psychology

SUBSTANTIVE REVIEW

The Effects of School-Based Condom Availability Programs (CAPs) on Condom Acquisition, Use and Sexual Behavior: A Systematic Review

Timothy Wang1 • Mark Lurie2 • Darshini Govindasamy3,4 • Catherine Mathews3,4

Published online: 17 June 2017

� The Author(s) 2017. This article is an open access publication

Abstract We conducted a systematic review to assess the

impact of school-based condom availability programs

(CAPs) on condom acquisition, use and sexual behavior. We

searched PubMed to identify English-language studies

evaluating school-based CAPs that reported process (i.e.

number of condoms distributed or used) and sexual behavior

measures. We identified nine studies that met our inclusion

criteria, with the majority conducted in the United States of

America. We judged most studies to have medium risk of

bias. Most studies showed that school-based CAPs increased

the odds of students obtaining condoms (odds ratios (ORs)

for individual studies ranged between 1.81 and 20.28), and

reporting condom use (OR 1.36–3.2). Three studies showed

that school-based CAPs positively influenced sexual

behavior, while no studies reported increase in sexual

activity. Findings suggest that school-based CAPs may be an

effective strategy for improving condom coverage and pro-

moting positive sexual behaviors.

Keywords School health � Condom use � Sexual behavior � Adolescent

Introduction

Globally, adolescents and young adults (15–24 years)

account for approximately 60% of incident sexually

transmitted infections (STIs) [1]. According to recent

UNAIDS estimates, in 2015 female and males aged

15–24 years accounted for approximately 20 and 14% of

new HIV-infections among adults ([15 years), respec- tively [2]. Annually, an estimated 16 million adolescents

(15–19 years) give birth in low- and middle-income

countries, with complications from childbirth being the

leading cause of mortality among adolescent females [3].

Several key studies and reports have highlighted the lim-

ited access that adolescents have to basic sexual repro-

ductive health services (i.e. STIs and pregnancy prevention

services) in high-, middle- and low- income countries

[4–6]. Due to the burden of these sexual and reproductive

health conditions (i.e. HIV and STI acquisition, pregnancy

complications) among this population, there is a need to

implement strategies that can increase access to and uti-

lization of STI and pregnancy prevention methods. Given

that approximately 75% of individuals in the school-going

age for secondary education globally are enrolled in sec-

ondary school [7], schools may serve as an ideal platform

to extend coverage for these services.

The Health Promoting Schools (HPS) concept was ini-

tiated by the World Health Organization in the 1980s, and

has been adopted by the European and Australian HPS

networks [8]. The HPS approach is characterized by a

formal health curriculum aimed at providing students with

the skills and knowledge needed to make healthy choices,

promote a healthy physical and social school environment,

and facilitate interaction between communities and schools

to promote health [8]. The Comprehensive School Health

Program (CSHP) was also developed during this period and

& Darshini Govindasamy [email protected]

1 Health Policy Research Department, The Fenway Institute,

Fenway Health, Boston, MA, USA

2 Department of Epidemiology, Brown University School of

Public Health, Providence, RI, USA

3 Health Systems Research Unit, South African Medical

Research Council, Francie Van Zijl Drive, Parow Valley,

Cape Town, PO BOX 19070, Tygerberg, Western Cape,

South Africa

4 Adolescent Health Research Unit, Department of Child and

Adolescent Psychiatry, University of Cape Town,

Cape Town, Western Cape, South Africa

123

AIDS Behav (2018) 22:308–320

https://doi.org/10.1007/s10461-017-1787-5

was adopted mainly by the United States of America

(USA) and Canada [8]. The CSHP includes eight compo-

nents: sequential health education from grades 1–12,

school-based health services, healthy school environments,

physical education in schools, food services, counseling

services, health promotion among school staff, and school

or community integration for health promotion.

While the HPS and CSHP concepts exist, literature

suggests that there is a considerable gap between the

conceptualization and the implementation in schools.

According to a school health census report conducted in the

USA between 2010 and 2011, few schools have imple-

mented all of the HPS or CSHP concepts, and few evalu-

ations have been conducted on its implementation [9].

However, in recent years, one component of the CSHP (i.e.

school-based health services) has been adopted and eval-

uated in several schools in the USA. Schools adopting this

approach in this setting usually have a school-based health

center (SBHC) on the school premises to provide health

services that are integrated into school programs [9].

Most of the studies on SBHCs are limited to high-in-

come settings [10]. Studies have shown that SBHCs serve

as an effective platform for reducing the structural barriers

to accessing care [10]. SBHCs are often operated by nur-

ses, physicians and school staff and seek to provide com-

prehensive services, including vaccinations, drug and

substance abuse counseling, anti-violence and anti-bullying

programs, and healthy eating and fitness programs for

students [9]. Importantly, these SBHCs provide a range of

reproductive health services, with the majority providing

services such as STI diagnosis and treatment and preg-

nancy screening [9]. However, the majority of SBHCs in

high-income countries do not distribute contraceptives (i.e.

condoms, birth control). According to a USA school census

report, 82.1% of SBHCs promote abstinence and 49.8% of

SBHCs are actually prohibited from providing contracep-

tives [9].

