摘要：Objectives. This study assessed relationships between condom availability programs accompanied by community discussion and involvement and adolescent sexual practices. Methods. Sexual practice and condom use differences were assessed in a representative sample of 4166 adolescents enrolled in high schools with and without condom availability programs. Results. Adolescents in schools where condoms were available were more likely to receive condom use instruction and less likely to report lifetime or recent sexual intercourse. Sexually active adolescents in those schools were twice as likely to use condoms, but less likely to use other contraceptive methods, during their most recent sexual encounter. Conclusions. The strategy of making condoms available, an indication of socioenvironmental support for condom use, may improve HIV prevention practices. There is a continuing need for effective HIV, sexually transmitted disease (STD), and pregnancy prevention programs that discourage early onset of sexual activity and encourage protection among adolescents who are already sexually active. Despite sustained declines during the 1990s in teenage pregnancy and birth rates, as well as rates of certain STDs, approximately 1 million American teenagers continue to become pregnant each year, and three quarters of these pregnancies are unintended. 1– 5 The decline in pregnancy rates has been attributed to declines in sexual activity, increased use of condoms, and longer acting hormonal contraceptive methods. 2, 5, 6 Yet, rates of HIV and other STDs among adolescents remain unacceptably high, 7 and it has been reported that 1 in 3 young people are infected with an STD by the age of 24 years. 8 According to 1 study, approximately 49% of all adolescents in grades 9 through 12 reported ever having had sexual intercourse (36% within the previous 3 months), and during their most recent sexual encounter, use of condoms (58%) or other birth control methods (16%) was not universal among those who were sexually active. 9 Factors associated with condom use among sexually active youths include the following: (1) positive beliefs or attitudes about condom use (e.g., that they do not reduce sexual pleasure), 10– 12 (2) perceiving peer norms as endorsing condom use, 12, 13 (3) confidence in knowledge of correct condom use or negotiation techniques, 10, 14 (4) believing condoms are effective and protective, 11– 14 (5) discussing condom use with partners, 11, 14 (6) not using alcohol or drugs in conjunction with sexual activity, 10, 13– 16 and (7) relationship status (i.e., use is more likely in short-term or casual relationships than in longer term or steady relationships). 17– 19 Therefore, interventions designed to enhance beliefs, perceptions, and skills related to condom use could be expected to reduce the number of unprotected sexual encounters among sexually active adolescents. The majority of school-based programs continue to focus on primary prevention to delay onset of sexual activity, particularly among younger adolescents; however, many school systems, with the support of parents and community members, also provide secondary prevention programs to meet the needs of sexually active students. School health service staff in junior and senior high schools nationwide offer family planning counseling services (these services are available in 28.6% and 38.2% of such schools, respectively), pregnancy screening and testing (16.6% and 20.9%), and STD diagnosis and treatment (15.8% and 19.5%). 20 Not all teachers are comfortable discussing sensitive topics in the classroom, 21– 24 but, according to one report, 33% and 58% of middle and senior high school teachers, respectively, provide instruction on condom efficacy, and 17% and 37%, respectively, demonstrate correct condom use techniques. 21 However, the practice of making condoms available in schools is far more controversial and less likely to be openly endorsed by school administrators. One study estimated that 4.7% of all middle schools and 8.4% of high schools nationwide make condoms available. 20 In another study, 50 school districts nationwide, representing 431 schools, were identified as having condom availability programs (0.35% of all districts and 2.2% of all high schools nationwide). 25 Approximately 42% of these school districts were located in Massachusetts. The purpose of the present study was to determine whether relationships exist between the presence or absence of condom availability programs in Massachusetts high schools and adolescent sexual practices. When condoms are available in schools and are successfully used by sexually active adolescents, they may be an effective means of preventing potentially harmful outcomes such as HIV/STDs and pregnancy. 26 In the relatively few evaluations of the use and impact of condom availability programs that have been reported in the literature, number of condoms distributed, changes in attitudes, number of students carrying condoms, and self-reported condom use consistency have been used to measure program effectiveness. 25, 27, 28 Several evaluations have shown that adolescents in schools with and without programs are equally likely to become sexual active, and in 2 of 3 studies, sexually active youths were more likely to report having used condoms during their most recent sexual encounter. 29, 30, 31 In the present study, we expected to replicate and possibly expand on these findings by assessing levels of sexual activity and condom use in a random sample of students in high schools with and without condom availability programs after controlling for demographic differences between communities and students.
