Adolescent contraception: review and guidance for pediatric clinicians.

The majority of adolescents initiate sexual activity during their teenage years, making contraception an important aspect of routine adolescent health care. Despite common misperceptions, all available methods of reversible contraception are appropriate for adolescent use. Contraceptive side effects profiles and barriers to use of certain methods should be considered when providing contraceptives to adolescents. In particular, ease of use, confidentiality, and menstrual effects are main concerns of adolescents. Contraceptive counseling with adolescents should describe method efficacy, discuss user preferences, explore barriers to use, counsel regarding sexually transmitted infection prevention, and consider what to do if contraception fails. Emergency contraception should be widely discussed with adolescents, as it is appropriate for use during gaps in other contraceptive use, method failure, and adolescents who are not using another form of contraception. Dual method use (condom plus a highly effective method of contraception) is the gold standard for prevention of both pregnancy and sexually transmitted infections.

Social and Structural Influences on Multiracial Identification and Health: a Public Health Mandate to Precisely Measure, Theorize, and Better Understand Multiracial Populations.

There is a growing group of adolescents and young adults in the USA who identify as multiracial. However, very little research, especially health research, focuses on understanding multiracial identification and health and behavioral outcomes for multiracial populations in comparison to their single-race counterparts. Understanding the intersectional influences on this identification process is critical to updating the literature on racial and ethnic identity and health with more accurate identifications and categories. It is especially critical that there is an explicit focus on understanding the impact of structural racism and discrimination when studying the process of racial identification and the impact on health. This review takes an interdisciplinary approach relying on a review of multiple research literatures: the historical literature on race, racism and categorization, psychological and adolescent medicine literatures on adolescent development, the sociological literature on racial and ethnic identification, and the limited public health research beginning to disentangle multiracial health outcomes. An empirically testable conceptual framework is offered to frame the organization of this review-demonstrating the multiple spheres of influence on racial and ethnic identification and the implication for health outcomes.

School placement for human immunodeficiency virus-infected children: the Baltimore City experience.

Over the past 6 years, the city of Baltimore has successfully implemented a school placement policy for human immunodeficiency virus (HIV)-infected children and children with acquired immunodeficiency syndrome (AIDS). Both policy and specific procedures are based on nationally promulgated guidelines. School placement policy is part of an overall AIDS policy that includes education of students and staff and adoption of universal precautions to prevent transmission of communicable diseases in school. Implementation has been marked by excellent collaboration between the departments of health and education. Important policy components include expedited clinical investigation of each case, an interagency review panel, strict protection of confidentiality, a restricted setting for certain children, a school site visit for each placement, and continued monitoring of the school placement by school nurses. Many HIV-infected students need special educational services and/or school health services. The Baltimore City school placement process has avoided the exaggerated publicity endured by some communities, where media reporting has aggravated community fears and invaded the lives of families with HIV-infected children. Baltimore City has succeeded in ensuring access to education, protecting families' confidentiality, and providing special care for HIV-infected students. Local communities should emphasize national guidelines in designing school placement policies for HIV-infected children. School placement policies work best in the context of a comprehensive policy incorporating AIDS education and care.

School and adolescent health and managed care.

BACKGROUND: The current rapid expansion of managed care in the United States creates opportunities and dilemmas for improving adolescent health. Collaboration among managed care organizations, schools, and public health agencies increasingly is critical to adequately address the health needs of youth and to increase adolescent access to effective prevention services. RESULTS: This paper discusses exigencies that schools and adolescent health care providers are facing, the relationship of managed care to public health, and the implications of managed care for adolescent health promotion. To illustrate some of these issues, we describe a unique collaborative relationship between HealthPartners, a managed care organization in Minneapolis, Minnesota, and Health Start, a nonprofit organization based in St. Paul, Minnesota, that manages the eight school-based health centers in the St. Paul Public Schools.

Developing quality measures for adolescent care: validity of adolescents' self-reported receipt of preventive services.