Given that contraception is an effective and low-cost

method for preventing STIs and pregnancy, lack of avail-

ability of contraception is a missed opportunity for SBHCs

to help prevent STIs and unwanted pregnancies in ado-

lescents and young adults [4, 10]. However, the minority of

SBHCs, primarily in the USA, have started condom

availability programs (CAPs) for students. These programs

have been controversial, as proponents argue that school-

based CAPs could assist in increasing condom use among

adolescents, while opponents argue that school-based

CAPs could increase sexual activity among adolescents

[11]. Due to the controversial nature, few SBHCs currently

operate CAPs to distribute condoms to students. To date,

no study has systematically reviewed the efficacy of

school-based CAPs. A better understanding of the impact

of school-based CAPs on students’ sexual behavior could

assist program planners and policy makers in their deci-

sion-making process around what sexual reproductive

health services SBHCs should offer. The objectives of this

systematic review were to determine the impact of school-

based CAPs on condom acquisition, condom use and sex-

ual behavior outcomes, and to assess the factors that

facilitate or impede the delivery of these programs.

Methods

Search Strategy

An electronic search was conducted in PubMed using a

comprehensive search strategy (Fig. 1) to identify studies

assessing school-based programs that made condoms

available to students. The search was limited to English

language papers, published before February 2016, with no

restriction on geographic region. The search strategy

included both PubMed’s Medical Subject Headings

(MeSH) terms (e.g. school health services, condoms) and

sub-terms (e.g. adolescents, sexual behavior, condom uti-

lization). Related citation searches on PubMed were con-

ducted to identify any study that met the inclusion criteria

but used less common MeSH terms that were not used in

Fig. 1 Search strategy

AIDS Behav (2018) 22:308–320 309

123

the original search. Additional online databases were

searched (i.e. Cochrane library and the Education Resource

Information Centre (ERIC)) to identify further articles.

Furthermore, co-authors (CM, ML) were contacted for

additional citations.

Inclusion Criteria

In order to be included in this review studies had to eval-

uate an intervention or program that distributed condoms

directly on school premises. In addition, studies had to

include process outcomes (i.e. condom acquisition or use

by adolescents) and any sexual behavior measures (e.g.

sexual activity, age of sexual debut, condom use during

sexual intercourse, number of sexual partners), as defined

by each study, to be eligible.

Screening and Data Extraction

Title and abstracts of all citations obtained from the search

were screened. Full-text of all potentially eligible studies

were retrieved and assessed using the full inclusion criteria.

TW and ML assessed whether potentially eligible studies

met the inclusion criteria. Included studies were reviewed

and all relevant variables were extracted.

Analysis

A descriptive analysis of key outcome measures was con-

ducted on all included studies. Point estimates or measures

of association together with corresponding 95% confidence

intervals (CIs) and test statistics were presented for each

outcome measure. Preliminary patterns between types of

school-based CAP components and program success were

assessed based on two criteria (i.e. anonymity and acces-

sibility for the students who wished to obtain condoms).

These factors were chosen as internationally these are

regarded as key attributes of quality adolescent health

services. [12] These programs were ranked (high, middle,

low) in the extent to which they maintained anonymity and

promoted accessibility (Fig. 2). Anonymity was assessed

based on level of privacy when obtaining condoms. The

requirement of parental consent was also assessed.

Accessibility was based on the ability of a student to

independently access condoms at various locations at no

cost, without the assistance of a nurse or faculty member.

Risk of Bias Assessment

We adapted the Effective Public Health Practice Project’s

Quality Assessment Tool for Quantitative Studies to assess

the risk of bias in each of the included studies [13]. Studies

were evaluated for selection, reporting and misclassifica-

tion bias by assessing and scoring the following factors:

study design, confounders, and assessment of exposure and

outcome measures. Total study risk of bias was classified

accordingly: high (score = 3), medium (score = 2) and

low (score = 1).

Results

Search Results

The PubMed database search identified 236 potential

citations. An additional 170 possible citations were iden-

tified through related citation searches and citations from

co-authors. Of the 406 combined citations, 356 citations

were excluded as they were either duplicates or did not

meet the inclusion criteria based on the title screen. The

title and abstracts of the 50 remaining potential citations

were then examined for inclusion. Overall, 31 studies did

not meet the inclusion criteria based on their abstracts;

hence the remaining 19 full text articles were retrieved and

then assessed for full inclusion. Of the 19 potentially eli-

gible studies, 10 did not meet the full inclusion criteria and

were excluded. The remaining 9 studies met the inclusion

criteria and were included in this review (Fig. 3). The

search was updated in March 2017 to identify new studies

and to include both USA and UK English spelling of key

terms (behavior/behavior, utilisation/utilization), but no

new studies were identified.

Study Setting and Demographics of Participants

Of the nine included studies, eight were conducted in the

USA and evaluated CAPs based in schools in urban areas

within Los Angeles, Seattle, Philadelphia, and New York

[14–20] (Table 1). The remaining study was conducted in

urban schools in Tijuana, Mexico [21]. All nine studies

were conducted in public secondary schools with students

in the 13–18 years old age range. All the USA-based

studies had approximately equal distributions of male and

female students; in the Mexico study, approximately 60%

of the student population were female [21].

Study Design Characteristics

The majority of studies (8/9) were outcome evaluations of

school-based CAPs. Three studies used cross-sectional study

designs to compare schools with CAPs to those without CAPs

[17, 19, 20]. Four studies used quasi-experimental study

designs [16]. Two studies used a longitudinal design with pre-

and post-CAP implementation surveys [14, 15]. Studies with

longitudinal elements had follow-up times that varied from 6

310 AIDS Behav (2018) 22:308–320

123

months to 5 years in length. Outcomes in all studies were

ascertained using self-reported surveys.

