Sexually Transmitted Diseases:
Adolescent Dual Use of Condoms and Hormonal Contraception: Trends and Correlates 1991–2001
ANDERSON, JOHN E. PhD*; SANTELLI, JOHN MD†; GILBERT, BRENDA COLLEY PhD†
From the *Divisions of HIV/AIDS Prevention and †Reproductive Health, National Center for HIV, STD and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
Correspondence: John E. Anderson, PhD, Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, MS E-46, Atlanta, GA 30333. E-mail: firstname.lastname@example.org
Received January 24, 2003,
revised April 28, 2003, and accepted May 2, 2003.
Background: Use of condoms with hormonal contraceptive methods (dual use) is recommended for adolescents at increased risk for sexually transmitted infections and pregnancy.
Goal: The goal was to measure the extent of dual use among adolescents, to estimate trends in dual use 1991–2001, to assess factors associated with dual use in 2001, and to develop information useful for prevention programs.
Study Design: We used 6 Youth Risk Behavior Surveys of 9th–12th graders conducted 1991–2001. Each survey was an independent, nationally representative sample. Sample sizes ranged from 10,904 to 16,262, and overall response rates ranged from 60–70%. We estimated trends in dual use for the 1991–2001 period using linear logistic regression models of dual use on year of survey controlling statistically for grade, sex, and race/ethnic group, and evaluated correlates of dual use with chi-squared analysis.
Results: Dual use increased significantly throughout 1991–2001, from 3.2% (95% confidence interval, ± 0.7%) in 1991 to 7.2% (± 0.8%) in 2001. During this period, condom use increased and pill use did not. In 2001, 32% (± 2.6%) of all users of hormonal methods (pill or injection) also used condoms. Students in a number of categories had higher rates of dual use: those who were white (8.9% ± 1.2%), 12th graders (9.2% ± 1.5%), and those aged 17 and older (8.8% ± 1.3%). Greater dual use was not associated with increased sexual or drug use risk behaviors.
Conclusion: Dual use has increased but remains low, especially among those most at risk.
SEXUALLY ACTIVE ADOLESCENTS face the need to prevent both pregnancy and sexually transmitted infections (STIs), including human immunodeficiency virus (HIV). The most prevalent highly effective contraceptive methods used in this age group (hormonal methods such as oral and injectable contraceptives) do not provide protection against infections. Those adolescents who are concerned about both risks might need to use both condoms and hormonal methods for dual protection from pregnancy and disease. 1 Use of dual methods has been recommended for teenagers at risk for both STIs and pregnancy, 2 and increasing dual protection among adolescents has been included in the list of health objectives for the nation. 3
Most studies have indicated that condom use is more prevalent with nonregular partners. Typically, as the length of relationships and amount of sexual activity increase, long-term methods such as oral contraceptives or injectable contraceptives are substituted for condoms 4–8; this might leave some adolescents at risk for STIs. Dual use and its correlates have been measured in studies of various populations, 4–11 but there have been relatively few studies of trends. The most recent national trend data from the National Survey of Family Growth (NSFG) suggest that dual use of condoms and hormonal methods was used by a small percentage of teenaged women, and that this percentage increased between 1988 and 1995. 12 Data from the National Survey of Adolescent Males (NSAM) indicate that use of dual methods did not increase for teenaged males between 1988 and 1995. 12 We have used a series of 6 nationally representative school-based surveys (the Youth Risk Behavior Survey [YRBS]), conducted 1991–2001 to measure trends and correlates in the dual use of condoms and hormonal contraceptives among sexually active adolescents. 13 As a series of nationally representative surveys conducted at frequent time intervals using the same methodology, the YRBS offers many advantages for evaluating trends in health behaviors of adolescents that are not available from other data systems.
The YRBS was conducted in 1991, 1993, 1995, 1997, 1999, and 2001. Each YRBS survey was designed as an independent sample of 9th–12th graders representative of all students in the United States; samples of 10,904–16,262 were collected for the 6 surveys with overall response rates of 60–70%. 13,14 Students completed self-administered paper questionnaires, and entered answers on machine-readable answer sheets. Separate questions on condom use and contraceptive method at last sexual intercourse enabled us to define a category of dual users among the sexually active respondents. (Exact question wording is listed in Table 1.) The ability to measure the use of injectable contraceptives began with the 1999 YRBS when the response category “Depo-Provera (injectable birth control)” (Pfizer Corporation, New York, NY) was added to the question on contraceptive method used at last sexual intercourse. We defined hormonal contraceptive use as the reported use of oral contraceptives in the 1991–1997 surveys, and use of oral contraceptives or Depo-Provera in the 1999 and 2001 surveys. We computed the percentages of students using condoms, hormonal contraception, and dual protection for those students who had been sexually active in the 3 months before completing the survey. We assessed the statistical significance of trends using linear logistic regression models of the method use variables by the year of survey. Because contraceptive practice can vary by age, gender, and other factors, the logistic regression analysis was performed controlling statistically for grade, sex, and race/ethnic group. The statistical significance of bivariate associations were evaluated by chi-squared tests. Confidence intervals and statistical tests were adjusted for the complex sample design using SUDAAN Software (Research Triangle Institute, Research Triangle Park, NC).