OBJECTIVE: To demonstrate the feasibility of directly surveying adolescents about the content of preventive health services they have received and to assess the validity of adolescent self-reported recall. DATA SOURCES/SETTING: Audiotaped encounters, telephone interviews, and chart reviews with 14-21 year olds being seen for preventive care visits at 15 pediatric and family medicine private practices, teaching hospital clinics, and health centers. DESIGN: 537 adolescents presenting for well visits were approached, 400 (75 percent) consented, 374 (94 percent) were audiotaped, and 354 (89 percent) completed telephone interviews either two to four weeks or five to seven months after their visits. Audiotapes were coded for screening and counseling across 34 preventive service content areas. Intraobserver reliability (Cohen's kappa) ranged from 0.45 for talking about peers to 0.94 for discussing tobacco. The sensitivity and specificity of the adolescent self-reports were assessed using the audiotape coding as the gold standard. RESULTS: Almost all adolescents surveyed (94 percent) remembered having had a preventive care visit, 93 percent identified the site of care, and most (84 percent) identified the clinician they had seen. There was wide variation in the prevalence of screening, based on the tape coding. Adolescent self-report was moderately or highly sensitive and specific at two weeks and six months for 24 of 34 screening and counseling items, including having discussed: weight, diet, body image, exercise, seatbelts, bike helmet use, cigarettes/smoking, smokeless tobacco, alcohol, drugs, steroids, sex, sexual orientation, birth control, condoms, HIV, STDs, school, family, future plans, emotions, suicidality, and abuse. Self-report was least accurate for blood pressure/cholesterol screening, immunizations, or for having discussed fighting, violence, weapon carrying, sleep, dental care, friends, or over-the-counter drug use. CONCLUSION: Adolescents' self-report of the care they have received is a valid method of determining the content of preventive health service delivery. Although recall of screening and counseling is more accurate within two to four weeks after preventive care visits, adolescents can report accurately on the care they had received five to seven months after the preventive health care visits occurred.

Interim outcomes for a community-based program to prevent perinatal HIV transmission.

The AIDS Prevention for Pediatric Life Enrichment (APPLE) project is a community-based program to prevent perinatal HIV infection by preventing infection in women. One project component tested a primary prevention model developed from principles of cognitive social learning theory which used street outreach and community-targeted small media materials to increase the use of condoms. Formative research was used to explore community perceptions about HIV/AIDS and to design media materials. Program evaluation employed a two-community, time series, quasi-experimental design. Annual street surveys samples individuals in areas where they were likely to encounter outreach workers. Baseline surveys found substantial pre-programmatic behavior change. After two years considerable APPLE name recognition (40%), contact with media materials (63%), and contact with outreach workers (36%) were found and norms reflecting social acceptability of condoms were more positive among women in the intervention community. Condom use at last sexual encounter rose in both communities but was significantly higher in the intervention community. Condom use also was higher among women who reported exposure to either small media or small media plus street outreach. Other self-reported HIV-prevention behaviors did not show change in the initial period.

A pilot program of contraceptive continuation in six school-based clinics.

PURPOSE: Few school-based health centers (SBHC) in the United States dispense contraceptives on-site and little is known about contraceptive continuation in these health centers. METHODS: An 11-month contraceptive continuation pilot project offering monthly reproductive health assessment and counseling to students enrolled in Baltimore school clinics was evaluated. One hundred-forty-three women voluntarily enrolled in the study over a seven month period. A monthly contraceptive calendar was developed to collect data on contraceptive use, pregnancy and STD risk, sexual behavior and parental support for contraceptive use. Physical assessment was provided as needed to assess the presence of STD's or pregnancy. Data were analyzed for the month prior to enrollment in the program and eleven months after entry into the program. RESULTS: Both contraceptive (OCP) use and abstinence increased over the course of the program. Condom use remained at approximately 30% with frequent use of OCP's and condoms, condoms or abstinence. Program drop-out was common. Thirteen students became pregnant while enrolled in the program and 35% of the students were diagnosed with one or more sexually transmitted diseases. Partner-switching was common, although two or more partners within any one month was rare. CONCLUSIONS: Monthly follow-up provided through SBHCs can improve contraceptive use although dropout rate and contraceptive failure remain high.

Patterns of ICD-9 diagnoses among adolescents using school-based clinics: diagnostic categories by school level and gender.

PURPOSE: Understanding utilization patterns in school clinics is important in discerning potential health outcomes among adolescents. This study reports on high-middle school and gender differences in ICD-9 diagnostic codes for students using Baltimore school clinics in the academic year 1989-90. METHODS: 12,953 visits resulted in 17,241 individual diagnoses. Data were grouped into 17 major diagnostic categories, subcategories for reproductive health and mental health, and 20 sentinel diagnoses. RESULTS: Reproductive health diagnoses were most common for high school clinics (28% of all diagnoses). Mental health (psychosocial) diagnoses were most common for middle school clinics (30%). Adolescent women were much more likely to use clinics for reproductive health care needs than adolescent men. Adolescent men and women used the clinics with equal frequency for mental health, although specific diagnoses varied considerably by gender. CONCLUSIONS: This overview of diagnostic patterns among adolescents using Baltimore's school-based clinics provides a unique view of differences in health care needs between younger and older teens and between male and female teens. These data have meaningful implications for clinic staffing and enhanced outreach efforts.

