Sexually Transmitted Diseases:
Condom Carrying Is Not Associated With Condom Use and Lower Prevalence of Sexually Transmitted Diseases Among Minority Adolescent Females
DiCLEMENTE, RALPH J. PhD,* †‡§; WINGOOD, GINA M. ScD, MPH,* §; CROSBY, RICHARD PhD,* §; SIONEAN, CATLAINN PhD,*; COBB, BRENDA K. PhD, RN,∥; HARRINGTON, KATHY MPH, MAEd, ¶; DAVIES, SUSAN L. PhD, MPH, ¶; HOOK, EDWARD W. III, MD, # AND; OH, M. KIM MD**
From the *Department of Behavioral Sciences and Health Education, Rollins School of Public Health, Emory University, Atlanta; the † Department of Pediatrics, Division of Infectious Disease, Epidemiology and Immunology, and the Department of Medicine (Infectious Diseases), Emory University School of Medicine, Atlanta; the § Emory/Atlanta Center for AIDS Research, Atlanta; the ∥ Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia; the ¶ School of Medicine, Department of Pediatrics, University of Alabama; the # Department of Health Behavior, School of Public Health, University of Alabama; and the **Department of Medicine, Division of Infectious Diseases, School of Medicine, University of Alabama, Birmingham, Alabama
The authors thank Dr. Jane R. Schwebke for provision of cultures for Trichomonas vaginalis and Kim Smith MT (ASCP) for assistance and oversight of testing for Neisseria gonorrhoeae and Chlamydia trachomatis.
Supported by a grant from the Center for Mental Health Research on AIDS, National Institute of Mental Health (1R01 MH54412) to the second author. Drs. Crosby and Sionean were supported through an Association of Teachers of Preventive Medicine/CDC STD Prevention Fellowship.
Correspondence: Ralph DiClemente, PhD, Department of Behavioral Sciences and Health Education, Rollins School of Public Health of Emory University, 1518 Clifton Road, NE, Atlanta, GA 30322. E-mail: firstname.lastname@example.org
Received for publication November 15, 2000, revised February 12, 2001, and accepted February 13, 2001.
In a study of African American adolescent females, it was observed that those who carried condoms were as likely as those who did not to report risky sex activity or to have a sexually transmitted disease.
Background: Most of the studies associated with condom carrying and use have been conducted with adults. Because minority teenage females are particularly at risk for STD/HIV infection, further investigations specifically focusing on this population are warranted.
Goal: To determine whether observed condom carrying among adolescent females was associated with multiple measures of self-reported condom use, self-reported history of sexually transmitted diseases, and prevalence of biologically confirmed sexually transmitted diseases.
Methods: For this study, 522 sexually active African American adolescent females were recruited from low-income neighborhoods in Birmingham, Alabama. Measures of self-reported condom use, STD history, and condom carrying were collected. Adolescents were also tested for three prevalent sexually transmitted diseases.
Results: At the time of the assessment, 8% of the adolescents were observed to have a condom with them. Condom carrying was not found to be significantly associated with condom use and prevalence of sexually transmitted diseases.
Conclusion: Condom carrying may not be an important outcome of sexually transmitted disease/HIV prevention programs designed to reduce HIV/sexually transmitted disease risk among adolescent females.
CONDOM CARRYING has been assessed as an outcome variable in at least two large-scale community-level HIV intervention programs. 1,2 Yet, only a limited number of studies have investigated the association between condom carrying and condom use.
A recent investigation of sexually transmitted disease (STD)-protective behaviors among mainly minority young adults (average age, 21 years) found that males and females who always carried condoms were significantly more likely to report condom use at last intercourse than those who did not always carry condoms. 3 The study concluded that condom carrying was an important correlate of condom use for males, and the only correlate of condom use for females. Hingson et al 4 found that teenagers who carried condoms were more likely to report condom use than those who did not carry condoms. Other studies have observed similar findings with adult women and samples of college students and young adults. 5–7
Whereas these data suggest that condom carrying may increase use, most of the studies were conducted with adults. Comparable findings have not been reported in studies specifically focused on adolescents. Moreover, none of the studies used biologic markers (i.e., STDs) as an objective outcome measure. Instead, the studies relied entirely on self-reported condom use, the validity of which is controversial. 8 Therefore, the validity and relevance of these studies for adolescents may be limited. Because minority teenage females are particularly at risk for STD/HIV infection, 9 further investigations specifically focusing on this population are warranted.
This study aimed to determine whether condom carrying among low-income African American adolescent females was associated with self-reported condom use or the history and prevalence of STDs.
From December 1996 through April 1999, project recruiters screened 1130 teenage females in adolescent medicine clinics, health department clinics, and school health classes to assess eligibility for participation in an HIV/STD risk-reduction intervention study. The current study used data from the baseline assessment only. Recruitment sites were in neighborhoods characterized by high rates of unemployment, substance abuse, violence, and STDs.
Adolescents were eligible to participate in the trial if they were African American females between the ages of 14 and 18 at the time of enrollment, if they had been sexually active in the preceding 6 months, and if they provided written informed consent. Of the adolescents screened, 609 females were eligible to participate in the study. Most of the 521 teenage females not eligible for participation (98%) were not sexually active. The current study consisted of 522 (85.7%) eligible, enrolled adolescent females who completed the baseline assessments. Most of the eligible teenagers who did not participate in the study were unavailable because of employment schedule conflicts. The Institutional Review Board Committee on Human Research approved the study protocol before it was implementation.