Study Results

Condom Acquisition

Four studies examined the effects of school-based CAPs on

condom acquisition by adolescent participants, and all

studies reported an increase in condom acquisition in

schools with a CAP [16–18, 21]. The largest effect was

observed in a quasi-experimental study in Mexico which

evaluated a school-based CAP delivered with HIV pre-

vention workshops [21]. This study found that the odds of

acquiring condoms among students in the intervention

schools were 20 times more than students in the control

schools (odd ratio (OR) 20.28, p \ 0.001), albeit the sample size was small (n = 320) [21]. The smallest effect

size was observed in a quasi-experimental study in the

USA in which the odds of acquiring condoms among stu-

dents was 1.8 times higher (OR 1.81, 95% CI 1.32–2.49) in

intervention schools where CAP implementation was

strengthened [16]. Furthermore, this study found that the

odds of acquiring condoms among sexually active students

in the intervention group were three times more than the

control group (OR 3.08, 95% CI 1.77–5.36) [16].

Condom Use

Seven studies examined the effects of school-based CAPs

on condom use. Two observational studies from the USA

showed no significant differences in condom use [14, 19],

Fig. 2 Anonymity and Accessibility Classification

Descriptions

AIDS Behav (2018) 22:308–320 311

123

whereas one school survey showed a 6% decrease in

condom use in last 3 months in schools with CAPs

(57–51% p = 0.042) [15]. The authors of this study

hypothesize that a substitution effect may have been pre-

sent as students may have substituted condoms accessed

from their school for condoms they acquired previously

from the community, which may have led to this marginal

decrease in condoms use [15]. The remaining three studies

showed increases in condom use [11, 17, 20]. The largest

effect was observed in a cross-sectional study in the USA

which showed that the odds of using condoms (OR 2.1,

95% CI 1.5–2.9) or using condoms as a form of contra-

ception (OR 2.1, 95% CI 1.5–2.8) were two times higher

among students that attended schools with CAPs [17]. A

similar effect was also observed in a cross-sectional study

conducted in the USA (OR 1.36; p \ 0.01) [9]. Moreover, this study showed that the odds of using a condom during

the last sexual intercourse within the past 6 months among

sexually active students from schools with CAPs almost

doubled (OR 1.85, p \ 0.01) [11].

Sexual Behavior

Eight studies assessed the impact of school-based CAPs on

sexual behavior. Overall, five studies showed no significant

differences in sexual behavior outcomes as measured by

Fig. 3 Selection process for the inclusion of studies

312 AIDS Behav (2018) 22:308–320

123

T a b le

1 C o n d o m

a n d se x u a l b e h a v io r o u tc o m e s o f sc h o o l- b a se d C A P s

F ir st

a u th o r, y e a r, c o u n tr y ,

st u d y d e si g n

S a m p le

a n d p a rt ic ip a n ts

C o n d o m

a c q u is it io n

C o n d o m

u se

S e x u a l b e h a v io r

P ro g ra m

c o m p o n e n ts

G u tt m a c h e r, 1 9 9 7 , U S A , Q u a si -

e x p e ri m e n ta l [1 1 ]

7 1 1 9 st u d e n ts in

1 2 ra n d o m ly

se le c te d N e w

Y o rk

sc h o o ls

w it h c o n d o m

d is tr ib u ti o n

p ro g ra m s a n d 5 7 3 8 st u d e n ts in

1 0 C h ic a g o

sc h o o ls c o m p le te d th e c ro ss -s e c ti o n a l

su rv e y , th e sc h o o ls a ll h a d si m il a r g e n d e r

a n d ra c ia l d is tr ib u ti o n

N o t

a ss e ss e d

U se d c o n d o m

a t la st se x u a l in te rc o u rs e :

O R 1 .3 6 (p

\ 0 .0 1 )

O R 1 .2 9 (p

\ 0 .0 1 )a

O R 1 .4 2 (p

\ 0 .0 1 )b

U se d c o n d o m

a t la st

in te rc o u rs e fo r

st u d e n ts w it h 3 ?

p a rt n e rs

in p a st 6

m o n th s:

O R 1 .8 5 (p

\ 0 .0 1 )

P e rc e n ta g e se x u a ll y

a c ti v e :

N e w

Y o rk : 5 7 .2 %

C h ic a g o : 5 7 .1 %

(N S )a

N e w

Y o rk : 3 9 .6 %

C h ic a g o : 3 7 .6 %

(N S )b

A n o n y m it y : L o w , st u d e n ts re c e iv e

c o n d o m s fr o m

c li n ic

v o lu n te e rs

a n d m u st

le a v e ID

n u m b e rs

A c c e ss ib il it y : L o w , st u d e n ts c a n ’t

a c c e ss

c o n d o m s in d e p e n d e n tl y ,

o n ly

1 lo c a ti o n to

re c e iv e c o n d o m s

C o n se n t: R e q u ir e d

F u rs te n b e rg , 1 9 9 7 , U S A ,

L o n g it u d in a l (w

it h C o h o rt

e le m e n t) [1 4 ]

In 1 9 9 2 , 9 P h il a d e lp h ia sc h o o ls im

p le m e n te d

h e a lt h re so u rc e c e n te rs

th a t d is tr ib u te d

c o n d o m s, su rv e y d a ta

w a s ta k e n in

1 9 9 1

a n d 1 9 9 3 b y in te rv ie w in g e li g ib le

1 4 – 1 8

y e a r o ld s in

ra n d o m ly

se le c te d c e n su s

b lo c k s a ro u n d H R C a n d n o n -H

R C sc h o o ls ,

4 9 0 st u d e n ts re sp o n d e d in

1 9 9 1 , 9 4 5

st u d e n ts re sp o n d e d in

1 9 9 3

N o t

a ss e ss e d

U se d c o n d o m

a t la st se x u a l in te rc o u rs e :

H R C (a ll ): 5 2 .2 – 5 8 %

(N S )

H R C (l o w ): 5 7 – 6 1 %

(N S )

