Theoretical assessment of university condom distribution programs: an institutional perspective.

Author:Butler, Scott M.


Male condoms are commonly used by young adults and college students to prevent unintended pregnancy and sexually transmitted infections (STIs; American College Health Association [ACHA], 2013; Reece et al., 2010). According to a national assessment of condom acquisition patterns by men in the U.S., those who acquired free condoms received them from settings common to universities including health clinics (20.5%), health fairs (13.4%), dorms/student groups (13.4%), and classrooms (3.6%; Reece, Mark, Schick, Herbenick, & Dodge, 2010). Over the last 12 years, several empirical studies assessing sexual behaviors among students have identified condom errors and problems as important epidemiological risk factors (Crosby, Sanders, Yarber, & Graham, 2003; Crosby, Sanders, Yarber, Graham, & Dodge, 2002; Crosby, Yarber, Sanders, & Graham, 2004; Sanders et al., 2012; Yarber et al., 2007; Yarber, Graham, Sanders, & Crosby, 2004). Condom availability is an important contextual factor for condom use among adolescents (Boldero, Moore, & Rosenthal, 1992) and college students (Crosby et al., 2003; Crosby et al., 2002; Kashima, Gallois, & McCamish, 1993). A study conducted by Crosby and colleagues (2003) assessing condom use and condom-related problems among 158 college students found 42.4% of participants wanted to use a condom but did not have one available and 17.6% had a problem with a condom during sexual activity and did not have a secondary condom available.

Condom distribution programs are structural-level public health interventions that extend beyond the individual's personal risk by addressing access to condoms within given environments (Centers for Disease Control and Prevention [CDC], 2010). According to the CDC, wide-scale distribution is an important programmatic consideration for effective condom distribution interventions (2010). In the U.S., condom distribution programs have been used to increase availability in school settings (Blake et al., 2003; Guttmacher et al., 1997) and large-scale community-based distribution initiatives have been effective in increasing availability in New York City and Washington D.C. (CDC, 2010). A recent meta-analysis of 21 condom distribution programs by Charania and colleagues (2010) revealed significant intervention effects upon condom use, condom acquiring/condom carrying, delayed sexual initiation among youth, and reduced incidence of STIs. Additional findings indicated programs which incorporated individual and community-level considerations were more effective than those which only focused upon structural components. Various assessments have indicated condom distribution programs are cost effective (Bedimo, Pinkerton, Cohen, Gray, & Farley, 2002; Charania et al., 2010; Kirby et al., 1999; Schuster, Bell, Berry, & Kanouse, 1998).

The majority of colleges and universities in the U.S. distribute condoms to their student populations (Butler, Black, & Coster, 2011a; Eastmann-Mueller, Jung, Roberts, 2014; Koumans et al., 2005). Results of the ACHA 2013 Pap and STI Survey conducted by the ACHA (n = 140) indicated 87.9% of institutions distribute condoms to their students for free and 36.4% sell condoms on campus (Eastmann-Mueller et al., 2014). A national investigation of 736 schools by Koumans and colleagues (2005) revealed 52% of institutions distribute condoms to students, including 74% of schools with a health center. A recent assessment of 358 colleges and universities with student health centers by Butler and colleagues (2011a) indicated 84.9% of student health centers distribute condoms to students, with the mean of 9,414 condoms distributed/year. Select campus demographics have been found to significantly predict sexuality-related service availability at colleges and universities (Butler, Black, & Avery, 2012: McCarthy, 2002; Miller, 2011) including sponsoring of a condom distribution program (Butler et al., 2011a; Koumans et al., 2005).

The Transtheoretical Model (TM) and the Health Belief Model (HBM) are common theoretical foundations used to guide public health interventions and assess individual-level risk of disease acquisition (Champion & Skinner, 2008; Prochaska, Redding, & Evers, 2008). Recently the TM and HBM have been used to assess institutional and organizational behavior (Leversque, Prochaska, & Prochaska, 1999; Price & Oden, 1999), sexuality-related services at colleges and universities (McCarthy, 2002), and university health policies (Reindl, Glassman, Price, Dake, & Yingling, 2014). McCarthy (2002) used the TM and the HBM to assess emergency contraceptive pill (ECP) availability among 358 college health centers nationally. Results indicated the majority of schools were in the maintenance stage (defined as having distributed ECP to students for 1 to 5 years) and the most common institutional benefits associated with distribution included prevention of pregnancy (97.3%), student appreciation (71.1%), and linking ECP with other traditional forms of contraception (59.4%).

Over the past 40 years, the Diffusion of Innovations Theory (DIT) has been used as a framework in over 5,200 empirical investigations (Rogers, 2003). The DIT can be applied to both individuals and the adoption of innovations by organizations (Rogers, 2003). Since its inception, the DIT has been used in various public health settings and has been applied to interventions designed to reduce risk of HIV (Haider & Kreps, 2004; Bertrand, 2008). Institutional complexity and institutional size are two constructs of the DIT which are hypothesized to positively correlate with organizational innovation (Rogers, 2003). Rogers (2003) defines complexity as the "degree to which an organization's members possess a relatively high level of knowledge and expertise, usually measured by the member's number of occupational specialties and their degree of professionalism (expressed by formal training)" (p.412). While the number of college and university employees who participate in condom distribution programs is unknown, previous research has indicated student peer educators have participated in distribution efforts (Butler & Black, 2001; Butler et al., 2011a; Butler, Hartzell, Przybyla, & Bickers-Bock, 2006). Despite the importance of condom availability and prevalence of condom distribution programs on college campuses, no previous investigation has used a theoretical framework to assess condom distribution programs from an institutional perspective.

The purpose of the present study was to assess college and university condom distribution programs using constructs of the TM, the HBM, and the DIT. Specifically, the foci of the study were six fold and were designed to assess the following (a) institutional stage of change associated with condom programs, (b) frequency of institutional barriers and benefits associated with condom programs, (c) relationship between the presence of a condom distribution program and institutional benefits and barriers, (d) relationship between campus demographics and institutional barriers, benefits, and complexity, (e) relationship between the number of condoms distributed/year and number of students, number of health center employees, institutional benefits, barriers, and institutional complexity, and (f) prevalence of college and university employees and student peer helpers/educators who are involved with condom distribution programs.



Four hundred thirty-eight participants (39.8% response rate) who served as their campus ACHA representative or the director of student health services department completed questionnaires regarding their institution's condom and safer sex product-related services. Institutionally, the participants resided in 47 U.S. states and Washington D.C. The sum student population of participating institutions was 4.8 million. The mean student population was 11,126 (SD = 12,680, Mdn = 6,000, and Mo = 12,000). The mean number of health center employees was 26.28 (SD = 46.62, Mdn = 9, Mo = 5).

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