Behavioral Interventions to Increase Condom Use Among College Students in the United States: A Systematic Review

Abstract

Background. Traditional undergraduate college students in the United States are in the age range that experiences the highest rate of sexually transmitted infections (STIs) and are vulnerable to contracting STIs. Increasing condom use among college students is a prevention strategy to reduce the spread of STIs. Aim. The purpose of this systematic review of the literature was to identify behavioral interventions that increased condom use behaviors and/or intentions among college students. Method. The Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines were followed in systematically searching, extracting, appraising, and synthesizing the evidence. A quality assessment was also conducted with the tool provided by the Effective Public Health Practice Project. Results. The initial search yielded 715 records. After critical appraisal, seven articles remained for review. Discussion. Four of the interventions were developed using the three constructs of the information, motivation, and behavioral skills model, and all four found significant increases in condom use or condom use intentions. Additionally, interventions that included modules to increase self-efficacy for condom use, taught participants where to get condoms and how to negotiate condom use with partners, or elicited positive associations (feels) toward condoms saw increased condom use or intention to use condoms.

Keywords

college health information motivation and behavioral skills primary prevention school-based sex behavior

Sexually transmitted infections (STIs) are particularly problematic for adolescents and young adults (15-24 years old) in the United States, as they account for nearly half of all incidences of STIs and have seen increasing rates of STIs (Centers for Disease Control and Prevention [CDC], 2016a, 2016b, 2016c, 2016d, 2017). In 2015, nearly two thirds of all new chlamydia infections and 570,000 new gonorrhea infections occurred among adolescents and young adults, and between 2016 and 2017, there was a 12.8% increase in gonorrhea among persons 20- to 24-year-olds (CDC, 2016a, 2016b, 2017). In 2017, the rate of reported primary and secondary syphilis cases among women 15 to 24 years old had increased 7.8% from 2016 and 83.3% from 2013 (CDC, 2017). Among men 15 to 24 years old in 2017, rates of reported primary and secondary syphilis had increased by 8.3% from 2016 and 50.9% from 2013 (CDC, 2017). Additionally, in 2017 women 20 to 24 years old had highest rate of primary and secondary syphilis compared with all other age-groups (CDC, 2017). Traditional undergraduate college students in the United States are typically between the ages of 18 and 22 years and are vulnerable to contracting STIs (Adeniyi & Okewole, 2014).

College students’ activities, including those that put them at risk of STIs, are often shaped by their academic and social environment. Social norms, behaviors exhibited by a group that are accepted as normal and to which people are expected to conform, are pervasive on college campuses (Berntson, Hoffman, & Luff, 2014; Scholly, Katz, Gascoigne, & Holck, 2005; Scull, Keefe, Kafka, Malik, & Kupersmidt, 2019). However, perceived social norms on a college campus may differ from actual college student experiences, perpetuating unrealistic ideas about normative behaviors. Students tend to overestimate the amount of sex their peers are having, the number of sexual partners, the incidences of STIs, and the rates of unintended pregnancies (Scholly et al., 2005). They also underestimate rates of condom use when compared with cross-sectional data (Scholly et al., 2005).

Although many students initiate sex as adolescents, unrealistic ideas about normative behaviors among college students may put them in danger of engaging in risky sexual behaviors, as college is typically where students participate in these behaviors (Katz, Tirone, & van der Kloet, 2012; Scull et al., 2019). Risky sexual behavior includes casual sex, multiple concurrent or overlapping sex partners, and lack of condom use, which leads to increased vulnerability to STIs (Johnson, Nshom, Nye, & Cohall, 2010; Scholly, Katz, Cole, & Heck, 2010; Wasie, Belyhun, Moges, & Amare, 2012). In 2018, only 50% of sexually active undergraduate students reported using condoms “most of the time” or “always” for vaginal sex within the last 30 days (American College Health Association, 2018). A safe way to reduce STI transmission when a vaccine is not available is by using condoms (Lazarus, Sihvonen-Riemenschneider, Laukamm-Josten, Wong, & Liljestrand, 2010). College students who are sexually active generally develop their condom use behaviors during high school, when many students have their sexual debut, and they carry these behaviors into college (Calloway, Long-White, & Corbin, 2014). Additionally, condom use behaviors often change as a student matriculates through college. One study showed that women decreased their frequency of condom use over the course of their first year in college (Walsh, Fielder, Carey, & Carey, 2013).