H R C (h ig h ): 3 7 – 5 0 %

(N S )

N o n -H

R C : 6 1 .9 – 6 4 .6 %

(N S )

E v e r h a d se x :

H R C (a ll ): 6 4 – 5 7 .6 %

(N S )

H R C (l o w ): 6 1 – 5 6 %

(N S )

H R C (h ig h ): 7 5 – 6 6 %

(N S )

N o n -H

R C : 5 5 .7 – 5 8 .8 %

(N S )

H a d se x in

la st 4

w e e k s:

H R C (a ll ): 3 2 – 2 8 .6 %

(N S )

H R C (l o w ): n o c h a n g e

H R C (h ig h ): 4 3 – 2 9 %

(N S )

N o n -H

R C : 2 4 – 2 5 .6 %

(N S )

H a d u n p ro te c te d se x in

la st

4 w e e k s:

H R C (a ll ): 7 .5 – 5 .6 %

(N S )

H R C (l o w ): n o c h a n g e

H R C (h ig h ): 1 4 – 6 %

(p = 0 .0 8 )

N o n -H

R C : 4 .8 – 5 .4 %

(N S )

A n o n y m it y : M id d le , st u d e n ts

g e n e ra ll y m u st in te ra c t w it h H R C

st a ff to

ta k e c o n d o m s

A c c e ss ib il it y : L o w , th e m a jo ri ty

o f

sc h o o ls d o n ’t a ll o w

st u d e n ts

to

a c c e ss

c o n d o m s in d e p e n d e n tl y , a n d

u su a ll y m u st

b e a c c e ss e d th ro u g h

th e H R C o n ly

C o n se n t: N o t re q u ir e d

AIDS Behav (2018) 22:308–320 313

123

T a b le

1 c o n ti n u e d

F ir st

a u th o r,

y e a r, c o u n tr y ,

st u d y d e si g n

S a m p le

a n d p a rt ic ip a n ts

C o n d o m

a c q u is it io n

C o n d o m

u se

S e x u a l b e h a v io r

P ro g ra m

c o m p o n e n ts

S c h u st e r, 1 9 9 8 ,

U S A ,

L o n g it u d in a l

[1 5 ]

1 9 4 5 st u d e n ts g ra d e 9 – 1 2 in

a L o s A n g e le s

h ig h sc h o o l to o k a b a se li n e su rv e y b e fo re

st a rt o f C o n d o m

A c c e ss ib il it y P ro g ra m .

1 1 1 0 st u d e n ts to o k th e fo ll o w -u p su rv e y

o n e y e a r la te r, 5 2 %

m a le , 4 8 %

fe m a le

N o t a ss e ss e d

E v e ry

ti m e :

3 7 – 5 0 %

(p = 0 .0 0 5 )a

2 7 – 3 2 %

(N S )b

A t re c e n t fi rs t in te rc o u rs e :

6 5 – 8 0 %

(p = 0 .0 3 8 )a

A n ti c ip a te d c o n d o m

u se

fo r

se x u a ll y in e x p e ri e n c e d :

6 2 – 9 0 %

(p \

0 .0 0 1 )a

7 3 – 9 4 %

(p \

0 .0 0 1 )b

E v e r h a d v a g in a l

in te rc o u rs e : 5 5 .8 – 5 5 %

(N S )a

4 5 .4 – 4 6 .1 %

(N S )b

V a g in a l in te rc o u rs e in

th e

la st

y e a r:

5 0 .6 – 5 1 .8 %

(N S )a

4 2 – 4 4 %

(N S )b

N u m b e r o f ti m e s h a v in g se x

in th e p a st y e a r:

1 0 .6 – 1 0 .4

(N S )a

1 1 .6 – 1 2 (N

S )b

P e rc e n ta g e w it h 3 o r m o re

se x u a l p a rt n e rs :

5 1 – 4 8 %

(N S )a

3 8 – 3 5 %

(N S )b

A n o n y m it y : H ig h , st u d e n ts d id

n o t

h a v e to

in te ra c t w it h a n y st a ff o r

le a v e a n y id e n ti fy in g in fo rm

a ti o n

A c c e ss ib il it y : H ig h , c o n d o m s w e re

p la c e d in

4 b a sk e ts th a t st u d e n ts

c o u ld

a c c e ss

e a si ly , in d e p e n d e n tl y ,

a n d fr e e o f c o st

C o n se n t: N o t R e q u ir e d

D e R o sa

2 0 1 2 ,

U S A , Q u a si -

e x p e ri m e n ta l

[1 6 ]

1 2 u rb a n C a li fo rn ia

h ig h sc h o o ls w it h C A P s

w e re

d iv id e d in to

c o n tr o l a n d in te rv e n ti o n

g ro u p s, w it h th e in te rv e n ti o n sc h o o ls

re c e iv in g a p ro c e ss

e v a lu a ti o n a n d

st ru c tu ra l in te rv e n ti o n to

im p ro v e th e

im p le m e n ta ti o n o f th e C A P s

A c q u ir e d c o n d o m s fr o m

C A P :

O R

1 .8 1 (9 5 %

C I 1 .3 2 , 2 .4 9 )

A c q u ir e d c o n d o m s fr o m

C A P

a m o n g se x u a ll y a c ti v e : O R

3 .0 8 (9 5 %

C I 1 .7 7 , 5 .3 6 )

N o t a ss e ss e d

E v e r h a d se x u a l in te rc o u rs e :

In te rv e n ti o n : 4 7 .8 %

C o n tr o l: 4 6 .1 %

(p = 0 .2 )

H a d se x u a l in te rc o u rs e in

th e

p a st

3 m o n th s:

In te rv e n ti o n : 7 7 %

C o n tr o l: 7 7 %

(p = 0 .9 8 )

A n o n y m it y , a c c e ss ib il it y , a n d

p a re n ta l c o n se n t o f th e in d iv id u a l

C A P s w a s n o t d is c u ss e d in

th is

st u d y b e c a u se

th e st u d y w a s

fo c u se d o n th e c o m p o n e n ts

o f th e

st ru c tu ra l in te rv e n ti o n th e y w e re

im p le m e n ti n g to

im p ro v e a lr e a d y

e x is ti n g C A P s

B la k e , 2 0 0 3 ,

U S A ,

C ro ss -s e c ti o n a l

[1 7 ]

M u lt is ta g e c lu st e ri n g d e si g n to

g e t

re p re se n ta ti v e sa m p le

o f M a ss a c h u se tt s

a d o le sc e n ts in

h ig h sc h o o l, h ig h sc h o o ls

w it h C A P c o m p a re d to

h ig h sc h o o ls

w it h o u t, 5 3 7 0 st u d e n ts se le c te d , 4 1 6 6

c o m p le te d su rv e y , 5 0 .7 %

m a le , 4 9 .3 %

fe m a le

P e rc e iv e c o n d o m s a s e a sy

to

a c q u ir e :

O R 1 .3

(9 5 %

C I 0 .8 , 2 .1 )

U se d c o n d o m

d u ri n g m o st

re c e n t se x : O R 2 .1

(9 5 %

C I

1 .5 , 2 .9 ; p = 0 .0 0 0 1 )

U se d c o n d o m s to

p re v e n t

p re g n a n c y : O R 2 .1

(9 5 %

C I 1 .5 , 2 .8 ; p = 0 .0 0 0 1 )

E v e r h a d se x u a l in te rc o u rs e :

O R 0 .8

(9 5 %

C I 0 .6 , 0 .9 )

p = 0 .0 0 3 7

M e a n a g e a t fi rs t in te rc o u rs e :

1 4 .4

c o m p a re d to

1 4 .3

(N S )

M e a n n u m b e r o f p a rt n e rs :

2 .8

c o m p a re d to

2 .8

(N S )

H a d se x u a l in te rc o u rs e in

th e

p a st

3 m o n th s:

O R 0 .8

(9 5 %

C I 0 .6 , 0 .9 )

p = 0 .0 2 5 2

A n o n y m it y : M id d le , th e m a jo ri ty

o f

th e h ig h sc h o o ls in

th is st u d y

d is tr ib u te d c o n d o m s th ro u g h

sc h o o l n u rs e s o r o th e r fa c u lt y

p e rs o n n e l

A c c e ss ib il it y : L o w /M

id d le , th e

m a jo ri ty

o f sc h o o ls

d id

n o t a ll o w

st u d e n ts to

a c c e ss

c o n d o m s

in d e p e n d e n tl y , b u t 1 0 %

d id

u se

m e th o d s li k e v e n d in g m a c h in e s

th a t a ll o w e d st u d e n ts

in d e p e n d e n t

a c c e ss , b u t n o t fr e e o f c o st

C o n se n t: N o t R e q u ir e d

314 AIDS Behav (2018) 22:308–320

123

T a b le

1 c o n ti n u e d

F ir st

a u th o r, y e a r,

c o u n tr y , st u d y

d e si g n

S a m p le

a n d p a rt ic ip a n ts

C o n d o m

a c q u is it io n

C o n d o m

u se

S e x u a l b e h a v io r

P ro g ra m

c o m p o n e n ts

K ir b y , 1 9 9 9 , U S A ,

Q u a si -e x p e ri m e n ta l

[1 8 ]

P re te st su rv e y a d m in is te re d in

1 0

S e a tt le

h ig h sc h o o ls b e fo re

im p le m e n ta ti o n o f c o n d o m

d is tr ib u ti o n p ro g ra m s (n

= 7 1 7 9 ),

p o st -t e st su rv e y a d m in is te re d 2

y e a rs

la te r d u ri n g im

p le m e n ta ti o n

(n = 7 8 9 3 ), re su lt s o f su rv e y s

c o m p a re d to

n a ti o n a l su rv e y o f

h ig h sc h o o ls (Y

R B S S ) in

th e sa m e

y e a rs

(s c h o o ls in

th e n a ti o n a l

su rv e y w it h c o n d o m

d is tr ib u ti o n

w e re

e x c lu d e d )

T o ta l n u m b e r o f c o n d o m s

o b ta in e d :

1 3 3 ,7 1 1

C o n d o m s o b ta in e d p e r

st u d e n t:

4 .4

(’ 9 3 – ’9 4 )

4 .7

(’ 9 4 – ’9 5 )

C o n d o m s o b ta in e d fr o m

b a sk e ts v s. v e n d in g

m a c h in e s:

1 3 1 ,1 8 5 fr o m

b a sk e ts v s.

