Positive Impact of a Structural Positive Impact of a Structural Intervention on Knowledge of and Intervention on Knowledge of and

Use of School-based Condom Use of School-based Condom Availability Programs by Urban High Availability Programs by Urban High

School StudentsSchool Students

Emily Q. Chung MPH, CHES, Patricia Dittus, Emily Q. Chung MPH, CHES, Patricia Dittus, PhD,PhD,

Christine J. De Rosa, PhD, Kathleen Ethier, Christine J. De Rosa, PhD, Kathleen Ethier, PhD,PhD,

Esteban Martinez, Kathy Wong, MS, Esteban Martinez, Kathy Wong, MS, Peter R. Kerndt, MD, MPHPeter R. Kerndt, MD, MPH

For the PROJECT CONNECT Study TeamFor the PROJECT CONNECT Study TeamFunded by Centers for Disease Control and Prevention, Cooperative Agreement U30/CCU922283-06

Condom Availability Condom Availability Program (CAP)Program (CAP)

• CAPs make condoms available in schools as CAPs make condoms available in schools as part of a coordinated school health programpart of a coordinated school health program

• A 1996 report found 50 school districts, 431 A 1996 report found 50 school districts, 431 schools with CAPsschools with CAPs

• CAPs provide opportunitiesCAPs provide opportunities Direct interaction with studentsDirect interaction with students Prevention counselingPrevention counseling Provision of informationProvision of information

• CAPs vary substantially in number of CAPs vary substantially in number of condoms distributed and students servedcondoms distributed and students served

Los Angeles Unified School Los Angeles Unified School District (LAUSD) CAPDistrict (LAUSD) CAP

• Implemented in 1992Implemented in 1992• All LAUSD high schools mandated to make All LAUSD high schools mandated to make

condoms available to studentscondoms available to students• Schools set up a committee, including Schools set up a committee, including

school nurseschool nurse• Committee defines parametersCommittee defines parameters• Condoms obtained from district coordinatorCondoms obtained from district coordinator• Prevention materials handed out with Prevention materials handed out with

condomscondoms• Passive parental consentPassive parental consent

Formative Research, LAUSD Formative Research, LAUSD CAPCAP

• Most students (55%) unaware they could Most students (55%) unaware they could get condoms at schoolget condoms at schoolaa

• Fewer than 1 in 4 sexually experienced Fewer than 1 in 4 sexually experienced students ever received condoms from students ever received condoms from CAPCAPaa

• Multiple barriersMultiple barriersbb Left to health clinicsLeft to health clinics Confusion/difficulty with consentConfusion/difficulty with consent Administrative buy-inAdministrative buy-in Lack of awareness among school staffLack of awareness among school staff Added logistical burdensAdded logistical burdens

aBased on youth surveysbBased on key informant interviews

CAP Intervention GoalsCAP Intervention Goals

• Enhance implementation of district-Enhance implementation of district-mandated CAPmandated CAP

• Increase the number of students Increase the number of students who are aware of the CAPwho are aware of the CAP

• Increase the number of students Increase the number of students who receive condoms from the CAPwho receive condoms from the CAP

CAP: Stages of ChangeCAP: Stages of Change

4: ActionStarting up a program.

3: PreparationHow are we

going to do that?

2: ContemplationWe ought to do that…

1: PrecontemplationCondom Availability Program?

What’s that?Do we have one?

5: MaintenanceContinuing and expanding

the program.

GOAL:GOAL:

Activities by StageActivities by Stage

• Stages 1 and 2: Educational meetings Stages 1 and 2: Educational meetings about policy and adolescent about policy and adolescent reproductive healthreproductive health

• Stage 3: Self-assessment, plan and Stage 3: Self-assessment, plan and materials developmentmaterials development

• Stage 4: Implementing plan, follow-upStage 4: Implementing plan, follow-up

• Stage 5: OutreachStage 5: Outreach

Raising Awareness of CAP (Outreach)Raising Awareness of CAP (Outreach)

Youth Survey MeasuresYouth Survey Measures

• Research QuestionResearch Question Do our enhancements to the CAP result in Do our enhancements to the CAP result in

increased knowledge of the program and increased knowledge of the program and increased use of the program?increased use of the program?