Changes in condom use behaviors during college may result from unique barriers toward condom use experienced by college students. These barriers can be categorized as barriers within the environment or within the student (El Bcheraoui, Sutton, Hardnett, & Jones, 2013; French & Holland, 2013; Picca & Joos, 2009; Wilson & Ickes, 2015). Within the environment, access to condoms for college students may be limited to student health centers, off-campus sexual health clinics, residence halls, peers, or off-campus outside sources, such as convenience stores and drug stores. Not having a condom available at the time of a spontaneous sexual encounter increases the risk of unprotected sex (El Bcheraoui et al., 2013). Convenience and drug stores that surround college campuses present a financial barrier, as they tend to inflate prices for condoms (Wilson & Ickes, 2015). Barriers to condom use that are within the student include a perceived low risk of contracting an STI, low self-efficacy for using a condom or negotiating condom use with a partner, and perceived social norms about condom use (El Bcheraoui et al., 2013; French & Holland, 2013; Heeren, Jemmott, Mandeya, & Tyler, 2007). Students may also experience embarrassment and discomfort when procuring or using condoms, which hinders consistent condom use (Fehr, Vidourek, King, & Nabors, 2017; Picca & Joos, 2009; Wilson & Ickes, 2015).

Condom use interventions that address the substantial and unique barriers to condom use among college students are an example of public health primary prevention to reduce the risk of STIs in young adults (French & Holland, 2013; Mertes, 2015; Picca & Joos, 2009; Wilson & Ickes, 2015). By reducing barriers to STI prevention and condom use among college students, sexual health outcomes can be improved. Other systematic reviews have focused on specific locations (e.g., sub-Saharan Africa, low-income countries) or are based on a specific intervention type (e.g., social marketing or social networks; Foss, Hossain, Vickerman, & Watts, 2007; Sweat, Denison, Kennedy, Tedrow, & O’Reilly, 2012; Wang, Brown, Shen, & Tucker, 2011). These reviews found increases in condom use, especially when specific interventions types were used and among high-risk sexual encounters (sex work and client; Foss et al., 2007; Sweat et al., 2012; Wang et al., 2011). However, no systematic review has been specific to college students. Therefore, the purpose of this systematic review of the literature was to identify behavioral interventions that increased condom use behaviors and/or intentions among college students. This review can be used to inform future research and interventions of the most effective theoretical constructs, study design, and components to use.

Methodology

The PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analyses) guidelines were followed when systematically searching, extracting, appraising, and synthesizing the evidence (Boland, Cherry, & Dickson, 2013; Tan & Melendez-Torres, 2016). A quality control analysis of the included studies was conducted to evaluate reliability, validity, and biases within studies using the quality assessment tool for quantitative studies provided by the Effective Public Health Practice Project (2010).

This systematic literature review used the following scholarly databases: PubMed, Scopus, and Web of Science. These databases were chosen for their wealth of scientific and social/behavioral articles. The search terms were entered as algorithms depending on the database and are presented in Table 1. The review was limited to undergraduate college students enrolled in a 4-year college or university located in the United States. Articles related to particular subgroups and special populations within the undergraduate student body were excluded, such as those enrolled in a junior college, community college, or online college, and studies focusing on specific populations, such as substance abusers or sex workers, as their results may be confounded by lifestyle differences and high-risk sexual behaviors that increase heterogeneity of results. The inclusion criteria were as follows: written in the English language, peer-reviewed, full text available, intervention focused on increasing condom use or the intention to use condoms, and papers published between January 1, 2006 and December 2016. This time frame was chosen because the review was conducted in January of 2017, and we wanted to provide contemporary articles that reflect the environmental, social, and behavioral climates that may be encountered by current and future college students.

Table 1.

Search Terms Algorithms for Each Database.