2 5 2 6 fr o m

v e n d in g

m a c h in e s

U se d c o n d o m

a t la st

se x in

p a st 3

m o n th s:

S e a tt le : 5 7 – 5 1 %

Y R B S S : 5 3 – 5 6 %

(p = 0 .0 4 2 )

E v e r h a d se x u a l in te rc o u rs e :

S e a tt le : 4 6 – 4 2 %

Y R B S S : 4 9 – 5 0 %

(p = 0 .1 2 6 )

H a d se x in

th e la st 3 m o n th s:

S e a tt le : 3 2 – 2 8 %

Y R B S S : 3 5 – 3 6 %

(p = 0 .0 2 4 )

4 ?

p a rt n e rs

li fe ti m e :

S e a tt le : 1 5 – 1 3 %

Y R B S S : 1 8 %

to 1 8 %

(p = 0 .2 1 9 )

4 ?

p a rt n e rs in

la st 3 m o n th s:

S e a tt le : 3 – 2 %

Y R B S S : 3 – 4 %

(p = 0 .0 1 5 )

A n o n y m it y : H ig h , a ll 1 0 sc h o o ls

d is tr ib u te d c o n d o m s th ro u g h

b a sk e ts , v e n d in g m a c h in e s, o r b o th

so st u d e n ts c o u ld

a c c e ss

c o n d o m s

p ri v a te ly

A c c e ss ib il it y : M id d le /H ig h , v e n d in g

m a c h in e s h a d a c o st a n d b a sk e ts

w e re

fr e e , b o th

m e th o d s a ll o w e d

st u d e n ts to

a c c e ss

c o n d o m s

in d e p e n d e n tl y in

m u lt ip le

lo c a ti o n s

C o n se n t: N o t R e q u ir e d

E th ie r, 2 0 1 1 , U S A ,

C ro ss -s e c ti o n a l [1 9 ]

1 2 u rb a n C a li fo rn ia

h ig h sc h o o ls ,

h a lf w it h sc h o o l- b a se d h e a lt h

c e n te rs , h a lf w it h o u t, 4 4 %

o f

st u d e n ts in d ic a te d th a t th e y h a d

e v e r h a d se x a n d w e re

in c lu d e d in

a n a ly se s, 1 2 2 6 m a le s, 1 3 7 4

fe m a le s

N o t a ss e ss e d

U se d c o n d o m

d u ri n g la st in te rc o u rs e :

C A P : 7 4 .3 %

N o C A P : 7 1 .1 %

(p = 0 .2 3 )a

C A P : 5 9 .6 %

N o C A P : 6 3 .4 %

(p = 0 .1 6 )b

B e c a u se

th e a n a ly ti c sa m p le

o n ly

c o n ta in e d se x u a ll y

e x p e ri e n c e d st u d e n ts , th is

w a s n o t a n o u tc o m e th a t

w a s a ss e ss e d

A n o n y m it y : M id d le , st u d e n ts h a d to

in te ra c t w it h h e a lt h se rv ic e s

p e rs o n n e l b u t n o id e n ti fy in g

in fo rm

a ti o n w a s re q u ir e d

A c c e ss ib il it y : L o w , st u d e n t c a n ’t

a c c e ss

c o n d o m s in d e p e n d e n tl y ,

o n ly

1 lo c a ti o n to

re c e iv e c o n d o m s

C o n se n t: R e q u ir e d

W o lk , 1 9 9 5 , U S A ,

C ro ss -s e c ti o n a l [2 0 ]

A d a m s C it y H ig h S c h o o l in

C o lo ra d o , 1 2 0 0 st u d e n ts in

g ra d e

9 – 1 2 , 1 5 2 st u d e n ts ra n d o m ly

sa m p le d , 7 1 m a le , 7 8 fe m a le

N o t a ss e ss e d

B e n e fi t- R is k A n a ly si s:

th e o d d s o f

e n c o u ra g in g a se x u a ll y a c ti v e

st u d e n t to

u se

a c o n d o m

a re

3 .2

(9 5 %

C I 2 .1 , 4 .9 ) ti m e s g re a te r

th a n th e o d d s o f e n c o u ra g in g a

n o n -s e x u a ll y a c ti v e st u d e n t to

b e c o m e se x u a ll y a c ti v e

P re v a le n c e o f se x u a l

a c ti v it y : C A P : 5 9 .8 %

C o lo ra d o E st im

a te : 5 4 .5 %

(p [

0 .0 5 )

A n o n y m it y : M id d le , st u d e n ts h a d to

in te ra c t w it h h e a lt h c e n te r st a ff o r

fa c u lt y re p s to

g e t c o n d o m s

A c c e ss ib il it y : L o w , st u d e n ts c a n ’t

a c c e ss

c o n d o m s in d e p e n d e n tl y ,

o n ly

1 lo c a ti o n to

re c e iv e c o n d o m s

C o n se n t: N o t R e q u ir e d

AIDS Behav (2018) 22:308–320 315

123

T a b le

1 c o n ti n u e d

F ir st

a u th o r, y e a r, c o u n tr y , st u d y

d e si g n

S a m p le

a n d p a rt ic ip a n ts

C o n d o m

a c q u is it io n

C o n d o m

u se

S e x u a l b e h a v io r

P ro g ra m

c o m p o n e n ts

M a rt in e z -D

o n a te , 2 0 0 4 , M e x ic o ,

Q u a si -e x p e ri m e n ta l

[2 1 ]

4 u rb a n sc h o o ls in

T ij u a n a w e re

ra n d o m iz e d ,

h a lf re c e iv e d H IV

p re v e n ti o n w o rk sh o p s

a n d h a lf d id

n o t. C A P s w e re

th e n st a rt e d in

o n e w o rk sh o p sc h o o l a n d o n e n o n -

w o rk sh o p sc h o o l to

c re a te

4 u n iq u e

c o n d it io n s: w o rk sh o p ? C A P , C A P o n ly ,

w o rk sh o p o n ly , a n d n e it h e r (c o n tr o l) . 3 2 0

st u d e n ts in

to ta l to o k p a rt in

th e st u d y ,

3 7 %

m a le , 6 3 %

fe m a le .

