Theoretical assessment of university condom distribution programs: an institutional perspective.
Butler, Scott M. ; Ragan, Kathleen ; Black, David R. 等
Introduction
Male condoms are commonly used by young adults and college students
to prevent unintended pregnancy and sexually transmitted infections
(STIs; American College Health Association [ACHA], 2013; Reece et al.,
2010). According to a national assessment of condom acquisition patterns
by men in the U.S., those who acquired free condoms received them from
settings common to universities including health clinics (20.5%), health
fairs (13.4%), dorms/student groups (13.4%), and classrooms (3.6%;
Reece, Mark, Schick, Herbenick, & Dodge, 2010). Over the last 12
years, several empirical studies assessing sexual behaviors among
students have identified condom errors and problems as important
epidemiological risk factors (Crosby, Sanders, Yarber, & Graham,
2003; Crosby, Sanders, Yarber, Graham, & Dodge, 2002; Crosby,
Yarber, Sanders, & Graham, 2004; Sanders et al., 2012; Yarber et
al., 2007; Yarber, Graham, Sanders, & Crosby, 2004). Condom
availability is an important contextual factor for condom use among
adolescents (Boldero, Moore, & Rosenthal, 1992) and college students
(Crosby et al., 2003; Crosby et al., 2002; Kashima, Gallois, &
McCamish, 1993). A study conducted by Crosby and colleagues (2003)
assessing condom use and condom-related problems among 158 college
students found 42.4% of participants wanted to use a condom but did not
have one available and 17.6% had a problem with a condom during sexual
activity and did not have a secondary condom available.
Condom distribution programs are structural-level public health
interventions that extend beyond the individual's personal risk by
addressing access to condoms within given environments (Centers for
Disease Control and Prevention [CDC], 2010). According to the CDC,
wide-scale distribution is an important programmatic consideration for
effective condom distribution interventions (2010). In the U.S., condom
distribution programs have been used to increase availability in school
settings (Blake et al., 2003; Guttmacher et al., 1997) and large-scale
community-based distribution initiatives have been effective in
increasing availability in New York City and Washington D.C. (CDC,
2010). A recent meta-analysis of 21 condom distribution programs by
Charania and colleagues (2010) revealed significant intervention effects
upon condom use, condom acquiring/condom carrying, delayed sexual
initiation among youth, and reduced incidence of STIs. Additional
findings indicated programs which incorporated individual and
community-level considerations were more effective than those which only
focused upon structural components. Various assessments have indicated
condom distribution programs are cost effective (Bedimo, Pinkerton,
Cohen, Gray, & Farley, 2002; Charania et al., 2010; Kirby et al.,
1999; Schuster, Bell, Berry, & Kanouse, 1998).
The majority of colleges and universities in the U.S. distribute
condoms to their student populations (Butler, Black, & Coster,
2011a; Eastmann-Mueller, Jung, Roberts, 2014; Koumans et al., 2005).
Results of the ACHA 2013 Pap and STI Survey conducted by the ACHA (n =
140) indicated 87.9% of institutions distribute condoms to their
students for free and 36.4% sell condoms on campus (Eastmann-Mueller et
al., 2014). A national investigation of 736 schools by Koumans and
colleagues (2005) revealed 52% of institutions distribute condoms to
students, including 74% of schools with a health center. A recent
assessment of 358 colleges and universities with student health centers
by Butler and colleagues (2011a) indicated 84.9% of student health
centers distribute condoms to students, with the mean of 9,414 condoms
distributed/year. Select campus demographics have been found to
significantly predict sexuality-related service availability at colleges
and universities (Butler, Black, & Avery, 2012: McCarthy, 2002;
Miller, 2011) including sponsoring of a condom distribution program
(Butler et al., 2011a; Koumans et al., 2005).
The Transtheoretical Model (TM) and the Health Belief Model (HBM)
are common theoretical foundations used to guide public health
interventions and assess individual-level risk of disease acquisition
(Champion & Skinner, 2008; Prochaska, Redding, & Evers, 2008).
Recently the TM and HBM have been used to assess institutional and
organizational behavior (Leversque, Prochaska, & Prochaska, 1999;
Price & Oden, 1999), sexuality-related services at colleges and
universities (McCarthy, 2002), and university health policies (Reindl,
Glassman, Price, Dake, & Yingling, 2014). McCarthy (2002) used the
TM and the HBM to assess emergency contraceptive pill (ECP) availability
among 358 college health centers nationally. Results indicated the
majority of schools were in the maintenance stage (defined as having
distributed ECP to students for 1 to 5 years) and the most common
institutional benefits associated with distribution included prevention
of pregnancy (97.3%), student appreciation (71.1%), and linking ECP with
other traditional forms of contraception (59.4%).
