Are Condom Availability Programs in Seattle Working to Reduce Disease?
The Seattle Public School District 1, Seattle, conducted an evaluation of an HIV/AIDS prevention and condom-availability program at public high schools in Seattle.
The school district conducted the evaluation through two student surveys, one administered in 1993, before the high schools began providing condoms, and the second in 1995, after they had begun making them available to students. The surveys were designed to measure the impact of condom availability upon student contraceptive use and sexual behavior.
The project director reported the following findings in the February 1999 issue of the American Journal of Public Health:
- School condom availability does not hasten or increase student sexual activity, and that making condoms available to students did not increase condom use.
- According to the researchers, the findings call into question whether the political effort necessary to implement condom-availability programs in schools will always result in increases in condom use, since students may already have ample access to condoms.
The Robert Wood Johnson Foundation (RWJF) provided partial support to the evaluation with a grant of $47,685 between May 1993 and September 1995.
Concern about adolescent HIV infection has prompted school boards across the nation to initiate active school-based AIDS prevention programs. In some high schools, prevention efforts have featured stepped-up educational programs, counseling, and, in some cases, on-site condom availability.
In the fall of 1992, Seattle's Board of Education passed a resolution stipulating that condoms be made available through all of its public high schools. The condom-availability program was supplemented by classroom instruction, school-wide peer-education activities, and, in some schools, school-based health centers.
Condoms were made available through two mechanisms: multiple baskets placed in school-based health clinics and clinic bathrooms (in the five schools that had health clinics), and in vending machines installed in public locations (in five schools without health centers and two with health centers). The vending machines charged 25 cents for a condom.
This RWJF grant to the Seattle Public Schools helped to support surveys designed to measure the impact of condom availability on students' use of condoms and sexual behavior. Questionnaires were completed by 7,544 students in 10 high schools (72 percent of total school enrollment) in early 1993, before any of the schools began providing condoms, and again by 8,400 students (77 percent of enrollment) in 1995, after the high schools had begun making condoms available.
The questionnaires included many questions identical to those used by the Centers for Disease Control's (CDC) Youth Risk Behavior Surveillance System (YRBSS), which surveyed nationally representative samples of 16,296 students in 1993 and 10,904 students in 1995. Seattle researchers used these groups for comparison. Investigators also counted the number of condoms students obtained through the vending machines and clinic baskets and conducted 16 focus groups with students and 34 interviews with staff at all 15 high schools.
The CDC provided $30,000 toward survey administration and data analysis, and an additional $175,000 to ETR Associates in Santa Cruz, Calif. (a firm specializing in research and evaluation activities related to health education) for additional in-depth evaluation and comparison of the Seattle data to national data. RWJF also funded similar evaluations in New York (see Grant Results on ID#s 020451 and 020848) and Philadelphia (ID#s 020589, and 30162).
The grantee reported the following findings in the February 1999 issue of the American Journal of Public Health:
- School condom availability enabled students to obtain condoms in schools instead of obtaining them elsewhere without increasing overall use. Between the inception of the program in April and May 1993 and June 1995, approximately 11,700 Seattle students obtained 133,711 condoms at school. Although some students did not obtain any condoms and others obtained more than 20, the annual totals represent an average of about 4.4 condoms per student during the 199394 academic year and 4.7 during the 199495 academic year. However, the results also revealed a very large substitution effect, with students obtaining the condoms from school instead of another source, such as a store or a friend or relative. According to students in focus groups, condoms even free condoms were quite accessible before they were made available in school.
- Students obtained many more condoms from baskets in the health centers than from vending machines. During the first two years of the program, students obtained more than 50 times as many condoms from baskets as they did from vending machines. Lack of privacy was the most important reason for the small number of condoms obtained from vending machines.
- Some 29 percent of all students obtained at least one condom at school, but only 13 percent actually used a school-obtained condom during sex; these percentages were higher for sexually experienced students. Among students who had ever used a condom from school, 62 percent had used one to five condoms, 18 percent had used six to ten condoms, 8 percent had used 11 to 20 condoms, and 12 percent had used 21 or more condoms.
- Sexually experienced students in schools with health centers were more than twice as likely to have obtained and used a condom from school as were sexually experienced students in schools with only vending machines (42 percent vs. 18 percent). Overall, students who were more sexually active were significantly more likely than their less active counterparts to have used a condom obtained from school.
- Condom availability in Seattle schools did not hasten the onset of sexual intercourse. The percentage of students who had ever had sex decreased slightly in the Seattle schools, from 46 percent to 42 percent, while it remained stable nationwide (49 percent to 50 percent). When compared with the national YRBSS data, the decrease in Seattle is not statistically significant. However, in the Seattle schools without health centers, there was a statistically significant decrease in the percentage of students who had ever had sex, relative to the change over time in the YRBSS samples.
- Making condoms available to students in Seattle did not increase condom use. Among students who had engaged in sex during the 3 months preceding each survey, the percentage who used a condom the last time they had sex decreased from 57 percent in 1993 to 51 percent in 1995 among the Seattle students, while it increased from 53 percent to 56 percent among students in the YRBSS samples. The decrease in condom use was much greater among students in schools that had clinics (and distributed many more condoms) than in schools without clinics. This finding was a source of surprise to the researchers, who suggested that health clinics, knowing that students were already obtaining many condoms from baskets, might have placed more emphasis on encouraging students to abstain from sex, have fewer sexual partners, and to use oral contraceptives, rather than emphasizing condom use. The researchers noted that because implementing school condom availability sometimes requires considerable political effort on the part of school districts, this study calls into question whether that effort will always lead to increases in condom use when students already have ample access to condoms.
Data from the two Seattle surveys were published in the American Journal of Public Health and are available through ETR Associates in Santa Cruz, California. Project staff also published two reports concerning the project: Seattle Public Schools: 1995 Teen Health Risk Survey, and An Evaluation of the Seattle School Condom Availability Program. See the Bibliography for details.
AFTER THE GRANT
All Seattle high school students continue to have free access to condoms through health clinic baskets, without parental permission. The Seattle school district continues to educate students about the importance of condom use and conducted another survey of high school students in 1999; the findings were published in 2000.
GRANT DETAILS & CONTACT INFORMATION
Evaluation of a Condom Availability Program in Seattle High Schools
Seattle Public School District 1 (Seattle, WA)
Dates: May 1993 to September 1995
(Current as of date of this report; as provided by grantee organization; not verified by RWJF; items not available from RWJF.)
Books and Reports
Hillard P, Peterfreund N, and Cheadle A. Seattle Public Schools: 1995 Teen Health Risk Survey. Seattle, Wash.: Seattle Public Schools, 1996.
Kirby D, Brown N, Peterfreund N, Hillard P, and Harrist R, An Evaluation of the Seattle School Condom Availability Program. Santa Cruz, Calif.: ETR Associates, 1997.
Kirby D, Brener ND, Brown NL, Peterfreund N, Hillard P, and Harrist R. "The Impact of Condom Availability in Seattle Schools on Sexual Behavior and Condom Use." American Journal of Public Health, 89(2): 182187, 1999. Abstract available online.
Report prepared by: Lauren Green
Reviewed by: Robert Crum
Reviewed by: Robert Narus
Program Officer: Donald Dickey