With pills, patches, rings, and shots: who still uses condoms? A longitudinal cohort study

Developing an Inclusive Model of Young Heterosexual and Sexual Minority Women's Sexual Decision-Making

Efforts to improve sexual health outcomes among young cisgender women require in-depth understanding of how women with diverse sexual identities make decisions about their sexual health. We conducted semi-structured interviews with 31 young cisgender women with diverse sexual identities and histories (age range 18-29 (M = 23.32); 81% White; 29% bisexual, 26% heterosexual, 16% lesbian, 13% queer, 10% pansexual, 3% gay, 3% demisexual) about their decision-making surrounding sexual risk reduction. By conducting thematic analysis, we found that, regardless of partner sex or gender, women adapted sexual health strategies based on how much commitment, trust, and communication existed in their relationships. Because heteronormative structural influences limited access to information and safer sex options, women had to rely on trust and communication more with other women and partners with vaginas, compared to men and partners with penises. Women did not consider safer sex strategies with partners with vaginas (e.g. hand washing) risk-reduction techniques; instead, they considered them general hygiene or a way to take care of a partner. We propose that an inclusive model of young women's sexual decision-making should: (a) highlight the influence of relationships; (b) frame prevention in terms of overall health instead of pregnancy and STIs; and (c) acknowledge that structural factors, such as heteronormativity and sex-negativity, constrain women's decisions.

A Trend Analysis of Condom use in Spanish Young People over the Two Past Decades, 1999-2020

HIV exposure is one of the greatest sexual risks in young people, and condom use is the best protective measure. Despite the preventive efforts, trend in condom use is still unclear. This study examines the trend of condom use by gender in Spanish young people, in different sexual practices (vaginal, oral and anal), relationships (regular and casual) and having sex after drugs consumption during the two past decades (from 1999 to 2020). For this, 14,472 people who ranged from 17 to 40 years old (63.5% women) filled the AIDS Prevention Questionnaire in each year. In general, low condom use remains stable and even gets worse regardless of the type of sexual practice, relationship and the substance consumption. Regarding gender, this trend is worse in women who have been less likely to report condom use than men have. Moreover, older people have reported a minor frequency of condom use than the youngest people have done, except for anal sex. Therefore, it is necessary to analyze why, despite preventive efforts, condom use seems to decrease over time.

Association between relationship characteristics, sexual health attitudes, and dual contraceptive use among young adult college students aged 18-24

Objective Determine the relationship characteristics, sexual health attitudes, and demographic factors associated with dual contraceptive use among college students. Participants: September-October 2018 via campus email, we recruited College of Public Health students attending a large, urban, public university (N = 424). Methods: Respondents completed a cross-sectional, Web-based sexual health questionnaire. Descriptive statistics were calculated. Multiple logistic regression models were run to determine the association between relationship characteristics, pregnancy and condom attitudes, demographics, and dual use the last time having sex. Results: In independent models, one-unit increase in trust (aOR = 0.982; 95% CI: 0.966-0.998) and commitment score (aOR = 0.987, 95% CI: 0.976-0.999) was inversely associated with dual use while sex with a casual date/acquaintance (aOR = 3.149; 95% CI: 1.550-6.397) was positively associated. In a fully adjusted model for all correlates, only trust score was significant (aOR = 0.982; 95% CI: 0.966, 0.998). Conclusions: Emotion-based constructs may be more influential on dual use behaviors than discrete relationship factors.

Contraception in Adolescents

Adolescents are at risk for unwanted pregnancy when they become sexually active, and contraception is an important part of mitigating this risk. Use of contraceptive methods, and long-acting reversible contraceptive methods such as implants and intrauterine devices in particular, has increased among adolescents. Although sexual activity has declined and contraceptive use has increased among adolescents in the United States in recent years, the unintended pregnancy rate remains high. All of the currently available contraceptive methods are safe and effective for adolescents to use; however, adolescents may have specific concerns about side effect profiles and unscheduled bleeding that should be addressed during contraceptive counseling. Healthcare providers should prioritize adolescents' needs and preferences when approaching contraceptive counseling, and also consider the unique access and confidentiality issues that adolescents face when accessing contraception.