• High school surveys onlyHigh school surveys only Does someone at your school (like a nurse Does someone at your school (like a nurse

or counselor) give out condoms to students or counselor) give out condoms to students who want them?who want them?

Have you ever gotten condoms from this Have you ever gotten condoms from this person at your school?person at your school?

AnalysisAnalysis

• Chi-square analyses Chi-square analyses Outcomes by data collection waveOutcomes by data collection wave Analyses performed by condition and Analyses performed by condition and

sexual experience (yes/no)sexual experience (yes/no)

• Logistic regression models included Logistic regression models included condition, waves, and condition X condition, waves, and condition X wave interaction termswave interaction terms

• Analyses restricted to high school Analyses restricted to high school studentsstudents

Change in Knowledge of Change in Knowledge of CAPCAP

Among all participantsAmong all participants::Increase in knowledge of CAP across Increase in knowledge of CAP across

waves was significantly greater for waves was significantly greater for intervention than control participantsintervention than control participants

55.1% - 56.7% - 66.4% vs. 47.7% - 44.7% - 55.1% - 56.7% - 66.4% vs. 47.7% - 44.7% - 52.4%, wave X condition interactions p<.0552.4%, wave X condition interactions p<.05

Driven by change among intervention Driven by change among intervention femalesfemales

51.2% - 55.8% - 64.6% vs. 45.8% - 42.9% - 51.2% - 55.8% - 64.6% vs. 45.8% - 42.9% - 53.3%, wave X condition interactions p<.05 53.3%, wave X condition interactions p<.05

Knowledge of CAP, Knowledge of CAP, All Students by ConditionAll Students by Condition

47.752.4

44.7

66.4

56.755.1

0

10

20

30

40

50

60

70

Wave 1 Wave 2 Wave 3

Per

cen

t w

ho

kn

ew o

f C

AP

Control

Intervention

N=13,331

Knowledge of CAP, All Females Knowledge of CAP, All Females by Conditionby Condition

51.2

42.9

53.3

45.8

64.655.8

0

10

20

30

40

50

60

70

Wave 1 Wave 2 Wave 3

Pe

rce

nt

wh

o k

ne

w o

f C

AP

Control

Intervention

N=7,317

Change in Knowledge of CAP Change in Knowledge of CAP Among Sexually Experienced Among Sexually Experienced

ParticipantsParticipants

•Knowledge of CAP increased Knowledge of CAP increased across wavesacross waves 62.6% - 63.7% - 70.3% vs. 51.4% - 49.1% 62.6% - 63.7% - 70.3% vs. 51.4% - 49.1%

- 60.7%, wave X condition interactions n.s.- 60.7%, wave X condition interactions n.s.

•Change was not significantly Change was not significantly different for intervention vs. different for intervention vs. control participantscontrol participants

Change in Knowledge of CAP Change in Knowledge of CAP Among Sexually Experienced Among Sexually Experienced Participants, All Females by Participants, All Females by

ConditionCondition

57.5

48.4

62.8

49.9

63.9

0

10

20

30

40

50

60

70

Wave 1 Wave 2* Wave 3

Perc

en

t w

ho

kn

ew

of

CA

P

Control

Intervention

*Wave 2 x condition interaction marginally significant, p<.10

70.2

Used CAP, Used CAP, All Students Who Knew of It*All Students Who Knew of It*

• Use of CAP did not differ between Use of CAP did not differ between conditionsconditions

• Use of CAP increased across waves in Use of CAP increased across waves in both conditionsboth conditions Intervention: 27.0% - 32.4% - 34.0%Intervention: 27.0% - 32.4% - 34.0% Control: 27.4% - 33.1% - 32.8%Control: 27.4% - 33.1% - 32.8% Wave X condition interactions n.s.Wave X condition interactions n.s.