Age of initiating selected health-risk behaviors among high school students in the United States.

PURPOSE: To estimate and compare the age of initiation of alcohol use, cigarette smoking, sexual intercourse, and marijuana use among female and male students in U.S. high schools. METHODS: Using data from the 1991 and 1993 national school-based Youth Risk Behavior Surveys, life-table analysis was used to create hypothetical cohorts to estimate age of initiation of selected health-risk behaviors. The sample size was 12,272 in 1991 and 16,296 in 1993, with an overall response rate of 68% in 1991 and 70% in 1993. RESULTS: Male students initiate each of these behaviors earlier than female students, but the pace of initiation for females accelerates so that by age 15 years the cumulative proportion of male and female students who have initiated these behaviors is similar. For both female and male students, the youngest cohort appears to initiate use of alcohol and sexual intercourse at earlier ages than older cohorts. Similarly, the younger cohorts of female students appear to initiate smoking cigarettes and using marijuana at earlier ages than older cohorts. CONCLUSIONS: Many high school students are initiating alcohol use, cigarette smoking, sexual intercourse, and marijuana use at early ages. These data suggest a need for intensive intervention programs by middle/junior high school to motivate and prepare students to avoid these behaviors. Clinicians should begin screening and counseling for risk behaviors in early adolescence.

Use of birth control pills, condoms, and withdrawal among U.S. high school students.

PURPOSE: To examine the use of contraception at last sexual intercourse among currently sexually active adolescents. METHODS: We analyzed data from national school-based Youth Risk Behavior Surveys (YRBS) conducted in 1991, 1993, 1995, and 1997. The YRBS is a self-administered, anonymous survey which uses a national probability sample of U.S. students in public and private schools from grades 9 through 12. RESULTS: From 1991 to 1997, condom use significantly increased (from 46% to 57%), birth control pill use decreased (from 21% to 17%), and use of withdrawal significantly decreased (from 18% to 13%). In 1997, although more students were using condoms, 13% reported using withdrawal and 15% reported using no method to prevent pregnancy at last sexual intercourse. In 1997, condom use among females was significantly lower in the 9th grade than in the 12th grade (p <.001), whereas birth control pill use was higher (p <.001) and use of withdrawal remained stable. Among males, condom use and withdrawal use remained stable from 9th to 12th grade, whereas birth control pill use by their partner increased (p <.001). CONCLUSIONS: Inadequate contraceptive use among sexually active adolescents continues to be a major public health problem in the United States. For young people who will not remain sexually abstinent, families, health care providers, schools, and other influential societal institutions should promote the correct and continued use of condoms as essential protection against sexually transmitted diseases and human immunodeficiency virus infection.

Guidelines for adolescent health research: a position paper of the society for adolescent medicine.

Their ambiguous legal and ethical status has become a barrier to adolescents' appropriate involvement in research from which they may benefit and which is needed to improve adolescent health care and to inform health policy. Involvement of adolescents in research should be based on a scientific and empathetic understanding of their developing capabilities and a careful assessment of risks and benefits. The important role of parents and communities as protectors of adolescents should be respected and enhanced as we acknowledge and respect developing adolescent autonomy. These guidelines provide a framework to interpret the federal regulations for protection of human subjects in light of the unique legal, ethical, developmental, contextual, and racial issues that affect adolescents. The guidelines are designed to protect individual adolescent research subjects and to facilitate important youth research that would promote the health of adolescents.

Risk factors for adolescent sexual behavior, fertility, and sexually transmitted diseases.

Current understanding of the risk factors related to adolescent initiation of sexual activity, use of contraception, pregnancy, and STDs is examined. From recent research on adolescent fertility, findings that have particular relevance to school health or reflect new understandings of adolescent sexuality are summarized. In selected cases, prevention programs that build directly on an understanding of these risk factors are cited.