[Contraceptive discontinuities in the use of oral and injectable hormonal contraceptives, and male condoms]

The study aimed to estimate the total contraceptive discontinuity rates in the use of oral and injectable hormonal contraceptives, and male condoms and dropout rates due to switches to more effective and less effective methods. Data on 2,051 women, users of primary healthcare services in three Brazilian state capitals, were collected using the contraceptive calendar. The results showed that 24.5% of users of oral hormonal contraceptives, 33.5% of users of injectables, and 39% of users of male condoms had discontinued the respective method after 12 months of use, independently of the reason, and that the rates varied little between the capitals but did depend on the method. The main reason for discontinuing use of the contraceptive method was the desire to become pregnant (20.8%). Conception while using the method was reported by 20% of the women, a proportion that reached 25.7% in users of male condoms. After 12 months with the method, the dropout rate for reasons related to the contraceptive method was 11.4% in users of injectables; 15.9% of users of male condoms switched to a more effective method; and 16.3% of users of injectables switched to a less effective method. Contraceptive discontinuity rates were high and varied according to the contraceptive method.

Associated factors and sex differences in condom non-use among adolescents: Brazilian National School Health Survey (PeNSE)

Background

Condom non-use among sexually active adolescents is a major cause of unintended pregnancy and sexually transmitted infections. In order to promote condom use, it is essential to understand factors associated with condom non-use.

Aim

Our aim was to evaluate sex differences and associated factors of condom non-use based on the nationally representative Brazilian National School Health Survey.

Methods

The study participants were 100,962 adolescents 13–18 years old, 9th graders from both public and private schools throughout Brazil. The following factors were considered as explanatory group variables for the outcome of condom non-use among adolescents: school and health service, sexual behavior, substance use, and self-reported body and health perception. Poisson regression model was performed.

Results

Of the total students, 28% (n = 28,157) had had sexual intercourse at least once. (boys, 37.1%; girls, 19.5%). Of these, 69.2% had used condoms the last time they had intercourse (girls: 68%; boys: 69.9%). The variables associated with condom non-use for both sexes were not having accessed a health service or approached a health professional for health-related care; not having received pregnancy prevention counseling or guidance on AIDS or STI prevention at school; early sexual initiation; no additional contraception method; substance use; feeling alone; not being satisfied with their own body; feeling fat or thin; and poor self-reported health. The number of sexual partners was also associated with condom non-use; however, contrasting behavior was indicated between sexes. A higher number of sexual partners indicated less use of condoms among girls, while for boys, a higher number of sexual partners indicated higher condom use.

Conclusion

High condom non-use appears to be associated with lack of health care access and sexual health education, poor sexual practices, substance use, and poor self-perception, indicating areas for health promotion programs.

Sexual Behavior Patterns and Condom Use in Newly Sexually Active Female University Students

Our objective was to describe sexual behavior patterns and condom use in newly sexually active female university students. We conducted a 4-year retrospective cohort study (2000-2007) of university women enrolled close to sexual debut (N = 250). Participants reported daily information on intercourse, condom use, and partner/partnership characteristics into Web-based biweekly sexual behavior diaries. We calculated intercourse frequency, proportion of condom-protected events, and incidence of new partner acquisition. We used logistic regression to examine factors associated with condom use at sexual debut; Kaplan-Meier methods to describe cumulative incidence of condom non-use after use at debut; and Cox proportional hazards ratios to examine factors associated with condom non-use. A total of 188 women had at least one male sex partner prior to enrollment or during follow-up. One-third (34.1%) of 27,736 intercourse events were condom-protected. Older age (20+ vs. < 20 years) and use of hormonal birth control were associated with lower likelihood of condom use at sexual debut (adjusted odds ratio [aOR] 0.41, 95% CI 0.17-0.97 and aOR 0.32, 95% CI 0.10-1.03, respectively). Women who reported partners with previous sex partners were less likely to discontinue using condoms after debut (hazard ratio = 0.35, 0.16-0.77) than those reporting partners without previous partners. In college-aged women, older age and hormonal contraceptive use were each inversely associated with condom use at first intercourse. Women with sexually experienced partners were more likely to continue using condoms. Continued efforts are necessary to promote condom use among college-aged women.