Data collection was conducted at the University of Alabama, Birmingham, Family Medicine Clinic. A self-administered survey was conducted in a group setting. Monitors assisted the adolescents with limited literacy, ensuring confidential responses. Subsequently, the adolescents completed face-to-face interviews that assessed sexual risk behaviors. These interviews were conducted in private rooms by trained interviewers. On completing the interview, the adolescents were instructed in the proper use of a Dacron swab to self-collect a vaginal specimen for STD testing. They were reimbursed $20 for their participation.
The interviewers asked the adolescents individually whether they had a condom with them. If they answered affirmatively, they were asked to show the condom. Several measures of recent sexual behavior were assessed by open-ended interview questions. Condom use at the most recent sexual intercourse and the on the last five intercourse occasions was assessed for sexual activity with steady and casual partners. Frequency of unprotected vaginal sex was assessed for the retrospective periods of 30 days and 6 months. The adolescents also were asked whether they ever had an STD, and whether they had an STD in the preceding 6 months.
Vaginal swab specimens were evaluated for Neisseria gonorrhoeae, Chlamydia trachomatis, and Trichomonas vaginalis.10–12 The first swab was placed in a specimen transport tube (Abbott LCx Probe System for Neisseria gonorrhoeae and Chlamydia trachomatis assays; Abbott Park, IL) and tested for chlamydia and gonorrhea DNA by ligase chain reaction (LCR). 10,11 The second swab was used to inoculate culture medium for T vaginalis (InPouch® TV test; BioMed Diagnostics, Inc., San Jose, CA).
Relationships between condom carrying and measures of condom use and STDs were assessed using contingency table analyses. Prevalence ratios, 95% CIs, and corresponding P values were calculated to determine the magnitude and significance of associations. Logistic regression was used to calculate adjusted odds ratios, their respective 95% CIs, and the corresponding P values. The ages of the adolescents and their scores on a 26-item condom barrier scale 13 (α = 0.87) were included as covariates in the logistic regression analyses to control for these identified differences between adolescents who did and those who did not carry condoms.
The average age of the adolescents was 16 ± 1.2 years. Past STD was reported by 25.7% of the adolescents, and 28.2% tested positive for C trachomatis and/or N gonorrhoeae, as assessed by DNA amplification assay, and/or T vaginalis, as assessed by culture. A history of pregnancy was reported by 40.2% of the adolescents, with 11.5% currently pregnant.
Nearly 10% of the adolescents (n = 51) indicated that they had a condom. However, only 42 of them could show the condom to the interviewer. Thus, 8% of the sample actually possessed a condom.
No significant associations were observed between condom carrying and condom use and STDs (Table 1). Null findings persisted despite employing multiple measures of condom use and STD infection. Further, null findings persisted in the adjusted analyses that controlled for observed differences between adolescents who did and those who did not carry condoms (Table 2).
Condom carrying was not associated with self-reported condom use, self-reported STDs, or biologically confirmed STDs. Moreover, approximately 20% of the adolescents who reported carrying condoms could not show the condom to the interviewer. It is therefore suspected that reports of condom carrying are exaggerated and may not serve as a marker for protective behavior without direct visual confirmation. Also of importance, given that the sample was selected on the basis of active sexuality and residence in a high-risk community, it is interesting to note that only 8% of the adolescents actually were carrying condoms.
Adolescents carrying condoms did not significantly differ from their peers who did not carry condoms in frequency of unprotected sex and prevalence of STDs. These findings suggest that condom carrying alone may not be sufficient to impact the use of condoms or the rates of STD infection among adolescent females. The findings also suggest that the influence of the male partner may be a critical factor in determining condom use because adolescent females may be less likely to exert influence over condom use by their partner. 14–16
The findings from this study are limited by the validity of the self-reported measures because any misreporting of condom use or STD history may have altered the findings. Furthermore, assessing the self-reported frequency of condom carrying among adolescents rather than the measure used in this study may have produced different findings. Yet, the measure used (directly observed condom carrying) was a primary strength of the research design and proved valuable by screening out adolescents who claimed to have condoms but could not show one.
Another potential limitation was the lack of adequate power to detect differences in sexual risk behaviors between adolescents who did and those who did not carry condoms. To determine power, the most reliable behavioral measure, condom use at last sexual intercourse, was examined. For condom use at last sexual intercourse, the current study, using a two-tailed test with α set at 0.05, had 0.90 power to detect significant differences in condom use. However, despite this high level of power, no statistically significant differences were observed between adolescents who did and those who did not carry condoms in terms of condom use at last sexual intercourse. For other categorical variables, such as STD infection and some behavioral variables (i.e., any unprotected sexual activity in the past 6 months), there was less power to detect significant differences. Future studies may benefit from larger sample sizes and sufficient power to detect statistically significant differences across a diverse range of biologic and behavioral outcomes.
In addition, the sample was limited to economically disadvantaged African American adolescents. Therefore, the findings may not be generalized to other racial or ethnic groups, or to adolescents from different socioeconomic strata. Further research is needed with diverse adolescent populations.
The findings from this study suggest that adolescent females who carry condoms may be as likely as those who do not to report risky sexual behavior or to be infected with an STD. Therefore, condom acquisition and carrying alone may not be an important outcome of STD/HIV prevention programs designed for adolescent females. Instead, programs based on multiple strategies and goals in the context of individual, family, and community influences may be more likely to promote safer sexual behavior among high-risk adolescent females. 17
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