Over the past 40 years, the Diffusion of Innovations Theory (DIT)
has been used as a framework in over 5,200 empirical investigations
(Rogers, 2003). The DIT can be applied to both individuals and the
adoption of innovations by organizations (Rogers, 2003). Since its
inception, the DIT has been used in various public health settings and
has been applied to interventions designed to reduce risk of HIV (Haider
& Kreps, 2004; Bertrand, 2008). Institutional complexity and
institutional size are two constructs of the DIT which are hypothesized
to positively correlate with organizational innovation (Rogers, 2003).
Rogers (2003) defines complexity as the "degree to which an
organization's members possess a relatively high level of knowledge
and expertise, usually measured by the member's number of
occupational specialties and their degree of professionalism (expressed
by formal training)" (p.412). While the number of college and
university employees who participate in condom distribution programs is
unknown, previous research has indicated student peer educators have
participated in distribution efforts (Butler & Black, 2001; Butler
et al., 2011a; Butler, Hartzell, Przybyla, & Bickers-Bock, 2006).
Despite the importance of condom availability and prevalence of condom
distribution programs on college campuses, no previous investigation has
used a theoretical framework to assess condom distribution programs from
an institutional perspective.
The purpose of the present study was to assess college and
university condom distribution programs using constructs of the TM, the
HBM, and the DIT. Specifically, the foci of the study were six fold and
were designed to assess the following (a) institutional stage of change
associated with condom programs, (b) frequency of institutional barriers
and benefits associated with condom programs, (c) relationship between
the presence of a condom distribution program and institutional benefits
and barriers, (d) relationship between campus demographics and
institutional barriers, benefits, and complexity, (e) relationship
between the number of condoms distributed/year and number of students,
number of health center employees, institutional benefits, barriers, and
institutional complexity, and (f) prevalence of college and university
employees and student peer helpers/educators who are involved with
condom distribution programs.
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 mean student population was 11,126 (SD = 12,680,
Mdn = 6,000, and Mo = 12,000). The mean number of health center
employees was 26.28 (SD = 46.62, Mdn = 9, Mo = 5).
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, & Black (2014) for
an additional report on condom and safer sex product availability and
Butler, Procopio, Ragan, Funke, & Black (2011) for a 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 >
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 condom availability
investigation conducted by Butler and colleagues (2011a), a list of 759
institutional members of the 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 Institutional Condom Assessment Questionnaire
(ICAQ) were mailed to each of the 1,101 selected institutions. An
additional reminder card was mailed was sent to those who had not
responded to previous recruitment efforts. All potential participants
who had not previously responded to recruitment efforts received a final
reminder email two weeks after the initial contact.
Measures
The participants completed the ICAQ developed by Butler and
colleagues (2011b). The ICAQ is a theoretically-framed valid and
reliable instrument designed to evaluate condom distribution programs
from an institutional perspective. Contained within the ICAQ are the
precontemplation (2 items), contemplation (1 item), preparation (1
item), and action/maintenance (1 item) constructs from the TM, the
institutional benefits (16 items) and institutional barriers (24 items)
constructs from the HBM, and the institutional complexity (2 items), and
institutional size (2 items) constructs of the DIT. In addition, the
ICAQ contains 10 items assessing school 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).
Colleges and universities that have considered offering to students
in the past but decided against it and those that previously sponsored a
program were coded as being in the precontemplation stage of the TM.
Those who were currently considering a program or preparing to implement
a program were coded as being in the contemplation and preparation
stages, respectively. Finally, schools that had implemented a program
less than one year ago were coded as in the action stage and those who
currently sponsored a program for more than one year as in maintenance.
The institutional benefits construct of the HBM was assessed through the
following question: "In your opinion, what are the benefits to
offering a condom distribution program on your campus."
Participants were given a list of 16 items representing potential
benefits to their program for which they responded yes by checking the
appropriate box or no by leaving it blank. The institutional barriers
construct was assessed through one question which assessed reasons for
not publicizing the program among those which sponsored a program and a
second question which read: "In your opinion, what are the
barriers/challenges to offering a condom distribution program on your
campus?" Participants were given a list of 9 items which assessed
reasons for not publicizing their program as well as a list of 16 items
which assessed institutional barriers to sponsoring a program.
Participants could respond to individual items by checking the
appropriate box for a yes response or no by leaving it blank.
The institutional complexity construct of the ICAQ contains two
questions, one of which assesses university staff/volunteers involved
with condom issues on campus through "giving condoms to students,
meeting with students regarding condom use, teaching students about
condom use, and/or advocating for condom education/distribution
programs" and the second which assesses the use of student peer
educators in condom programs through outreach, counseling, and the
sponsorship of sexual health events. Institutional size was addressed
through two items including one item assessing student population and
another on the number of employees at the student health center.