Database	Search terms
PubMed: 58 results: With the criteria published between 2006 and 2016	(“STI” [tiab] OR “ STIs” [tiab] OR “STI’s” OR “Sexually Transmitted Infections” [Mesh] OR “sexually transmitted infections” [tiab] OR “sexually transmitted infection” [tiab] OR “Sexually Transmitted Diseases”[Mesh] OR “sexually transmitted diseases”[tiab] OR “sexually transmitted disease”[tiab] OR “STD”[tiab] OR “STDs”[tiab] OR “STD’s”[tiab]) AND (“prevention” [tiab] OR “reduce” [tiab] “reduction” [tiab] OR “reducing” [tiab] OR “decreasing” [tiab] OR “decrease” [tiab] OR “decreased” [tiab]) AND (“interventions” [tiab] OR “intervention” [tiab]) AND (“college student” [tiab] OR “college students” [tiab] OR “ college” [tiab] OR “colleges” [tiab] OR “university” [tiab] OR “universities” [tiab] OR “ campus” [tiab] OR “ campuses” [tiab] OR “undergraduate students” [tiab] OR “ undergrads” [tiab] OR “undergraduate student” [tiab]) AND (“condom” [tiab] OR “condoms” [tiab] OR “condom use” [tiab] OR “ barrier” [tiab] OR “ barriers” [tiab] OR “ barrier method” [tiab] OR “sheath” [tiab] OR “ sheaths” [tiab] OR “ prophylactic” [tiab] OR “ prophylactics” [tiab] OR “safe sex” [tiab] OR “risky sex” [tiab] OR “ unprotected sex” [tiab] OR “risk” [tiab])
Scopus: 162 results: With the criteria published between 2006 and 2016	TITLE-ABS-KEY (“STI” OR “ STIs” OR “sexually transmitted infections” OR “sexually transmitted infection” OR “sexually transmitted diseases” OR “sexually transmitted disease” OR “STD” OR “STDs” OR “STD’s”) AND TITLE-ABS-KEY (“prevention” OR “reduction” OR “reducing” OR “decreasing”) AND TITLE-ABS-KEY (“interventions” OR “intervention”) AND TITLE-ABS-KEY (“college student” OR “college students” OR “ college” OR “colleges” OR “university” OR “universities” OR “ campus” OR “ campuses” OR “undergraduate students” OR “ undergrads” OR “undergraduate student”) AND TITLE-ABS-KEY (“condom” OR “condoms” OR “condom use” OR “ barrier” OR “ barriers” OR “ barrier method” OR “sheath” OR “ sheaths” OR “ prophylactic” OR “ prophylactics” OR “safe sex” OR “risky sex” OR “ unprotected sex” OR “risk”) AND PUBYEAR AFT 2006
Web of Science: 495 results: With the criteria published between 2006 and 2016	#1 ((TS= (STI* OR Sexually transmitted infection* OR STD* OR Sexually transmitted disease))) AND* LANGUAGE: (English) AND DOCUMENT TYPES: (Article) Indexes=SCI-EXPANDED, SSCI, A&HCI, ESCI Timespan=2006-2016 #2 ((TS= (prevent* OR reduc* OR decreas))) AND* LANGUAGE: (English) AND DOCUMENT TYPES: (Article) Indexes=SCI-EXPANDED, SSCI, A&HCI, ESCI Timespan=2006-2016 #3 ((TS=intervention) AND* LANGUAGE: (English) AND DOCUMENT TYPES: (Article) Indexes=SCI-EXPANDED, SSCI, A&HCI, ESCI Timespan=2006-2016 #4 ((TS= (colleg* OR college student* OR universit* OR campus* OR undergrad* OR undergraduate student))) AND* LANGUAGE: (English) AND DOCUMENT TYPES: (Article) Indexes=SCI-EXPANDED, SSCI, A&HCI, ESCI Timespan=2006-2016 #5 ((TS=(condom* OR condoms OR condom use OR barrier* OR barrier method* OR sheath* OR prophylactic* OR safe sex OR risky sex OR unprotected sex OR risk))) AND LANGUAGE:(English) AND DOCUMENT TYPES: (Article) Indexes=SCI-EXPANDED, SSCI, A&HCI, ESCI Timespan=2006-2016 #6 #5 AND #4 AND #3 AND #2 AND #1 Indexes=SCI-EXPANDED, SSCI, A&HCI, ESCI Timespan=2006-2016

The interventions included within the systematic review were those that resulted in statistically significant increases in condom use behaviors and/or intentions (e.g., self-reported condom use or intention to use condoms with future partners) among undergraduate students on a college campus. Various study designs (e.g., experimental, quasi-experimental experimental, random control, case-control) and intervention methodologies were included.

Articles were compiled and sorted with the bibliography tool RefWorks and duplicate articles were removed. Titles and abstracts were scanned based on inclusion criteria (Step 1). Articles remaining after Step 1 were read in full (Step 2) and retained if they met the inclusion criteria (Figure 1; Moher, Liberati, Tetzlaff, & Altman, 2009). Data were extracted from the articles that remained after Step 2 and are presented in Table 2, including author and title, setting, stated purpose, study population, behavioral theory, study design, incentives, and results. Last, the articles were critically appraised for study quality (selection bias, study design, data collection method, blinding, controlling for confounders, withdrawals/dropouts) and rated as strong, moderate, or weak (Effective Public Health Practice Project, 2010). Two researchers participated in Step 1, Step 2, and the quality assessment.