Being on the Safe Side: A Qualitative Study of Condom Use Motivations According to Contraceptive Type among Adolescents in Atlanta, Georgia

STUDY OBJECTIVE

Quantitative data suggest that adolescent users of long-acting reversible contraception (LARC), compared with short-acting methods (pill, patch, ring, depot medroxyprogesterone acetate [DMPA]), might be less likely to use condoms. We qualitatively describe and explain adolescent contraceptive users' motivations for condom use, including variation according to contraceptive type.

DESIGN

Individual, in-depth qualitative interviews, analyzed thematically.

SETTING

Participants were recruited from public family planning clinics and an adolescent medicine clinic, as well as university and other community settings in Atlanta, Georgia.

PARTICIPANTS

Sexually active contraceptive users aged 17-19 years old (n = 30), including LARC (n = 10), DMPA (n = 10), and oral contraceptive (n = 10) users.

RESULTS

Of the 30 participants, most (n = 25; 83%) used condoms with their more effective contraceptive method, although 11 of 25 used them inconsistently (44%). Oral contraceptive users were particularly motivated to use condoms for pregnancy prevention, because of concerns about contraceptive method efficacy and a desire to be on "the safe side." In contrast, LARC users were primarily motivated by sexually transmitted infection (STI) prevention. DMPA users' motivations were more mixed. Across contraceptive type, factors influencing condom use motivations included sexual health education, personal awareness and/or experience, and perceived consequences and risk.

CONCLUSION

Because all participants were using an effective contraceptive method, it is notable that pregnancy prevention was a prominent motivator for using condoms, although LARC users reported STI prevention to be a more important motivation. Parental and school-based sexual health education that clearly addresses STI prevention in addition to pregnancy prevention has the potential to influence condom use motivations and behavior.

Relationship Violence Typologies and Condom Use in Young Adult Dating Relationships

CONTEXT

Intimate partner violence is one dimension of relationships that may influence condom use, yet few studies have examined male- and female-initiated violence in efforts to understand variation in condom use.

METHODS

Power dynamics and relationship conflict approaches were employed to examine the association between relationship violence and condom use. In a latent class analysis of 8,599 dating relationships from Wave 3 (2001-2002) of the National Longitudinal Study of Adolescent to Adult Health, when the respondents were aged 18-25, relationship violence was characterized by the severity and frequency of violence and the perpetrator's gender. Random-effects logistic regression analyses assessed the association between violence classes and condom use.

RESULTS

One in five young adult dating relationships involved violence in the past year. Four violence classes were identified: one male-dominant class (3% of relationships), in which many relationships had reciprocal violence; two female-dominant classes, differentiated by the frequency and severity of violence (2% low-intensity, 4% medium-intensity); and one class with limited or no violence (91%). Male-perpetrated violence was reported less frequently but was more severe than female-perpetrated violence. Respondents in relationships in the male-dominant/high-intensity and the female-dominant/medium-intensity classes were less likely to report condom use than those in relationships in the no/low-violence class (odds ratios, 0.4-0.5).

CONCLUSIONS

This work expands on research focusing only on male-perpetrated violence and highlights the importance of capturing relationship violence in national data sets. Future surveys that collect information about violence from both partners can inform efforts to prevent violence and to support victims.

Contraceptive Method Choice Among Young Adults: Influence of Individual and Relationship Factors

Because decisions related to contraceptive behavior are often made by young adults in the context of specific relationships, the relational context likely influences use of contraceptives. Data presented here are from in-person structured interviews with 536 Black, Hispanic, and White young adults from East Los Angeles, California. We collected partner-specific relational and contraceptive data on all sexual partnerships for each individual, on four occasions, over one year. Using three-level multinomial logistic regression models, we examined individual and relationship factors predictive of contraceptive use. Results indicated that both individual and relationship factors predicted contraceptive use, but factors varied by method. Participants reporting greater perceived partner exclusivity and relationship commitment were more likely to use hormonal/long-acting methods only or a less effective method/no method versus condoms only. Those with greater participation in sexual decision making were more likely to use any method over a less effective method/no method and were more likely to use condoms only or dual methods versus a hormonal/long-acting method only. In addition, for women only, those who reported greater relationship commitment were more likely to use hormonal/long-acting methods or a less effective method/no method versus a dual method. In summary, interactive relationship qualities and dynamics (commitment and sexual decision making) significantly predicted contraceptive use.