Data Analyses
Descriptive statistics and measures of central tendency were
conducted on each of the items of the ICAQ. Each yes response for items
of the institutional benefits, institutional barriers, and institutional
complexity constructs was assigned a value of 1 and each no response a
value of 0. A composite score was created for each construct by summing
the values. A mean value of the number of condoms distributed to
students/year was computed (for additional data regarding measures of
central tendency regarding number of condoms distributed to
students/year see Butler et al., 2014). The Spearman Rho correlation was
used to assess the relationship between the number of condoms
distributed to students per year and the student population and number
of health center employee variables as well as the number of condoms
distributed/year and the institutional benefits, institutional barriers,
and institutional complexity constructs. Univariate and multivariate
logistic regression assessments were used to predict the presence of a
condom distribution program. Institutional benefits, barriers, and
complexity mean comparisons across campus demographics were conducted
using ANOVA tests. Simple Chi Squared Tests were used to assess the
relationship between campus demographic variables and the use of peer
educators in condom initiatives. 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. Post Hoc
mean assessments were conducted using the Tukey HSD test. All data
analyses were conducted using SPSS version 22.0.
Results
Transtheoretical Model
Of the 86.3% of colleges and universities that currently sponsor a
condom distribution program, 1.3% reported they have been giving condoms
to students for less than one year (Action stage). The remainder of the
institutions were in the maintenance stage with the majority (68.3%)
sponsoring their program for more than 10 years. Nearly one fifth
(18.5%) reported having a program for 6 to 10 years and 10.2% reported
their program has existed for 1 to 5 years. Only 4 schools reported
being in the contemplation stage and one in the preparation. Among those
who do not offer condoms to students, 11.9% had considered offering
condoms to students in the past but decided against it and 13.4% offered
a program in the past and had no intention of implementing a new one.
Health Belief Model
The mean of the composite score for the institutional benefits
construct was 7.38 (SD = 3.14). Additional data regarding perceived
institutional benefits are contained in Table 2. Results of the
demographic comparisons indicated significant mean institutional benefit
composite score differences across student population, F(3) = 5.94, p =
.001, type of academic institution, F(1) = 19.23, p < .001, student
residency, F(2) = 4.71, p = .009, and faith-based-affiliation, F(3) =
57.33, p < .001. Post hoc results indicated schools with student
populations of < 5,000 scored lower than those with 5,000-9,999
students (p = .026) and those with > 25,000 (p = .001). In addition,
schools with primarily commuter student populations scored significantly
higher than those with primarily residential (p = .008). Comparisons
across geographic region were not significant, F(3) = 1.53, p = .207.
Additional results of the institutional benefit mean comparisons across
campus demographics are contained in Table 3. Results of the univariate
logistic regression model indicated that the institutional benefits
construct was a statistically significant predictor of condom
distribution programs, OR = 1.703, 95% CI = 1.507-1.924, p < .001. In
addition, a statistically significant correlation was observed between
the institutional benefits construct and the number of condoms
distributed to students/year, r(343) = .359, p < .001.
The mean composite score of the institutional barriers construct
for all participating institutions was 1.72 (SD = 1.80). Additional data
regarding perceived institutional barriers among schools which do and do
not sponsor a condom distribution program are contained in Tables 4 and
5. The mean score for colleges and universities who do not currently
sponsor a condom distribution program was 3.28 (SD = 2.52) and 1.47 (SD
= 1.52) for those which currently offer condoms to their students.
Results of the demographic mean comparisons indicated faith-based
institutions score significantly higher than non-faith-based, F(1) =
15.49, p < .001. The additional mean comparisons across region, type
of institutions, student population, and student residency were not
significant, F(3) = 2.94, p =.033, F(1) = .004, p =.948, F(3) = 1.53, p
= .205, and F(2) = .276, p =.759 respectively. Additional results
comparing mean perceived institutional barriers composite scores across
demographic variables are contained in Table 6. The institutional
barriers construct significantly inversely predicted the sponsorship of
campus condom distribution programs, OR = .623, 95% CI = .536-.724, p
< .001, and was significantly correlated to the number of condoms
distributed to students/year, r(343) = -.276, p = < .001. The
multivairaite logistic regression model indicated both the benefits and
barriers constructs retained statistical significance, OR = 1.740, 95%
CI = 1.519-1.994, p < .001, and OR = .598, 95% CI = .494-.724, p <
.001, respectively. Table 7 contains result regarding reasons for not
advertising distribution programs among schools which currently offer
condoms to their students.
Diffusion of Innovations Theory
The mean composite score on the institutional complexity score
among all participating institutions was 6.07 (SD = 4.00). Additional
data regarding the prevalence of university employees involved in condom
programs among schools which sponsor a program are contained in Table 8.
Nearly two thirds (63.7%) of all participating institutions use student
peer helpers/educators as part of their distribution efforts. See Table
9 for assessment of the prevalence of peer-based condom initiatives
across campus demographics. Among schools which use peers in condom
initiatives (n = 279), the most common response was the use of peers to
give away condoms at campus events (80.6%) and in organizing
condom-related events (68.1%) on campus. The least common use was to
give away condoms at bars near campus (4.7%) and give away condoms at
nearby restaurants (1.4%). Additional uses of peers in campus
programming included conducting condom-related outreach (64.9%),
counseling on condom-related issues (30.2%), as well as other
non-specified uses of peers in condom programs (14.0%).