Figure 1.

PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analyses) flow diagram.

Table 2.

Study Summary.

Author(s) and title	Setting	States purpose	Study population	Behavioral theory	Study design	Incentive	Results
Calloway, Long-White, and Corbin (2014): Reducing the risk of human immunodeficiency virus (HIV)/AIDS in African American college students: An exploratory investigation of the efficacy of a peer educator approach	HBCU in the United States	To test the efficacy of a peer led HIV/AIDS intervention designed for African American college students	N = 129; Mean age: 18 years; Race/ethnicity; AA: 92%; Gender: Female: 79%	HBM, SCT	Experimental RCT Preassessment (beginning of semester for freshman seminar students). Peer led 4-module (50 minutes per module) HIV prevention intervention Postassessment (end of semester for freshman seminar students).	$10 gift card	After the intervention students were less embarrassed to put a condom on themselves or on their partner, were more likely to use a condom and ask their partner if they had ever been tested for HIV. There was a significant difference found in the postassessment HIV/AIDS prevention self-efficacy mean scores between the two groups. The mean difference between pre- and postassessment HIV/AIDS prevention self-efficacy scores among the intervention group was statistically significant.
Ellis, Homish, Parks, Collins, and Kiviniemi (2015): Increasing condom use by changing people’s feelings about them: An experimental study	College campus (location not stated)	To examine how experimentally manipulated affective associations with condoms influence subsequent behavior in a condom selection task, thereby providing support for causal relation of affective associations to behavior in this health domain.	N = 171; Mean age: 20.23 years; Race/ethnicity: CA: 67%, API: 15%, Hispanic: 11%, AA: 9%; Gender Female: 72%	Behavioral affective associations model	Experimental RCT • Baseline survey • Intervention: Evaluative conditioning where images of condoms paired with positive or neutral affective stimuli • Behavioral choice task (condom selection task)	$10	Participants in the positive condition reported more positive affective associations postevaluative compared with those in the neutral conditions. Among participants who regularly used condoms at baseline, those in the positive condition also selected significantly more condoms.
Helion, Reddy, Kies, Morris, and Wilson (2008): Influence of communicator’s race on efficacy or an HIV/STD prevention intervention among AA and Caucasian college students	Public University in the Midwest	To examine the influence of communicator’s race on the efficacy of intervention videos in the reduction of HIV and other sexually transmitted diseases (STDs) among African American and Caucasian college females.	N = 167; Mean age 22.44 years; Race/ethnicity CA: 53%, AA: 47%; Gender: Female: 100%	Not stated	Experimental RCT • Pretest • DVD intervention with either an AA or White model • Posttest	$3.00-$15 plus 1.5 hours of extra credit	The intervention was effective in increasing intentions to use condoms with a current partner across the follow-up period (After DVD, 2-week follow-up, 4 week follow up). There was no effect of race of communicator on any variable for African American or Caucasians.
Kiene and Barta (2006): A brief individualized computer-delivered sexual risk reduction intervention increases HIV/AIDS preventative behavior	University of Con-necticut	To report development and evaluation of a computer-delivered, theory-based, individually tailored HIV risk-reduction intervention.	N = 157; Mean age 18.86 years; Race/ethnicity: CA: 81, Latino/a: 6.4%, AA: 4.5%, Asian American:4.5%, Other: 5%, Biracial/multiracial: 8%; Gender: Female: 71.3%, Male: 28.7%	IMB	Experimental RCT • Baseline assessment • Computer delivered workshop • Follow-up assessment	Course credit	Participants who interacted with the computer-delivered HIV/AIDS risk reduction intervention exhibited a significant increase in risk reduction behavior. Specifically, participants reported a greater frequency of keeping condoms available and displayed greater condom-related knowledge at a 4-week follow-up session. Among sexually active participants, there was a significant increase in self-reported condom use.
Moore and Harris (2014): Sex is like jelly beans: Educating students on the risks of oral sex	Private Southern University	To provide a descriptive analysis of a promising IMB-based presentation that uses an innovative activity of sharing jelly beans to clarify personal risk for STIs, along with pre- and posttest results from its initial delivery.	N = 95; Mean age: 19.2 years; Race/ethnicity: C: 68.1, AA: 4.3%, Asian American: 2.9%, Other/multiracial: 14.5%; Gender: Male: 20.3%, Female: 79.7%	IMB	Quasi experimental (one group pre/post) • Pretest • Workshop • Post test	Cultural credit	Motivation to use condoms during any form of sex significantly increased after the workshop. Participants were more motivated to get tested for STIs and vaccinated for HPV post-workshop.
Norton, Fisher, Amico, Dovidio, and Johnson (2012): Relative efficacy of a pregnancy, STI/HIV prevention-focused intervention on changing sexual risk behavior among young adults	University of Con-necticut	To compare the efficacy of three separately focused but content-matched sexual risk–reduction interventions designed to increase condom use and reduce risky sexual behavior among young adults over time	N = 198; Mean age: 18.63 years; Race/ethnicity: White: 85.4%, non-White: 14.6%; Gender: Female: 69.7%, Male: 30.3%	IMB	Experimental RCT • Pre-test • Intervnetion-1 of 4 groups (pregnancy prevention, STI prevention, HIV prevention or control) • Posttest 4-week and 8-week follow-up	$10 and research credit	Participants exposed to the pregnancy or STI interventions reported greater condom use at last sexual event across follow up periods and less risky sexual behavior than those exposed to the HIV intervention or the control.
O’Grady, Wilson, and Harman (2009): Preliminary findings from a brief, peer-led safer sex intervention for college students living in residence halls	Public University in the Rocky Mountain Region	To evaluate a single-session peer-led safer sex intervention, based on the information–motivation–behavioral skills theoretical model, for college students residing in campus residence halls.	N = 108; Mean age: 18.85 years; Race/ethnicity: CA: 97.7%; Gender: Female: 63.8%, Male: 33.3%, Unknown: 2.9%	IMB	Experimental RCT • Pretest • 1-hour control session or 5 module intervention session • Posttest	Course Credit	Both the control and intervention sessions increased intentions to perform preventative behaviors (e.g., keep condoms available).