*Among all students regardless of sexual experience

Went to School Nurse for Went to School Nurse for CondomsCondoms

Among all participants, regardless of sexual Among all participants, regardless of sexual experience:experience:

• Increase across waves significantly greater Increase across waves significantly greater for intervention than control participantsfor intervention than control participants 6.7% - 7.9% - 9.6% vs. 7.0% – 6.7% - 7.2%, 6.7% - 7.9% - 9.6% vs. 7.0% – 6.7% - 7.2%,

wave 3 X condition interaction p<.05wave 3 X condition interaction p<.05

• Driven by change among intervention Driven by change among intervention malesmales 10.7% - 11.1% - 14.7% vs. 10.9% - 11.2% - 10.7% - 11.1% - 14.7% vs. 10.9% - 11.2% -

9.3%, wave 3 X condition interaction p<.059.3%, wave 3 X condition interaction p<.05

Went to School Nurse for Went to School Nurse for CondomsCondoms

• Among sexually experienced Among sexually experienced students only, increase driven by students only, increase driven by intervention femalesintervention females 6.7% - 10.5% - 10.1% vs. 7.4% - 6.1% - 6.7% - 10.5% - 10.1% vs. 7.4% - 6.1% -

10.0%, wave 2 X condition interaction 10.0%, wave 2 X condition interaction p<.05p<.05

Went to School Nurse for Went to School Nurse for Condoms, All Females by Condoms, All Females by

Condition*Condition*

*Among sexually experienced students

7.4 106.16.7

10.5 10.1

0

10

20

30

40

50

60

70

Wave 1 Wave 2 Wave 3Per

cen

t w

ho

wen

t to

Sch

oo

l N

urs

e fo

r co

nd

om

s

Control

Intervention

Summary of FindingsSummary of Findings

• Increase in knowledge of CAP Increase in knowledge of CAP greatergreater in in interventionintervention schools schools

• Going to School Nurse for condoms Going to School Nurse for condoms significantly greater for intervention significantly greater for intervention than for control participantsthan for control participants

ConclusionsConclusions

• Enhancements to implementation of Enhancements to implementation of CAP are feasible, practical, low-costCAP are feasible, practical, low-cost

• Enhancements resulted in:Enhancements resulted in: Greater increase in knowledge of Greater increase in knowledge of

program among students in intervention program among students in intervention schoolsschools

Increase in seeing School Nurse for Increase in seeing School Nurse for condoms among students in condoms among students in intervention schoolsintervention schools

Implications for Implications for InterventionsInterventions

• Implementation of district-mandated CAP can Implementation of district-mandated CAP can vary:vary: EnforcementEnforcement Person responsiblePerson responsible

• Minor enhancements (i.e., moving personnel Minor enhancements (i.e., moving personnel through stages of change) can result in through stages of change) can result in substantial improvement in implementationsubstantial improvement in implementation

• Improved implementation results in greater Improved implementation results in greater student knowledge of CAP and seeking student knowledge of CAP and seeking condoms from School Nursecondoms from School Nurse

Condom Availability Condom Availability Programs: Next StepsPrograms: Next Steps

• Intervention: Intervention: Enlist student leadership groups in normalizing Enlist student leadership groups in normalizing

use of CAPuse of CAP Increase outreachIncrease outreach Maintain functioning of programsMaintain functioning of programs

• Evaluation: Evaluation: Examine how changes in knowledge and use of Examine how changes in knowledge and use of

CAP impact participant condom useCAP impact participant condom use Examine relationship between number of Examine relationship between number of

condoms distributed and participant condom condoms distributed and participant condom useuse

Thank You!Thank You!CollaboratorsCollaborators: :

Peter Kerndt, MD, MPHPeter Kerndt, MD, MPHKathleen Ethier, PhD Kathleen Ethier, PhD Patricia Dittus, PhDPatricia Dittus, PhDNicole Liddon, PhDNicole Liddon, PhD

Abdelmonem Afifi, PhDAbdelmonem Afifi, PhDWilliam Cumberland, PhDWilliam Cumberland, PhD

Harlan RotblattHarlan RotblattRic LoyaRic Loya

Robin Jeffries, MPHRobin Jeffries, MPHSharon Hudson, PhDSharon Hudson, PhD

…for the Project Connect Study Team

Project StaffProject Staff: : Christine J. De Rosa, PhDChristine J. De Rosa, PhD

Emily Q. Chung, MPH, CHESEmily Q. Chung, MPH, CHESSteve Martinez, BASteve Martinez, BA

Kathy Wong, MSKathy Wong, MSLindsay Du Plessis, MPHLindsay Du Plessis, MPH

Email: echung@hra-paramount.org