PIP: It is important to understand the risk factors related to adolescent initiation of sexual activity, use of contraception, pregnancy, and sexually transmitted diseases (STD). This understanding is important in identifying and caring for youths at risk and designing primary and secondary prevention programs for schools and communities. The current understanding of these risk factors and recent findings are summarized in this paper. Intermediate determinants of fertility are broadly discussed with closer attention given to specific biopsychosocial risk factors affecting fertility and the potential for contracting STDs. The roles of demographics, geography, poverty and ethnicity, religion, school performance, family factors, peer influences, puberty, risk-taking behavior, drugs, sexual abuse, self-esteem and psychological variables, school health education, and school-based clinics are considered. The social determinants of contraceptive use/STD protection, pregnancy continuation or abortion, and STDs are also discussed.

Adolescent reproductive health: roles for school personnel in prevention and early intervention.

The practical roles school staff can play in addressing adolescent reproductive health issues such as teen-age pregnancy, STDs, and HIV/AIDS are reviewed. Particular attention is given to identification and assessment of adolescents most at risk for pregnancy, STDs, and HIV/AIDS, and the regulations that address protection of students' privacy in this area.

PIP: Since schools have uniquely high access to youth, they are extremely well-suited places in which to prevent and intervene early in the course of adolescent reproductive health problems. This paper review practical roles which school staff may play in addressing issues such as teen pregnancy, sexually transmitted diseases, and HIV/AIDS. It also discusses identifying and assessing adolescents most at risk for these problems and existing regulations to protect students' privacy. School-based and school-linked programs should be tailored to meet the needs of populations served and include effective, theory-based classroom education; confidential health services; and health counseling. Programs must be supported by administrators and other school staff. With health educators, school nurses, counselors, and other school personnel having multiple roles in counseling, educating, and providing care, staff must be knowledgeable about adolescent reproductive health and comfortable discussing it. Further, staff also need to be well-informed about and respect students' rights to privacy.

Strategies to maximize retention of a sample of young adolescents in a longitudinal evaluation of Healthy & Alive!

The authors implemented strategies to maximize cohort retention to avert loss of statistical power and minimize bias in a longitudinal evaluation of a middle school HIV/STD prevention intervention. A retention rate of 80% of the baseline sample (n = 2,975) at six months and 73% at 18 months was achieved despite high reported rates of student mobility and a major system reorganization in one urban district. The strategies increased retention but did not eliminate differences in demographic characteristics and behaviors between the groups of retained and lost students. Results confirm the need to implement retention strategies early and to maintain them throughout data collection. Information from a tracking data base can be used to prioritize students for follow-up to reduce bias from sample loss.

Birth weight outcomes for repeat teenage pregnancy.

To investigate the outcomes for repeat teenage pregnancy and the effect of interpregnancy interval on birth weight, birth certificate data were reviewed from all mothers under 26 years delivering their second baby during 1981-1983 at an urban teaching hospital. Initially, 409 mothers who had delivered their first baby at the same hospital were identified. Mothers were divided into three groups: mothers under 20 years for both births; mothers under 20 years for the first birth, with the second birth delayed until 20 to 25 years; and mothers 20-25 years for both births. Group 1 mothers had high but identical rates of low birth weight (17.5%) for both parities, high rates of very low birth weight infants (less than 1501 g), and no change in mean birth weight between the two pregnancies. Group 2 mothers were older at first birth and had better outcomes for first and second births than group 1 mothers. For group 1 mothers, the initiation of prenatal care was delayed at second pregnancy compared to first pregnancy (46% receiving first trimester care versus 59% at first delivery). In contrast, groups 2 and 3 showed improvement in accessing prenatal care for the second pregnancy. Interpregnancy interval had no influence on the birth weight of the second infant in any group.

Multiple sexual partners among U.S. adolescents and young adults.

CONTEXT: Because many teenagers and young adults fail to use condoms correctly and consistently, the number of sexual partners they have is an important risk factor for sexually transmitted diseases, including HIV. Identifying factors that are associated with having multiple partners can help in the design of disease interventions. METHODS: Data on 8,450 males and females aged 14-22 who participated in the 1992 Youth Risk Behavior Survey were used to examine the prevalence of and factors associated with young people's having multiple partners. RESULTS: In all, 63% of female respondents and 64% of males were sexually experienced. Among those who had had sex during the three months before the survey, 15% and 35%, respectively, had had two or more partners during that period. At each age, the majority of sexually experienced respondents had had more than one lifetime partner; between ages 14 and 21, the proportion who had had six or more rose from 8% to 31% among females and from 14% to 45% among males. In logistic regression analyses, alcohol use, illicit drug use and young age at first coitus were associated with increased odds that females had had two or more partners in the previous three months, and being married lowered the odds; black or Hispanic race or ethnicity, alcohol use and young age at first coitus increased the odds for males, and being married reduced the odds. As the number of reported alcohol-related behaviors increased, the adjusted proportion of respondents who had recently had multiple partners rose from 8% to 48% among females and from 23% to 61% among men. CONCLUSIONS: The strong association between alcohol use and having multiple sexual partners underscores the need to educate young people about the effects of alcohol on partner choice and the risk of infection with sexually transmitted diseases.