Results comparing mean institutional complexity composite scores
across demographic variables are contained in Table 10. Demographic
comparisons indicated significant mean composite score differences
across region, F(3) = 5.41, p = .001, student population, F(3) = 29.66,
p = .001, type of academic institution, F(1) = 27.43, p < .001, and
faith-based-affiliation, F(3) = 62.93, p < .001. Post hoc results
indicated schools in the Midwest scored significantly lower than those
in the Western (p = .001) and Southern regions (p = .015). In addition,
schools with student populations of < 5,000 scored lower than those
with 5,000-9,999 students (p = .01), those with populations of
10,000-24,999 (p < .001) and those with > 25,000 (p = .008).
Comparisons across student residency were not significant, F(2) = .453,
p = .636. The mean number of condoms distributed to students/year was
significantly correlated to the total student population, r(342) = .451,
p < .001, the number of health center employees, r(342) = .525, p
< .001, and institutional complexity, r(342) = .630, p < .001.
Discussion
The present study is the first investigation to use a theoretical
framework to assess condom distribution programs within colleges and
universities nationally. The multi-level approach using constructs from
the TM, HBM, and DIT revealed unique insights into distribution efforts,
benefits and barriers to programming, and prevalence of employees who
participate in programs or serve as advocates for condom availability.
Assessing schools from an institutional perspective is beneficial and
extends beyond previous assessments which have been focused upon service
availability and excluded key factors within colleges and universities
which enable or restrict program efforts. Currently there are no
benchmarks for condom distribution programs within college and
university settings and there is a dearth of the large-scale assessments
needed to enable their creation. The present investigation provides a
critical step towards this goal and identifies the need for additional
focus upon the influence of campus demographics, employee
infrastructure, and policies upon condom availability.
Results indicate the vast majority of colleges and universities
sponsor a condom distribution program. Assessment of the TM constructs
revealed the majority of the institutions with condom programs report
they have been distributing condoms for more than 10 years (maintenance
stage). This result corroborates a finding from Koumans and colleagues
(2005) whose national assessment revealed that the majority of colleges
and universities offer condoms to their students. Overall, condom
distribution programs appear to have become an asset in increasing
condom availability within higher education schools settings and play a
significant role in routine sexual health care. Only four schools were
reported in the contemplation stage and one in the preparation stage,
which indicates the majority of schools without condom programs have no
plans to initiate a program in the near future.
From an institutional viewpoint, condom distribution programs were
found to enhance the health of students from a variety of perspectives.
While common institutional benefits to programs include the prevention
of STIs and reduction of unintended pregnancies, additional benefits
were more broadly defined and included encouragement of healthy
behaviors and healthy communication among students. These findings
indicate the presence of condom availability within schools extend
beyond common measures of epidemiological risk. In addition, it is
noteworthy that employees believe condom programs provide the best
possible care for students and encourage interaction with health care
providers. As hypothesized by the HBM, the institutional benefits
construct significantly predicts the sponsorship of a campus program and
is significantly correlated with the number of condoms given to
students/year. While the institutional barriers construct also
significantly inversely predicts condom availability, magnitude of the
observed effect size was less (OR = 1.740 vs. OR = .598, respectively).
Among schools that offer condoms to students, the most common
barriers to distribution were associated with fiscal aspects of program
implementation. Among those which do not offer condoms to students, the
most common barriers included religious affiliation-based objections,
institutional ideology, and administrative objections. While previous
assessments of sexuality-related services among U.S. colleges and
universities have revealed faith-based schools were less likely to offer
select services (Butler et al., 2011a; Butler et al., 2012), the present
study is the first to report religious affiliation as a self-identified
barrier within these institutions. In addition, nearly one quarter of
schools which sponsor a condom program report not advertising condom
availability because of concerns of creating controversy. Future
research is needed to assess the sexual behaviors and condom use among
students who attend faith-based colleges and universities. The
identification of these patterns will assist in the development of
sexual health care policies and practices tailored to individuals
attending these institutions.
Results of the institutional complexity assessments indicate a
variety of employees within college and university settings are involved
with condom issues on campus and condom distribution efforts. Many
schools employed clinical health care providers such as nurses, nurse
practitioners, and physicians who are willing to meet with students
regarding condom issues. Nearly two thirds employed a university health
educator who advocated for condom programs which suggests condom-based
programs within some schools are focused upon primary prevention
efforts. Additional findings are consistent with previous investigations
which found peer educators play a significant role in condom
distribution efforts (Butler & Black, 2001; Butler et al., 2011a;
Butler et al., 2006). In addition, 72.8% of schools with condom
distribution programs identified the student health center director as a
professional involved with condom availability. These findings suggest
key administrators within college and university settings are necessary
for the advocacy of condom programs and the creation of condom-related
health policies. Less than one third of all schools with condom programs
employed sexuality educators and program coordinators who are involved
with condom initiatives. Given the common duties ascribed to these
professionals, it can be hypothesized that only the minority of
institutions employ these types of individuals. Of the three
correlational assessments conducted using constructs of the DIT,
institutional complexity was the strongest correlation to the number of
condoms given to students/year (r = .630). Finally, complexity
assessments indicated significant mean differences across campus
demographics with schools with larger student populations reporting more
employees who support condom initiatives. On average, faith-based
schools employed fewer employees than non-faith-based (6.75 vs 3.14,
respectively). Future research is needed to identify the role of key
college and university employees in the creation of comprehensive condom
distribution programs.