As noted previously 14 and shown in Table 1, the 6 YRBS surveys indicate steadily increasing condom use throughout the 1991–2001 period for both male and female students, a statistically significant linear trend. Trends in oral contraceptive use during this period were not statistically significant. In the 1999 and 2001 surveys, 3–4% reported Depo-Provera use. The highest levels of hormonal contraceptive use, as defined here, were observed for 2001. In Table 1, males reported higher condom use and females greater use of hormonal methods. The trends are the same for both genders, however.
The 6 surveys have a significant linear increase in dual use (Fig. 1), from 3.2% in 1991 to 7.2% in 2001. This increase was evident for both males and females (Table 1). Although the percentage using dual methods was small, it represents a relatively large and increasing percentage of all hormonal contraceptive users. In 2001, 39.5% of males (95% confidence interval, ± 6.5%) and 27.9% (± 4.1%) of females for whom oral or injectable contraceptives were used at last sexual intercourse also reported using condoms.
In 2001, dual use was higher among white students, students in higher grades, older students, and persons with fewer than 4 sexual partners in the past 3 months (Table 2). Dual use did not differ by gender or by categories of pregnancy history, drug risk, or a combined risk behavior measure (defined as lifetime drug injection or 4 or more sexual partners in the past 3 months).
The YRBS data indicate that the percentage of dual users was small but increased steadily between 1991 and 2001. By 2001, 7.2% of 9th–12th graders reported using condoms and a hormonal method of birth control during last sexual intercourse. The YRBS finding that there was no association between dual use and measures of risk behavior is similar to findings from studies in other populations, including a street survey of high-risk women, 9 a household-based general population sample of youth, 10 and a sample of college women. 8 In contrast, an analysis of women 15-44 years of age in the 1995 NSFG found dual use to be more prevalent among women with more sexual partners. 15 In the YRBS data, dual use was found to be higher among white high school students. Patterns of difference in dual use among race and ethnic groups have varied among studies, with some having higher rates of dual use for black respondents 6,10,15 while others have found no difference between white and black respondents. 4,12
The YRBS data found no difference between genders, with both males and females reporting approximately 7% dual use in 2001. This is in contrast to comparisons made between male and female adolescents using the 1995 NSAM and NSFG, which indicate 16% dual use for males and 8% for females, in household-based samples of 15-19 year olds. Sample design could account for some of these differences; the NSAM and NSFG surveys are household-based and include 15-19 year olds, and YRBS is a sample of 9th–12th graders, most of whom are in the 14-17 age range, and does not include school dropouts. Estimates from 1995 NSAM and 1995 NSFG for 15- to 17-year-olds were used for Healthy People (HP) 2010 as baseline measures of dual use. HP 2010 targets call for baseline values of 16% dual use for males and 7% for females to increase to 20% for males and 11% females by 2010. 3 The 2001 YRBS estimates are similar to values for females from 1995 NSFG and quite a bit lower than the male estimates from the 1995 NSAM. Our analysis of dual contraceptive use was limited to sexually active high school students. Other data from the YRBS indicate the percentage of respondents who were recently sexually active declined from 37-33% during the 1991-2001 period. 14
The results of the 1991-2001 YRBS surveys are necessarily affected by the method of sampling, data collection, and measurement used, and should be interpreted accordingly. The data reported here are representative of students attending high school and do not reflect behaviors of high school-aged youth who have dropped out of school. Nationally, approximately 5% of 16- to 17-year-olds were not enrolled in school and had not completed high school. 16 Surveys such as YRBS rely on self-reported data, which contain some unknown level of reporting error. The YRBS questionnaire has been found to yield good test–retest reliability. 17 Estimates of trends in sexual behavior and condom use variables from the YRBS are generally similar to those found in household-based surveys of adolescents. 18 The contraceptive use variables used here are based on the last sexual intercourse and do not necessarily reflect behavior during previous sexual activity or with other partners. Measurement limited to the last sexual act cannot provide a detailed accounting of condom or contraceptive use, but it has been found to be a useful method of collecting summary data and has been used in many survey questionnaires. 19 The YRBS results need to be understood in the context of all ongoing household and school-based health survey research of youth. The unique contribution of the YRBS is the ability to assess trends through repeated measurements at several frequently spaced points in time using the same methodology.
The YRBS data indicate that over a 10-year period, dual protection was reported by an increasing number of male and female adolescents. The decision to adopt dual use depends on a number of factors that are not measured by the YRBS: infection status of the partner, for example, or the relative costliness of an unintended pregnancy. 20 The trends in the YRBS data suggest that there is an increasing acceptance of the dual use of condoms and hormonal methods among sexually active teenagers, which could lead to further success by prevention programs in promoting this strategy among at-risk teens.
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