Variability in Condom Use Trends by Sexual Risk Behaviors: Findings from the 2003-2015 National Youth Risk Behavior Surveys

OBJECTIVE

This study aimed to examine variability in condom use trends by sexual risk behavior among US high school students.

METHODS

Data were from the 2003-2015 national Youth Risk Behavior Surveys conducted biennially among a nationally representative sample of students in grades 9 to 12. We used logistic regression to examine variability in trends of condom use during last sexual intercourse among female and male students by 4 sexual risk behaviors: drank alcohol or used drugs before last sexual intercourse, first sexual intercourse before age 13 years, 4 or more sex partners during their life, and 2 or more sex partners during the past 3 months.

RESULTS

Between 2003 and 2015, significant declines in self-reported condom use were observed among black female (63.6% in 2003 to 46.7% in 2015) and white male students (69.0% in 2003 to 58.1% in 2015). Among female students, declines in self-reported condom use were significant only among those who drank or use drugs before last sexual intercourse, had 4 or more sex partners during their life, or had 2 or more sex partners during the past 3 months. There was a significant interaction between trends in condom use and first sexual intercourse before age 13 years, suggesting more pronounced declines among female students who initiated first sexual intercourse before age 13 years compared with their female peers. Trends did not vary by sexual risk behavior for male students.

CONCLUSIONS

Results suggest that declines in self-reported condom use have occurred among female students at greater risk for acquiring a sexually transmitted disease.

Dual Contraceptive Method Use Among Youth in Alternative Schools

Dual contraceptive method use, or using a highly effective contraceptive method plus a barrier method like condoms, is gaining attention as a strategy for preventing unplanned pregnancy and sexually transmitted diseases. We investigated rates of dual method use among a sample of youth in urban alternative schools, and explored the relationship between dual method use and sexual partner type. The study analyzed data from 765 students enrolled in 11 district-run continuation high schools in northern California. We explored the association between dual method use and sexual partner type (steady only, a mix of steady and non-steady, and non-steady only) using logistic regression. Differences in dual rates by partner type were statistically significant, with higher rates of dual methods use reported among young people reporting non-steady sexual partners only, as compared to those with steady partners only. The data illustrate that young people in alternative school settings could gain from further intervention on the benefits, skills, and challenges of using two methods of contraception as opposed to one with both steady and non-steady sexual partners.

Contraceptive Method Use and Chlamydia Positivity Among California Family Planning Clients: The Case for New Multipurpose Prevention Technologies

BACKGROUND

Adolescent girls and young women experience high rates of sexually transmitted infection (STI) with currently available contraceptive methods, yet few studies examine the burden of chlamydial infection by contraceptive method used.

MATERIALS AND METHODS

In this cross-sectional analysis, we linked July 2012-June 2013 claims from a publicly-funded family planning program in California to chlamydia laboratory test results. Female clients were classified by the most effective contraceptive method reported by providers during the year: tier 1 (high-efficacy permanent or long-acting reversible methods), tier 2 (shorter-acting hormonal methods), or tier 3 (barrier methods, emergency contraception, or natural family planning). In addition, we identified clients who received condoms from providers. We used log-binomial models to estimate adjusted prevalence ratios comparing chlamydia positivity by contraceptive method(s).

RESULTS

Of 74,636 female clients of ages 15-29 years with chlamydia test results, 5.1% had at least one positive test during the year. Chlamydia positivity was highest among tier 2 users (5.3%) compared with 4.5% and 4.9% among tiers 1 and 3 users, respectively (p < 0.001). Positivity was higher among clients who received condoms from providers than those who did not (6.3% vs. 4.3%, p < 0.001). In adjusted analyses, there were no significant differences in positivity by contraceptive tier. However, clients who received condoms had 1.32 (95% confidence interval: 1.24-1.40) times the positivity of those who did not.

CONCLUSIONS

We found high chlamydia positivity among young female family planning clients regardless of contraceptive method. The development and provision of additional Multipurpose Prevention Technologies that confer protection against both pregnancy and STIs may help to address unmet need for STI prevention.