Previous psychometric assessments reveal the ICAQ is a valid and
reliable instrument for assessing condom distribution programs among
colleges and universities nationally (Butler et al., 2011b). In
conjunction with our previous report (see Butler et al., 2014), the
present investigation indicates the ICAQ is a useful tool to assess
programs including the number of condoms typically distributed to
students/year, methods of distribution, demographic predictors of
availability, as well as the relationship between availability and
theoretical constructs of the TM, HBM, and DIT. The creation of the ICAQ
is one step in overcoming the dearth of instruments developed
specifically to assess the unique aspects of sexual health care and
sexuality-related services within colleges and universities. In the
future, the ICAQ can be a useful tool to guide future research designed
to assess condom distribution programs and will allow administrators,
clinicians, and prevention professionals to compare the efforts within
their campus to national benchmarks. In addition, the ICAQ can be used
to assess the comprehensiveness of condom availability within individual
colleges and universities and may guide future development of health
policies.
The present study has limitations to consider. Data procured for
the investigation was self-reported by a single individual selected to
represent condom distribution efforts for the entire campus. Given the
subjectivity of selected theoretical constructs (e.g., perceived
institutional benefits and barriers); the reported data may be
reflective of one individual's opinion and not adequately represent
the views on campus in their entirety. Nonetheless, selecting the campus
health center director or the ACHA designated representative as the
study participant may increase the validity of results as these
individuals are more likely to be informed of condom distribution
efforts and/or author policies regarding condom availability on campus.
Future research is needed to assess the opinions and perspectives of a
variety of employees on college campuses with regard to condom
distribution programs and the benefits/barriers to program
implementation.
While the present study met all of the statistical assumptions to
ensure the necessary power to enable statistical significance, there may
be limitations on the generalizability of specific findings. For
example, one key finding reveals religious affiliation as a prevalent
institutional barrier to sponsoring condom distribution programs.
However, it is noteworthy that only 83 faith-based colleges and
universities participated in the investigation. Future research is
needed to assess the institutional barriers and benefits within these
environments; specifically a large-scale investigation dedicated to
faith-based schools is needed to corroborate the findings of the present
study and allow greater external validity of findings. Finally, while
both the present study and the previous report (Butler et al., 2014)
suggest additional efforts are needed to increase the comprehensiveness
of condom distribution programs, the effect of these efforts on key
public health outcomes such as STI and unintended pregnancy reduction is
unknown. Future large-scale collaborative research is needed across
college and university campuses to assess the overall impact of condom
distribution efforts.
The present study attempts to overcome a significant lack of
knowledge regarding the prevalence of college and university condom
distribution programs. Results overcome the limitations of previous
investigations by providing unique insights into factors that enable or
restrict programming. Given the prevalence of condom use among students
and the severity of sexuality-related problems among this population,
additional large-scale assessments are needed to adequately gauge if the
sexual health care needs of college students are being met. Future
research should incorporate health behavior theoretical constructs into
investigations to overcome the lack of knowledge concerning sexual
health service availability and delivery within higher education
settings.
Scott M. Butler, PhD, MPH, ACS
School of Health and Human Performance, Georgia College
Kathleen Ragan, BS, CHES
Rollins School of Public Health, Emory University
David R. Black, PhD, MPH, HSPP, CHES, CPPE, FASHA, FSBM, FAAHB,
FAAHE
Department of Health and Kinesiology, Purdue University
Barbara Funke, PhD, MCHES
School of Health and Human Performance, Georgia College
Contact and Additional Information to be addressed to: Scott M.
Butler, PhD, MPH
School of Health and Human Performance, Georgia College
Campus Box 112, Milledgeville, GA 31061
478-445-1218, scott.butler@gcsu.edu
References
American College Health Association. (2013). American College
Health Association--National college health assessment II: Reference
group executive summary spring 2013. Linthicum, MD: American College
Health Association.
Bedimo, A.L., Pinkerton, S.D., Cohen, D.A., Gray, B., & Farley,
T.A. (2002). Condom distribution: A cost utility analysis. International
Journal of STD & AIDS, 13, 384-392.
Bertrand, J.T. (2004). Diffusion of innovations and HIV/AIDS.
Journal of Health Communication, 9, 113-121.
Boldero, J., Moore, S., & Rosenthal, D. (1992). Intention,
context, and safe sex: Australian adolescents response to AIDS. Journal
of Applied Social Psychology, 22, 1374-1396.