A c q u ir e d c o n d o m s in

la st

3

m o n th s:

W o rk sh o p ? C A P O R 2 0 .2 8 (p

\ 0 .0 0 1 )

P e rc e iv e d d if fi c u lt y to

o b ta in

c o n d o m s:

W o rk sh o p ? C A P

B = - 0 .7 8 (p

= 0 .0 5 4 )

N o t

a ss e ss e d

In it ia ti o n o f se x u a l p ra c ti c e s:

W o rk sh o p ? C A P H R 0 .1 4

(p \

0 .0 0 1 )

W o rk sh o p : H R 0 .1 4 (p \

0 .0 0 1 )

C A P H R 0 .1 2 (p \

0 .0 0 1 )

S e x u a l in te rc o u rs e in

la st 3

m o n th s:

W o rk sh o p ? C A P O R 0 .5 4

(p = 0 .4 7 )

W o rk sh o p : O R 0 .3 0 (p

=

0 .1 1 3 )

C A P O R 0 .9 8 (p

= 0 .9 8 5 )

U n p ro te c te d se x u a l

in te rc o u rs e in

la st 3

m o n th s:

W o rk sh o p ? C A P O R 0 .3 8

(p = 0 .3 4 7 )

W o rk sh o p : O R 0 .7 3 (p

=

0 .7 3 )

C A P O R 1 .6 3 (p

= 0 .6 7 8 )

A n o n y m it y : L o w , st u d e n ts m u st

in te ra c t w it h st u d y st a ff to

g e t

c o n d o m s a n d m u st

u se

a p e rs o n a l

ID c a rd

A c c e ss ib il it y : L o w , st u d e n ts c a n ’t

a c c e ss

c o n d o m s in d e p e n d e n tl y ,

c o n d o m s o n ly

a v a il a b le

a t 1

lo c a ti o n

C o n se n t: N o t sp e c ifi e d

a M a le s o n ly

b F e m a le s o n ly

316 AIDS Behav (2018) 22:308–320

123

exposure to sexual intercourse within the last 3 months,

frequency of sexual intercourse, and prevalence of multiple

partners [11, 14–16, 20]. No study reported a significant

increase in sexual activity among students attending

schools with CAPs. However, three studies reported a

significant decrease in some of their sexual behavior out-

comes because of the CAPs [17, 18, 21]. The largest effect

was observed in a quasi- experimental trial conducted in

urban schools in Mexico [21]. This study found that stu-

dents in the intervention group who were exposed to

school-based CAPs and HIV prevention workshops had an

86% decreased risk of initiating sexual practices compared

with students who attended schools in the control group

(HR 0.14, p \ 0.001) [21]. It is unclear what factors may have led to this finding in this study as key program

attributes (anonymity and accessibility) were judged to be

‘‘low’’ [21] compared to other studies in the USA with

programs that we considered to have medium to high

anonymity and accessibility.

A cross-sectional study found that the odds of ever

having sexual intercourse or having sexual intercourse in

the past 3 months were 20% lower among students in

schools with CAPs, (OR 0.8, 95% CI 0.6–0.9, p = 0.0037)

and (OR 0.8, 95% CI 0.6–0.9, p = 0.0252), respectively

[17]. Furthermore, 2 years’ post-implementation of a

school-based CAP in public high schools in the USA was

associated with a 4% decrease in the percentage of students

having sex in the last 3 months (32–28%) [15].

School-Based CAP Components

None of the included studies assessed factors facilitating or

impeding delivery of the school-based CAP. Overall, four

studies were judged to have implemented school-based

CAPs with medium levels of anonymity (Table 1). The

majority of studies (n = 5) were judged to have imple-

mented school-based CAPs with low accessibility as con-

doms were not available at multiple locations or could not

be accessed independently by the student. Two studies

from the USA indicated that parental consent was required

for students to access CAPs [14, 19]. There was no distinct

pattern identified between condom acquisition or use and

the anonymity or accessibility of the CAP or parental

consent as almost all studies found that CAPs were posi-

tively associated with condom acquisition and/or condom

use.

Risk of Bias

Five studies were judged to have moderate risk of bias as

authors employed rigorous study designs and adjusted for

confounders or reported adequate survey completion rates

(60–80%) [14–18] but were prone to potential selection

bias (Table 2). Three studies were judged to have high risk

of bias as there was a lack of information regarding selec-

tion of participants and participant completion rate was low

[11, 19, 20]. One study was judged to have low risk of bias

as the study did not report information regarding the

validity or reliability of their measurement tool [21].

Discussion

The aim of this review was to evaluate the effects of

school-based CAPs on condom acquisition or condom use

and sexual behavior. Most studies were conducted in urban

public high schools in the USA. Overall, results from this

review suggest that school-based CAPs are effective in

increasing condom acquisition and use, and have a positive

influence on adolescent sexual behavior. Findings suggest

that school CAPs may be an effective strategy for

improving condom coverage and promoting positive sexual

behaviors among this vulnerable population.

School-based programs have been shown to improve

students’ access to and uptake of health services, as found

in an earlier published review [10]. In our review, most

studies showed that students in schools with CAPs were

more likely to have obtained condoms than students in

schools without CAPs. Our review suggests that when

school-based CAPs are combined with school-based HIV

prevention educational programs this leads to a greater

impact on condom acquisition, although this was only

investigated in one study. [21].

The odds of students acquiring condoms, particularly

among sexually active adolescents, were almost doubled

among students attending schools that strengthened the

implementation of school-based CAPs through health

promotion activities and enhanced co-ordination between

the school clinic and campus [16]. Most studies also

reported increases in condom use among students who

attended schools with CAPs, particularly among sexually

active students in their last sexual intercourse [11, 17, 20].