Motivating factors for dual-method contraceptive use among adolescents and young women: a qualitative investigation

OBJECTIVE

This qualitative study explores how adolescents and young women perceive the need for and describe the use of dual method contraception.

STUDY DESIGN

We interviewed 20 sexually active women aged 16-24 who attended an adolescent-focused Title X family-planning clinic and were using a non-barrier contraceptive method. We used a semi-structured interview guide that included domains related to sexual activity, knowledge of and use of contraceptives and condoms, and relationship factors. We coded transcripts using grounded theory techniques and used an iterative process to develop overarching themes.

RESULTS

Dual method contraceptive users primarily discussed pregnancy prevention as their motivating factor. Many expressed anxieties over an unplanned pregnancy and reported condom use as "back-up" contraception. Risk perception for pregnancy or STI acquisition did not necessarily change as relationship trust increased, but rather, their anxiety regarding the negativity of such outcomes decreased. Dual-method contraception use decreased when participants reported that condoms were not readily available, or when they self-described immaturity. Less frequently, participants reported dual method use for sexually transmitted infection (STI) prevention, and many substituted STI testing for condom use. Contraceptive type (short-acting vs. long-acting) did not influence reported attitudes towards dual method use.

CONCLUSION

Health educators and clinicians encourage condom use in young women due to the significant morbidity associated with STI acquisition. Most participants in our study view condoms as a way to improve pregnancy prevention. Acknowledging and addressing this divergence in motivation will allow caregivers to improve strategies for communicating the importance of dual method use.

IMPLICATIONS

Young women primarily describe pregnancy prevention as the reason for dual method use, STI protection is less salient. Consideration of this viewpoint by health educators and clinicians will allow us to communicate more effectively to prevent STI morbidity.

Risk factors that influence sexual and reproductive health in Portuguese university students

BACKGROUND

University students have unprotected sex and associate alcohol and/or drugs with sexual practices. These behaviours are risk factors for influencing sexual and reproductive health that can be targeted by nursing interventions.

AIM

The aim of this study was to determine the risk and protective factors influencing sexual and reproductive risk-taking behaviours in university students.

METHODS

We conducted a cross-sectional and correlational study in a sample of 1946 students. Data were collected using a self-report questionnaire on the individual, environmental, cognitive and psychosocial factors related to knowledge of sexually transmitted infections, attitude for sexual and reproductive health, subjective norms, Condom Use Self-Efficacy and Sexual Sensation Seeking scales.

RESULTS

Older male students were at higher risk for all risk behaviours studied. Students involved in committed relationships were at risk because of decreased condom use. Individuals who placed high importance on sexual sensation seeking were at increased risk. The higher the importance students placed on peers' opinion, the more protective their behaviours were.

CONCLUSION

The results of this study showed that university students are exposed to sexual risks. Individual, cognitive and psychosocial factors influence the risk-taking behaviours.

IMPLICATIONS FOR NURSING AND HEALTH POLICY

The findings of this study should be further incorporated into health care with nurses' leadership, adapting healthcare services to the specific needs of this population and promoting educational programmes.

Providing Contraception to Adolescents

Adolescents have high rates of unintended pregnancy and face unique reproductive health challenges. Providing confidential contraceptive services to adolescents is important in reducing the rate of unintended pregnancy. Long-acting contraception such as the intrauterine device and contraceptive implant are recommended as first-line contraceptives for adolescents because they are highly effective with few side effects. The use of barrier methods to prevent sexually transmitted infections should be encouraged. Adolescents have limited knowledge of reproductive health and contraceptive options, and their sources of information are often unreliable. Access to contraception is available through a variety of resources that continue to expand.

Effects of relationship context on contraceptive use among young women

OBJECTIVES

To understand how relationship status influences contraceptive use among young people.

STUDY DESIGN

Data were collected as part of a longitudinal study on hormonal contraception among unmarried adolescent and young women who wanted to avoid pregnancy for at least one year, recruited at family planning clinics in the San Francisco Bay Area. Follow-up surveys were completed at 3, 6, and 12months. Longitudinal analysis was used to examine whether relationship characteristics, including type and length of sexual relationship are associated with current use of effective contraception.