Blake, S.M., Ledsky, R., Goodenow, C., Sawyer, R., Lohrman, D.,
& Windsor, R. (2003). Condom availability programs in Massachusetts
high schools: relationships with condom use and sexual behavior.
American Journal of Public Health, 93, 955-962.
Butler, S., & Black, D.R. (2011). Prevalence and duties of
collegiate human sexuality peer helpers: Results of a national study.
Perspectives in Peer Programs, 23, 24-33.
Butler, S., Black, D.R., & Avery, G. (2012). Emergency
contraceptive pill, contraceptive, and sexually transmitted infection
service availability among U.S. college health centers. Electronic
Journal of Human Sexuality, 15. Retrieved from
http://www.ejhs.org/volume15/Health.html
Butler, S.M., Black, D.R., & Coster, D. (2011a). Condom and
safer sex product availability among U.S. college health centers.
Electronic Journal of Human Sexuality, 14. Retrieved from
http://www.ejhs.org/volume14/safersex.htm
Butler, S., Hartzell, R., Przybyla, S., & Bickers-Bock, L.
(2006). Moving Beyond Peer Education: Using Peer Advocates to Increase
Condom Availability on College Campuses. Perspectives in Peer Programs,
20, 40-45.
Butler, S. M., Procopio, M., Boteler, C., Ragan, K., Funke, B.,
& Black, D.R. (2011b). Institutional condom assessment
questionnaire. In T. D. Fisher, C. M. Davis, W. L. Yarber, & S. L.
Davis (Eds.), Online companion to the Handbook of sexuality-related
measures. New York City: Routledge. Retrieved from
http://cw.routledge.com/textbooks/9780415801751/table-of-contents.asp
Butler, S.M., Procopio, M., Ragan, K., Funke, B., & Black, D.R.
(2011). Condom and safer sex product availability among colleges and
universities in rural settings. Health Education Monograph Series, 28,
10-15.
Butler, S., Procopio, M., Ragan, K., Funke, B., & Black, D.
(2014). Assessment of University Condom Distribution Programs: Results
of a National Study. The Electronic Journal Human Sexuality, 17, March
26.
CDC. (2010). Condom distribution as a structural level
intervention. Retrieved from
http://www.cdc.gov/hiv/resources/factsheets/condom_distribution.htm
Champion, V.L., & Skinner, C.S. (2008). The health belief
model. In K. Glanz, B.K. Rimer., & K. Viswanath (Eds.). Health
behavior and health education theory, research, and practice (4th ed.,
pp 45-62). San Francisco: Jossey-Bass.
Charania, M.R., Crepaz, N., Guenther-Gray, C., Henny, K., Liau, A.,
Willias, L., & Lynes, C. (2011). Efficacy of structural-level condom
distribution interventions: A meta-analysis of U.S. and international
studies, 1998-2007. AIDS and Behavior, 15, 1283-1297.
Crosby, R.A., Sanders, S.A., Yarber, W.L., Graham, C.A., &
Dodge, B. (2002). Condom use errors and problems among college men.
Sexually Transmitted Diseases, 29, 552-557.
Crosby, R.A., Sanders, S.A., Yarber, W.L., & Graham, C.A.
(2003). Condom use errors and problems: The neglected aspect of studies
assessing condom effectiveness. American Journal of Preventive Medicine,
24, 367-370.
Crosby, R.A., Yarber, W.L., Sanders, S.A., & Graham, C.A.
(2004). Condom use as a dependent variable: A brief commentary about
classification of inconsistent users. AIDS and Behavior, 8, 99.
Eastmann-Mueller, H., Jung, A., & Roberts, C. (2014). ACHA 2013
pap and sti survey for calendar year 2012 data. Retrieved from
http://www.acha.org/topics/docs/ACHA_CY2012_PapTest_and_STI_Survey_FullDataReport.pdf
Guttmacher, S., Lieverman, L., Ward, D. Freundenberg, N., Radosh,
A., & Des Jarlais, D. (1997). Condom availability in New York City
public high schools: relationships to condom use and sexual behavior.
American Journal of Public Health, 87, 1427-1433.
Haider, M., & Kreps, G.L. (2004). Forty years of diffusion of
innovations: utility and value in public health. Journal of Health
Communication, 9, 3-11.
Kashima, Y. Gallois, C., & McCarnish, M. (1993). The theory of
reasoned action and cooperative behavior: It takes two to use a condom.
British Journal of Social Psychology, 32, 227-239.
Kirby, D., Brener, N.D., Brown, N.L. Peterfreund, N., Hillard, P.,
& Harrist, R. (1999). The impact of condom distribution in Seattle
schools on sexual behavior and condom use. American Journal of Public
Health, 89, 182-187.
Koumans, E.H., Sternberg, M.D., Motamed, C., Kohl, K., Schilinger,
J.A., & Markowitz, L.E. (2005). Sexually transmitted disease
services at US colleges and universities. Journal of American College
Health, 53, 211-217.
Levesque, D.A., Prochaska, J.M., & Prochaska J.O. (1999).