PIP: This study estimated the prevalence of having multiple sex partners (MSPs) and examined potential risk factors associated with having MSPs among adolescents and youth in the US. Data were obtained from the 1992 National Health Interview Survey and Youth Risk Behavior Survey among a multistage probability cluster sample that was weighted to represent the youth aged 12-21 years. This analysis was based on a limited sample of 4075 youth who were sexually experienced (SE). Initial factor analysis yielded 2 clusters related to first intercourse: substance use and weapon carrying or fighting. Weapons was excluded due to poor internal consistency. Orthogonal rotation revealed 2 cluster factors: alcohol use and illicit drug use. Cross-tabulations were used to identify potential independent predictors. Logistic regression was used to estimate the independent influence of predictors. Findings indicate that most had 2 or more lifetime partners (LPs). The proportion of those with 6 or more LPs rose from 8% at age 14 to 31% at age 21 among females and from 14% to 45% among males. Only 20% of SE females and 13% of SE males reported 1 lifetime partner. Alcohol use, illicit drug use, and young age at first intercourse were associated with increased odds of females having 2 or more partners in the preceding 3 months. Marriage lowered the odds for both sexes. The same 3 factors, in addition to being Black or Hispanic, increased the odds for males. Increases in alcohol-related behaviors contributed to increases in adjusted proportions of recent MSPs from 8% to 48% among females and from 23% to 61% among males.

The association of sexual behaviors with socioeconomic status, family structure, and race/ethnicity among US adolescents.

OBJECTIVES: This study assessed the relation of socioeconomic status (SES), family structure, and race/ethnicity to adolescent sexual behaviors that are key determinants of pregnancy and sexually transmitted diseases (STDs). METHODS: The 1992 Youth Risk Behavior Survey/Supplement to the National Health Interview Survey provided family data from household adults and behavioral data from adolescents. RESULTS: Among male and female adolescents, greater parental education, living in a 2-parent family, and White race were independently associated with never having had sexual intercourse. Parental education did not show a linear association with other behaviors. Household income was not linearly related to any sexual behavior. Adjustment for SES and family structure had a limited effect on the association between race/ethnicity and sexual behaviors. CONCLUSIONS: Differences in adolescent sexual behavior by race and SES were not large enough to fully explain differences in rates of pregnancy and STD infection. This suggests that other factors, including access to health services and community prevalence of STDs, may be important mediating variables between SES and STD transmission and pregnancy among adolescents.

Adolescent sexual behavior: estimates and trends from four nationally representative surveys.

CONTEXT: Accurate information about trends over time in adolescent sexual behavior is essential to understand changes in adolescent pregnancy and sexually transmitted diseases and to monitor the progress of health promotion activities in the United States METHODS: Estimates from the National Survey of Family Growth (NSFG), the National Survey of Adolescent Males (NSAM), the Youth Risk Behavior Survey (YRBS) and the National Longitudinal Study of Adolescent Health (Add Health) were compared. While methodologies and populations varied by survey, adolescents aged 15-17 who attend high school were a common subpopulation among all four. For each survey, the prevalence of sexual intercourse, contraceptive use and multiple sexual partners was measured in this population. RESULTS: Trend comparisons fell into four categories. First, some similar significant trends were found across surveys. The proportion of all males and of white males who reported ever having had sexual intercourse decreased significantly, while condom use rose significantly among males in both the NSAM and the YRBS. For such behaviors as ever having had sexual intercourse (among Hispanic males and black females), using the pill and using the condom (among all females) and having four or more lifetime sexual partners (among white males), a significant trend was found in one survey while a similar but nonsignificant trend was found in another. Several trend comparisons were not significant in any survey. Finally, having had intercourse in the past three months (among all males and all females), having had two or more partners in the past three months (for males) and having had four or more lifetime sexual partners (among white females and all males) showed a significant trend in one survey but lacked a parallel nonsignificant trend in another. Prevalence estimates in 1995 differed significantly in at least one comparison of surveys for all behaviors except having four or more lifetime sexual partners (both genders) and having two or more recent sexual partners (females). Gender differences within the YRBS and between the NSFG and the NSAM generally were consistent. CONCLUSIONS: Trends over time and gender differences were similar across surveys, underscoring their value for tracking adolescent sexual behaviors. Differences in prevalence estimates across surveys probably result from differences in question wording, diverse interview settings and modes of data collection, and varying statistical power. These findings suggest a need to increase our understanding of how methodologies influence survey response in research on adolescents.

