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The Trade-Off Between Hormonal Contraceptives and Condoms Among Adolescents

This summary includes the following sections:

Background

One of the objectives set forth by Healthy People 2010 is that sexually active adolescents use both hormonal contraceptives (HC) and condoms to prevent unwanted pregnancy and sexually transmitted infections (STIs). Studies show that there has been an increase in condom use by adolescents over the past 20 years and a decrease in HC use. Rates of combined use for adolescents remain low. Research also indicates that there is an inverse relationship between HC use and condom use among many populations. In addition, many adolescents begin contracepting with condoms and then later switch to HC methods.

Studies have examined the influence of pregnancy and STI concerns on HC and condom use separately, but little is known about adolescents' motivations to combine the two contraceptive methods. The effect of partner type — i.e., whether the relationship is considered serious or casual — on pregnancy and STI concerns and contraceptive use has also been studied, but little is known about how partner type affects the relationship between HC and condom use.

In this article, the authors examine whether an inverse relationship exists between adolescents' HC and condom use, whether pregnancy and STI concerns influence this association, and whether decisions to use one method or the other are affected by partner type — either main (serious) or casual. Using "HC use" as the independent variable and "condom use" as the dependent variable, the authors formed three hypotheses:

  1. Teens with strong concerns about pregnancy will decrease condom use once initiating HC use, so a strong inverse relationship between HC and condom use will be seen for this group,

  2. Teens with strong STI concerns will maintain condom use, even if using HC, and

  3. The inverse relationship in the first hypothesis will only be true for teens with main partners and not for those with casual partners.

Methods

Sample Selection

Adolescents were recruited from two San Francisco health clinics. The first was an HMO adolescent clinic where clients sought primary care or reproductive health services, and the second was a free STI clinic where clients sought pelvic exams, family planning services and STI testing. All adolescents visiting the clinics from February 1997 through August 1998 were screened for eligibility in the study. A client was eligible if s/he were English-speaking, 14-19 years old, living within the metropolitan area, and had ever had sexual intercourse. Consent for participation was obtained. Demographic and sexual history information was obtained with verbal consent for those who declined to participate in the study. Eighty-two percent of all eligible adolescents agreed to participate, resulting in a final sample of 436 participants: 141 males and 295 females.


Design

Prior to their exams, all participants had private interviews with a research assistant to gather baseline contraceptive use, sexual behavior, demographic and contact information. Following the exam, participants were interviewed about their concerns regarding pregnancy and STIs. Six months following the clinic visit, participants were interviewed by telephone about their contraceptive use and sexual behaviors.

Measures

Demographic information was gathered at baseline only and included gender, age, race, ethnicity, clinic site and maternal education, an indicator of socioeconomic status. Information about pregnancy and STI concerns was also collected at baseline. These items assessed how detrimental participants thought it would be to contract an STI or become/get a partner pregnant, and their perceptions of the risk that either would happen to them.

At baseline and six-month follow-up, participants were asked to categorize all partners within the last six months as "casual," defined as "someone you've had sex with only once, or a few times, or you have sex with on an ongoing, casual basis," or "main," defined as "someone that you have sex with and you consider to be the person that you are serious about." They were also asked about contraceptive use at last intercourse with each partner type.

At follow-up only, participants were asked about the presence of one or both types of partners during the previous six months and about the length of the relationship with the last main and/or casual partners. Adolescents' contraceptive behavior at the six-month follow-up was the outcome of interest.


Data Analysis

Data were categorized by gender and contraceptive behaviors with main and casual partners. Categorical data were analyzed by chi-square tests. The items dealing with pregnancy/STI concerns were combined into scales based on constructs from the Theory of Planned Behavior and analyzed with independent sample t-tests. Logistic regression was used to look at the relationship between condom and HC use, with condom use as the dependent variable.