Stages of change and integrated service delivery. Consulting Psychology
Journal: Practice & Research, 51, 226-241.
McCarthy, S. (2002). Availability of emergency contraceptive pills
at university and college student health centers. Journal of American
College Health, 51, 15-22.
Miller, L.M. (2011). Emergency contraceptive pill (ECP) use and
experiences at college health centers in the mid-Atlantic U.S.: Changes
since ECP went over-the-counter. Journal of American College Health, 59,
683-689.
Peterson. (2006). Peterson's 4 year colleges (37th ed.).
Lawrenceville, NJ: Thompson Peterson.
Price, J.H., & Oden, L. (1999). Reducing firearm injuries: The
role of public health departments. Public Health Reports, 114, 533-539.
Prochaska, J.O., Redding, A.R., & Evers, K.E. (2008). The
transtheoretical model and stages of change. In K. Glanz, B.K. Rimer.,
& K. Viswanath (Eds.). Health behavior and health education theory,
research, and practice (4thed., pp 97-117). San Francisco: Jossey-Bass.
Reece, M., Herbenick, D., Chick, V., Sanders, S.A., Dodge, B.,
& Fortenberry, J.D. (2010). Condom use rates in a national
probability sample of males and females ages 14 to 94 in the United
States. Journal of Sexual Medicine, 7 (suppl 5), 266-276.
Reece, M., Mark, K., Schick, V., Herbenick, D., & Dodge, B.
(2010). Patterns of condom acquisition by condom-using men in the United
States. AIDS Patient Care and STDs, 24, 429-433.
Reindl, D., Glassman, T., Price, J., Dake, J., & Yingling, F.
(2014). Perceptions of college and university presidents regarding
tobacco-free campus policies. Journal of American College Health, 62,
193-202.
Rogers, E.M. (2003). Diffusion of innovations (5th ed.). New York:
Free Press. Sanders, S., Yarber, W., Kaufman, E., Crosby, R., Graham,
C., & Milhausen, R. (2012). Condom use errors and problems: a global
view. Sexual Health, 9, 81-95.
Schuster, M., Bell, R., Berry, S., & Kanouse, D. (1998). Impact
of a high school condom availability program on sexual attitudes and
behaviors. Family Planning Perspectives, 30, 67-72.
Yarber, W. L., Graham, C. A, Sanders, S. A., & Crosby, R. A.
(2004). Correlates of condom breakage and slippage among university
undergraduates. International Journal of STD & AIDS, 15, 467-472.
Yarber, W.L., Crosby, R.A., Graham, C.A., Sanders, S.A., Hartzell,
R.M., & Butler, S. (2007). 'Do you know what you are
doing?' College students' experience with condoms. American
Journal of Health Education, 38, 322-331.
Table 1
Regional, Institutional, and Setting Demographics of Participant
Institutions (n = 438)
Respondents
Demographic Region n %
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
Perceived Institutional Benefits Associated with Condom Distribution
Programs (n = 378)
Variable n %
Reduction of STIs 365 96.6
Encourages healthy student behaviors 356 94.2
Encourages sexual responsibility 354 93.7
Reduce unintended pregnancies 351 92.9
Encourage healthy sexual communication 317 83.9
Student appreciation 290 76.7
Provides best possible health care 211 55.8
Encourage interaction with health care providers 208 55.0
Reduce health care expenses 186 49.2
Reduce health care utilization 117 31.0
Cost effectiveness 96 25.4
Administrative approval 66 17.5
Improve campus image 53 14.0
Parental approval 19 5.0
Financial profit 9 2.4
Other 24 6.3
Table 3
Comparisons of Institutional Benefits Across Campus Demographics
(n = 438)
Demographic M(SD)
Region
South 7.41(2.79)
Northeast 7.32(3.51)
Midwest 6.89(3.49)
West 7.86(2.79)
Type of Institution
Public 7.97(2.67) **
Private 6.66(3.49)
Student Population Size
<5,000 (a) 6.71(3.32) *
5,000-9,999 (b) 7.62(3.32)
10,000-24,999 (ab) 7.73(2.94)
[greater than or equal to]25,000 (b) 8.49(2.28)
Residential Characteristic
Primarily Residential (b) 6.94(3.50) *
Primarily Commuter (a) 7.98(2.72)
Equal Residential/Commuter (ab) 7.19(2.94)
Religious Affiliation
Non-Faith-Based 7.90(2.66) **
Faith-Based 5.17(3.99)
* p < .01, ** p < .001
Note. Means within a demographic variable group sharing a common
subscript do not statistically differ at [alpha] = .05 according to
the Tukey HSD procedure.
