15.5 13.5
Equal 53.3 38.9 21.1 18.9 18.9 11.1
Primarily 43.9 38.0 22.5 13.9 13.4 13.4
Residential
Faith Affiliation
Non-Faith-Based 58.0 45.6 27.6 21.4 16.9 13.5
Faith-Based 18.1 ** 12.0 ** 6.0 ** 6.0 ** 6.0 8.4
Note. Assessments were conducted using the Pearson Chi Squared test.
Level of significance set at .01. *p < .01, **p < .001
a = Sexual lubricants, b = Latex dams, c = Flavored latex dams, d =
Condom carriers, e = Latex gloves, f = Non-latex gloves
Table 7
Publicizing Methods among Institutions with Condom Distribution
Programs (n = 378)
Variable n %
Peer educator/helper outreach 219 57.9
Advisers in residential halls 209 55.3
Staff outreach 183 48.3
Brochures 123 32.5
Campus website 123 32.5
Fliers 103 27.2
Posters 70 18.5
Campus newspaper 63 16.7
Faculty lectures 58 15.3
Social networking 52 13.8
Emails 31 8.2
Campus television 11 2.9
Text messaging 2 .5
Phone book 2 .5
Other 44 11.6
