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

AIDS Behav DOI 10.1007/s10461-017-1787-5 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 Ó 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 promoting positive sexual behaviors. Keywords School health
Condom use
Sexual behavior
Adolescent & Darshini Govindasamy 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 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), respectively [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 limited access that adolescents have to basic sexual reproductive 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 utilization of STI and pregnancy prevention methods. Given that approximately 75% of individuals in the school-going age for secondary education globally are enrolled in secondary school [7], schools may serve as an ideal platform to extend coverage for these services. The Health Promoting Schools (HPS) concept was initiated 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 123 AIDS Behav was adopted mainly by the United States of America (USA) and Canada [8]. The CSHP includes eight components: 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 implemented all of the HPS or CSHP concepts, and few evaluations 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 evaluated 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-income 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 nurses, physicians and school staff and seek to provide comprehensive 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 pregnancy 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 contraceptives [9]. Given that contraception is an effective and low-cost method for preventing STIs and pregnancy, lack of availability of contraception is a missed opportunity for SBHCs to help prevent STIs and unwanted pregnancies in adolescents 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 schoolbased 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 123 assist program planners and policy makers in their decision-making process around what sexual reproductive health services SBHCs should offer. The objectives of this systematic review were to determine the impact of schoolbased CAPs on condom acquisition, condom use and sexual behavior outcomes, and to assess the facto (...truncated)