Table 4
Perceived Institutional Barriers Among Schools Which Sponsor a Condom
Distribution Program (n = 378)
n %
Expense of condoms 116 30.7
Lack of available funds 110 29.1
Lack of distributions means 61 16.1
Administrative objections 40 10.6
Parental objections 38 10.1
Religious affiliation-based objections 33 8.7
Institutional ideology 19 5.0
Efficacy of condoms 16 4.2
Encourages sexual activity 13 3.4
Student objections 13 3.4
Liability concerns 11 2.9
Lack of student demand 10 2.6
Policy restrictions 7 1.9
Clinician objections 3 0.8
Lack of student need 1 0.3
Other 30 7.9
Table 5
Perceived Institutional Barriers Among Schools That Do Not Sponsor a
Condom Distribution Program (n = 60)
n %
Religious affiliation-based objections 47 78.3
Institutional ideology 31 51.7
Administrative objections 29 48.3
Policy restrictions 14 23.3
Parental objections 10 16.7
Encourages sexual activity 9 15.0
Expense of condoms 9 15.0
Lack of available funds 9 15.0
Lack of distributions means 6 10.0
Lack of student demand 5 8.3
Student objections 5 8.3
Clinician objections 4 6.7
Efficacy of Condoms 3 5.0
Lack of student need 3 5.0
Liability concerns 2 3.3
Other 10 16.7
Table 6
Comparisons of Institutional Barriers Across Campus Demographics
(n = 438)
Demographic M(SD)
Region
South 2.03(1.92)
Northeast 1.54(1.87)
Midwest 1.86(1.66)
West 1.38(1.59)
Type of Institution
Public 1.71(1.72)
Private 1.72(1.86)
Student Population Size
<5,000 1.93(2.10)
5,000-9,999 1.62(1.50)
10,000-24,999 1.52(1.58)
[greater than or equal to]25,000 1.58(1.66)
Residential Characteristic
Primarily Residential 1.77(1.87)
Primarily Commuter 1.72(1.77)
Equal Residential/Commuter 1.60(1.62)
Religious Affiliation
Non-Faith-Based 1.56(1.59) **
Faith-Based 2.41(2.238)
** p < .001
Table 7
Reported Reasons for Not Publicizing Condom Availability Among Schools
Which Sponsor a Program (n = 88)
n %
Concerns about creating controversy 21 23.9
Do not want to appear to promote sexual activity 21 23.9
Lack of funding 17 19.3
Administrative objections 15 17.0
Do not want to promote sexual activity 4 4.5
Policy Restrictions 4 4.5
Do not want to promote condom use 1 1.1
Other 33 37.9
Table 8
Employees Who are Involved with Condom Issues on College and
University Campuses (n = 378)
n %
Nurse 291 77.0
Student Peer Helper/Educator 279 73.8
Health Center Director 275 72.8
Nurse Practitioner 273 72.2
Health Educator 255 67.4
Residential Adviser 202 53.4
Physician 204 54.0
Mental Health Counselor 110 29.1
Sexuality Educator 109 28.8
Physician Assistant 92 24.3
Sexuality Program Coordinator 85 22.5
Administrative Assistant 80 21.2
Psychologist 64 16.9
Faculty Member 60 15.9
Campus Administrator 42 11.1
Psychiatrist 31 8.2
Social Worker 30 7.9
Athletic Coach 29 7.7
Sexual Assault Nurse Examiner 27 7.1
Academic Adviser 17 4.5
Spiritual/religious Counselor 10 2.6
Other 51 13.5
Table 9
Prevalence of Peer-based Condom Initiatives Across Campus Demographic
Characteristics (n = 438)
Demographic n %
Region
South 84 68.3
Northeast 68 59.5
Midwest 60 57.7
West 60 68.2
Type of Institution
Public 172 73.2 *
Private 98 51.6
Student Population Size
<5,000 90 48.1 *
5,000-9,999 44 66.7
10,000-24,999 89 74.8
[greater than or equal to]25,000 48 87.3
Residential Characteristic
Primarily Residential 116 62.0
Primarily Commuter 90 60.8
Equal Residential/Commuter 62 68.9
Religious Affiliation
Non-Faith-Based 253 71.3 *
Faith-Based 26 31.3
* p < .001
Note. Assessments were conducted using the Pearson Chi Squared test.
Level of significance set at .01.
Table 10
Comparisons of Institutional Complexity Across Campus Demographics
(n = 438)
Demographic M(SD)
Region
South (b) 6.48(4.07) *
Northeast (ab) 5.91(3.90)
Midwest (a) 4.91(3.74)
West (b) 7.06(3.89)
Type of Institution
Public 6.97(3.86) **
Private 5.00(3.83)
Student Population Size
<5,000 (a) 4.30(3.00) **
5,000-9,999 (b) 6.29(3.55)
10,000-24,999 (b) 7.47(4.00)
[greater than or equal to]25,000 (b) 8.60(4.39)
Residential Characteristic
Primarily Residential 5.83(4.21)
Primarily Commuter 6.24(3.79)
Equal Residential/Commuter 6.10(3.76)
Religious Affiliation
Non-Faith-Based 6.75(3.84) **
Faith-Based 3.14(3.24)
* p = .001, ** p < .001
Note. Means within a demographic variable group sharing a common
subscript do not statistically differ at [alpha] = .05 according to
the Tukey HSD procedure.