Timing of alcohol and other drug use and sexual risk behaviors among unmarried adolescents and young adults.

CONTEXT: Although alcohol and drug use by young people has been associated with sexual risk behavior in some research, detailed data are lacking on the timing of substance use in relationship to sexual risk-taking. METHODOLOGY: Cross-sectional data on 7,441 unmarried young people aged 14-22 from the 1992 Youth Risk Behavior Survey (household supplement) were used in the analysis. Alcohol and other drug use at last sexual intercourse, substance use in the past 30 days (recent use), the number of different substances ever used (lifetime use) and age at initiation of alcohol use are examined here. The outcome variables assessed through multivariate regression analyses were condom use at last intercourse and more than one sexual partner in the past three months. RESULTS: Failure to use a condom was strongly associated with the lifetime substance-use scale or, alternatively, with age at initiation of alcohol. Once the number of substances ever used was controlled for, neither substance use at last sexual intercourse nor recent use was associated with the likelihood of using a condom at last coitus. Among young men and women, recent substance use and use of either alcohol or drugs at last intercourse were both strongly associated with having had more than one sexual partner in the past three months. For females only, lifetime use also increased the probability of recent multiple partners. CONCLUSIONS: The relationships between alcohol and other drug use and two sexual behaviors--condom use and multiple partners-suggest distinct mechanisms of influence and the need for different prevention strategies.

Combined use of condoms with other contraceptive methods among inner-city Baltimore women.

Data from a street survey conducted among 717 women aged 17-35 in two inner-city Baltimore communities in 1991-1992 indicate that 17% of the entire sample, 38% of women using the pill and 11% of users of methods other than the pill used a condom in addition to another method the last time they had intercourse. Although adolescents reported the highest rate of combined condom and pill use (22% of 17-19-year-olds), condom use was significantly associated with pill use among adult women (odds ratio of 1.57) but not among adolescents (odds ratio of 1.03). Condom use was negatively associated with use of methods such as the diaphragm, the IUD, the implant and the sponge (odds ratio of 0.21) among both adolescents and adults. Logistic regression analyses show that positive attitudes toward safer sex, ever having refused sex without a condom and believing in condom efficacy all significantly predicted use of the condom with another method. Having ever been tested for HIV was negatively related to combined use, while behavioral risk factors showed no association.

PIP: In 1991 and 1992, in Baltimore, Maryland, interviews were conducted with 717 sexually active women aged 17-35 living in two inner-city neighborhoods to determine the prevalence of combined use of condoms with other contraceptive methods and the demographic, attitudinal, and behavioral correlates of combined use. The typical woman was Black (96%), had never been married (84%), and had at least completed high school (65%). 45% were currently employed. 49% had made changes in their personal behavior since learning about AIDS. More than 80% said that they could do a lot to prevent HIV infection. 24% had at least one personal risk factor for HIV in the last year. 10% had partners who took part in high-risk behaviors in the last six months. Both personal risk factors and partner risk factors were associated with each other (odds ratio [OR] = 5.1). Oral contraceptives (OCs) were the most common method used during last intercourse (40.1%) followed by condoms (33.2%). 38.1% used the condom with OCs. 10.7% used the condom with any other contraceptive method but OCs. Combined use was highest among teenagers (24.1% vs. 7.4-15%) and OC users (41.6% vs. 32.1-36.8%). Condom use had a positive association with OC use among adult women (20-35 years) (OR = 1.57) but not among teenagers. Spermicide use was also associated with condom use (OR = 3.01). Use of diaphragms, sponges, the IUD, and the levonorgestrel implant had a negative relationship with condom use (OR = 0.19, 0.14, 0.32, and 0.35, respectively). Positive attitudes towards safer sex (OR = 1.39), ever having refused sex without a condom (OR = 7.09), and greater belief in condom efficacy (OR = 1.89) predicted combined use. Ever having been tested for HIV predicted non-use (OR = 0.53). Personal and partner behavioral risks for STDs and HIV did not predict combined method use.