Results

The mean participant age was 17 years. The sample was ethnically and racially diverse. There were slight but significant differences for age, ethnicity and socioeconomic status between the STI Clinic and the HMO participants. During the six months between baseline and follow-up, 62% of females and 45% of males reported having only main partners, 31% of females and 33% of males had main and casual partners, and 7% and 23%, respectively, had only casual partners. Both females and males reported more HC use and less condom use with main partners than with casual partners. The researchers' data supported all three of their hypotheses:

  • The first hypothesis stated that an inverse relationship between HC and condom use would be strongest among teens with strong concerns about pregnancy. The authors found this to be true. For females who perceived pregnancy as more negative, non-HC users were much more likely to use condoms (about 65%) than HC users (about 33%), creating a strong inverse relationship. For females who perceived pregnancy less negatively, condom use was almost the same (42-50%) for both HC users and non-HC users.

  • The second hypothesis was that adolescents with strong concerns about STIs would maintain condom use despite HC use. For both males and females, regardless of HC use, condom use was higher when the perceived risk of STIs was high. Almost 60% of females and 70% of males in this group used condoms at last intercourse.

  • The third hypothesis was that the inverse relationship predicted in the first hypothesis would only be true for main partner relationships and not for casual relationships. The authors found this to be true. Among females, only 38% of HC users also used condoms with their main partners, compared with 57% of non-HC users. For males with main partners, 42% whose main partner used HC also used condoms, compared with 65% of males whose main partners did not use HC. These numbers indicate an inverse relationship between condom and HC use for both genders. When the analyses were done for participants' casual partners, condom use was unaffected by HC use.

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Discussion of the Results

Results suggest that the inverse relationship between condom and HC use is influenced by partner type and STI and pregnancy concerns, factors that need to be considered when developing interventions to meet the Healthy People 2002 objective of dual condom and HC use.

When adolescents had main partners, they tended to swap condom use for HC, a finding that suggests the two decisions are related at least under certain conditions. Young women with main partners were more likely to report using HC and not condoms when they had highly negative views of pregnancy or very low perceived risk of acquiring an STI. Condom use and HC use were not related to one another unless females reported these extreme views. For young men, greater concerns about pregnancy and STIs were related to increased condom use.

The authors suggest that women with main partners who hold negative views of pregnancy or perceive themselves to be at low risk for STI may use condoms initially to prevent pregnancy and later switch to HC, a more effective pregnancy prevention method. Conversely, if an adolescent's main concerns are STI-related, she may be likely to continue to use condoms regardless of her HC use. Indeed, young women reporting strong concerns about STIs had the highest rate of dual use — 22%. Condom and HC use for casual relationships appear to be unrelated. When adolescents choose to use condoms with a casual partner, it could be due to an increased concern about STIs with casual partners or to the ease and availability of condoms. The reasoning behind adolescents' differing behaviors with casual and main partners still needs further exploration and understanding.

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Limitations of the Study

The models used in this study were better at predicting female behavior than male behavior. This could be due to the small numbers of young men enrolled in the study, the limitations posed in asking males to report on their partners' behaviors, issues related to the sex-specific nature of condoms and HC, and sex differences in motivation to use a particular method. Other limitations include a sample size that limited the power of analyses, a sample recruited only from clinics, and a conceptual design that did not directly look at dual users and nonusers of the methods.

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Implications (by the article's authors)

  • In order to reach Healthy People 2010 objectives, clinicians and other interventionists should encourage sexually active adolescents, most of whom report having main partners, to continue their condom use while taking hormone contraceptives.

  • Clinicians who counsel adolescents on contraceptive methods can benefit from an understanding of the interactions between partner type and STI and pregnancy concerns.

  • Clinicians should assess patients' perceptions of STI and pregnancy risk. They should then link the two when discussing contraceptive method choices rather than treating them as two separate issues. Advice should be tailored to the patient's perceptions and situation by expressly addressing her views of her risk for pregnancy and STIs.

Ott, M., Adler, N., Millstein, S., Tschann, J., and Ellen, J. (Jan/Feb 2002). The Tradeoff Between Hormonal Contraceptives and Condoms Among Adolescents. Perspectives on Sexual and Reproductive Health. 34(1), 6-13.

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