RESULTS

Among women with a partner at baseline, 78%, 70%, and 61% had the same partner at 3, 6, and 12months follow up, respectively. Women in casual relationships were less likely to use effective contraceptive methods, compared to women in consistent relationships (AOR=0.67, p<.01). Women in new relationships (0-3months) were less likely to use effective contraceptive methods (AOR=0.60, p<.001) compared to women in relationships more than one year in length. Younger women (AOR=0.76, p<.05), black women (AOR=0.67, p<.05) and Latina women (AOR=0.73, p<.05) were also significantly less likely to use effective contraception. These effects remained even after controlling for condom use.

CONCLUSIONS

Relationship type and length are independently significantly associated with current effective contraceptive use among adolescent and young women. Women in casual relationships and new relationships were significantly less likely to use effective contraceptive methods.

IMPLICATIONS

Family planning providers should discuss women's relationship context and association with contraceptive use in order to help women think of contraception as a long-term personal strategy. Since relationship status affects contraceptive use, providers and programs that aim to reduce unintended pregnancy can consider strategies to create a paradigm shift around contraceptive use that focuses on the woman's reproductive goals, current life stage, and life goals.

Effects of initiating a contraceptive implant on subsequent condom use: A randomized controlled trial

OBJECTIVE

To evaluate whether initiation of a contraceptive implant, a method of long-acting reversible contraception, reduces condom use, as measured by a biomarker of recent semen exposure [prostate-specific antigen (PSA)].

STUDY DESIGN

We conducted a randomized controlled clinical trial in which 414 Jamaican women at high risk for sexually transmitted infections (STIs) attending family planning clinics received the contraceptive implant at baseline ("immediate" insertion arm, N=208) or at the end ("delayed" insertion arm, N=206) of a 3-month study period. Participants were tested for PSA at baseline and two follow-up study visits and were asked about their sexual activity and condom use.

RESULTS

At baseline, 24.9% of women tested positive for PSA. At both follow-up visits, the prevalence of PSA detection did not significantly differ between the immediate versus delayed insertion arm [1-month: 26.1% vs. 20.2%, prevalence ratio (PR)=1.3, 95% confidence interval (CI)=0.9-1.9; 3-month: 25.6% vs. 23.1%, PR= 1.1, 95% CI=0.8-1.6]. The change in PSA positivity over the three study visits was not significantly larger in the immediate arm compared to the delayed arm (1-sided p-value of .15).

CONCLUSIONS

Contraceptive implants can be successfully introduced into a population at high risk of unintended pregnancy and STIs without a biologically detectable difference in unprotected sex in the short term. This information strengthens the evidence to support promotion of implants in such populations and can help refine counseling for promoting and maintaining use of condoms among women who choose to use implants.

IMPLICATIONS

Sex unprotected by a condom was not higher over 3 months in women receiving a contraceptive implant, compared with those not receiving the implant.

Pregnancy prevention and condom use practices among HIV-infected women on antiretroviral therapy seeking family planning in Lilongwe, Malawi

Background

Programs for integration of family planning into HIV care must recognize current practices and desires among clients to appropriately target and tailor interventions. We sought to evaluate fertility intentions, unintended pregnancy, contraceptive and condom use among a cohort of HIV-infected women seeking family planning services within an antiretroviral therapy (ART) clinic.

Methods

200 women completed an interviewer-administered questionnaire during enrollment into a prospective contraceptive study at the Lighthouse Clinic, an HIV/ART clinic in Lilongwe, Malawi, between August and December 2010.

Results

Most women (95%) did not desire future pregnancy. Prior reported unintended pregnancy rates were high (69% unplanned and 61% unhappy with timing of last pregnancy). Condom use was inconsistent, even among couples with discordant HIV status, with lack of use often attributed to partner’s refusal. Higher education, older age, lower parity and having an HIV negative partner were factors associated with consistent condom usage.

Discussion

High rates of unintended pregnancy among these women underscore the need for integ rating family planning, sexually transmitted infection (STI) prevention, and HIV services. Contraceptive access and use, including condoms, must be improved with specific efforts to enlist partner support. Messages regarding the importance of condom usage in conjunction with more effective modern contraceptive methods for both infection and pregnancy prevention must continue to be reinforced over the course of ongoing ART treatment.