This review did not observe a pattern between significant

increase in condom use and the anonymity, accessibility,

and consent requirements of the CAP. This suggests that

there could be other potential factors which influence stu-

dent’s decision to obtain and use condoms from school-

based CAPs besides anonymity and accessibility (e.g.

environmental context), and warrants further investigation.

Overall, these findings suggest that integration of school-

based CAPs with other school health services may be

effective in increasing condom access and utilization,

particularly among high-risk groups.

There is a perception that providing condoms at schools

may promote negative sexual behaviors and increase sex-

ual activity. However, no study included in this review

AIDS Behav (2018) 22:308–320 317

123

reported an increase in sexual activity among students at

schools with CAPs. Three studies showed that school-

based CAPs were associated with positive sexual behavior

outcomes [17, 18, 21], and this effect (88% decrease in risk

of initiating sexual intercourse) was largest when school-

based CAPs were delivered with HIV prevention work-

shops [21]. Perhaps these workshops reinforced the benefits

of condom use and promoted abstinence.

While the sample size of this review was limited, the

findings suggest that CAPs can be effective in increasing

condom access and utilization without promoting negative

sexual behaviors or causing increases in sexual activity.

The findings of this review suggest that schools should

consider integrating CAPs along with other health services

provided to students. The limited number of eligible studies

suggests the value of additional research on school-based

CAPs and their effects. In particular, future research should

explore the comparative effectiveness of different types of

school-based CAPs, and investigate the impact of various

program attributes such as anonymity and accessibility. To

guide program planners and policy makers, we need further

research on the cost and cost-effectiveness of different

school-based CAPs and the barriers and facilitators of

school-based CAP delivery.

Given that our review suggests school-based CAPs are

likely to be effective at increasing the acquisition and use of

condoms, school-based CAPs should be considered as one

part of a comprehensive, multi-component strategy to pre-

vent STIs and unwanted pregnancy among adolescents.

Researchers have recently evaluated such a broad, multi-

faceted strategy implemented in the United Kingdom, one

component of which was policy to support schools to dis-

tribute contraception and condoms. [22, 23] The evaluation

showed that over 16 years, during which the strategy was

implemented, there was a 51% decrease in the under-18

conception rate. [22, 23] The number of schools establish-

ing CAPs was not reported in the evaluation. [22, 23].

The main strengths in this review are the use of a broad

search strategy, with no country restriction, and assessment

of risk of bias among included studies. Although the search

was confined to one electronic database (PubMed), we

searched two extra online databases (Cochrane library,

ERIC) and were unable to identify any further eligible

studies. Weaknesses include that only English manuscripts

were eligible for inclusion; the actual number of duplicate

articles and studies which were included was not ade-

quately recorded in the initial screening; and only co-au-

thors in this review were contacted for additional articles.

Table 2 Risk of bias assessment

Author Selection

bias

Study

design

Confounders Data

collection

method:

exposure

measure

Data

collection

method:

outcome

measure

Global

rating

Comments

Guttmacher

[11]

2 3 1 3 3 3 Cross-sectional design

Validity and reliability for exposure measures

not described

Furstenberg

[14]

2 2 1 3 3 2 Validity and reliability for exposure and outcome

measures not described

Schuster [15] 1 2 1 3 3 2 Validity and reliability for exposure and outcome

measures not described

De Rosa [16] 1 2 1 3 3 2 Validity and reliability for exposure and outcome

measures not described

Blake [17] 2 3 1 1 3 2 Cross-sectional design

Validity and reliability for outcome measure not

descried

Kirby [18] 1 2 1 3 3 2 Validity and reliability for exposure and outcome

measures not described

Ethier [19] 2 3 2 3 3 3 Cross-sectional design

Validity and reliability for exposure and outcome

measures not described

Wolk [20] 3 3 2 3 3 3 Percentage of selected students who agreed to

participate not described

Cross-sectional design. Validity and reliability

for exposure measures not described

Martinez-

Donate [21]

2 2 1 3 2 1 Validity and reliability for exposure measures

not described

318 AIDS Behav (2018) 22:308–320

123

Furthermore, this review found that the evidence-base is

subject to several limitations. Firstly, urban areas in the

USA were disproportionately represented in this review,

possibly due to the fact that there might be fewer school-

based CAPs operating outside of urban areas in the USA.

Secondly, no studies were identified from low- and middle-

income countries, and it is unclear whether similar patterns

may be observed in these settings. Thirdly, most of the

included studies used observational study designs with self-

reported outcome measures, with moderate risk of bias;

hence, caution should be applied when reviewing the

results of those studies.

In conclusion, it appears that school-based CAPs have

the potential to have a positive impact on improving sexual

health among adolescents who are affected by a dispro-

portionately large proportion of disease burden from STIs

and HIV. This review shows that many of the school-based

CAPs evaluations have reported statistically significant

increases in condom acquisition and condom use among

students. Findings suggest that school-based CAPs may be

an effective strategy for improving condom coverage, and

promoting positive sexual behaviors. However, further

research is needed to rigorously assess these associations,

particularly research employing experimental study

designs, including studies assessing factors that facilitate

and impede the implementation of school-based CAPs,

condom access and use.

Acknowledgements Co-authors (CM, DG) would like to acknowl- edge support from the South African Medical Research Council.

Funding No funding was received to conduct this study.

Compliance with Ethical Standards

Conflict of interest Authors TM, ML, DG and CM have no conflict of interest to declare.

Ethical Approval This article does not contain any studies with human participants or animals performed by any of the authors.

Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://crea

tivecommons.org/licenses/by/4.0/), which permits unrestricted use,

distribution, and reproduction in any medium, provided you give

appropriate credit to the original author(s) and the source, provide a

link to the Creative Commons license, and indicate if changes were

made.

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