Note. HBCU = Historically Black College or University; HBM = health belief model; SCT = social cognitive theory; IMB = information, motivation and behavioral skills model; RCT = randomized control-trial; AA = African American (Black); API = Asian/Pacific Islander; CA = Caucasian American (White).

Results

Initial search results across the databases yielded 715 records (Figure 1). One article was added to the review from hand searching the references of other articles. After the removal of duplicates, a total of 621 records remained for abstract and title review. Of these, 577 were excluded based on title and abstract as they did not meet the inclusion criteria (Step 1). A total of 44 full-text articles were read and reviewed (Step 2). Articles not meeting the inclusion criteria were excluded after critical appraisal of content (Figure 1). After Step 2, a total of seven articles remained and were included in the review.

Data were extracted and are summarized in Table 2. The study designs included experimental (Calloway et al., 2014; Ellis, Homish, Parks, Collins, & Kiviniemi, 2015; Helion, Reddy, Kies, Morris, & Wilson, 2008; Kiene & Barta, 2006; Norton, Fisher, Amico, Dovidio, & Johnson, 2012; O’Grady, Wilson, & Harman, 2009) and quasi-experimental (termed quantitative approach; one group pretest–posttest study design; Moore & Harris, 2014). The number of study participants ranged from 95 to 198 (Moore & Harris, 2014; Norton et al., 2012). The mean age of study participants ranged from 18.6 to 22.2 years (Helion et al., 2008; Norton et al., 2012). All the articles included in this review increased condom use behaviors and/or intentions. Additionally, each article was read and rated based on the criteria indicators on the quality assessment tool for quantitative studies by two researchers. The global rating of each study ranged from moderate and strong. The mean outcomes of two assessors are provided in Table 3.

Table 3.

Quality Assessment of Included Articles.

Author(s)	Selection bias	Study design	Confounders	Blinding	Data collection method	Withdrawals and dropouts	Global rating
Calloway, Long-White, and Corbin (2014)	2	1	3	1	1	1.5	2
O’Grady, Wilson, and Harman (2009)	2	1	1	1.5	1	3	2
Helion, Reddy, Kies, Morris, and Wilson (2008)	1	1	1	1.5	1	1.5	1
Moore and Harris (2014)	2.5	2	N/A	N/A	1	1.5	2
Norton, Fisher, Amico, Dovidio, and Johnson (2012)	2	1	1	1.5	1.5	2	1
Kiene and Barta, (2006)	1	1	1.5	1	1.5	1	1
Ellis, Homish, Parks, Collins, and Kiviniemi (2015)	1	1	1	1.5	1.5	1	1

Note. 1 = Strong, 2 = Moderate, 3 = Weak; n = 2. N/A = not available.

Information, Motivation, and Behavioral Skills

Six of the seven articles included in this systematic review explicitly stated the behavior theory used to conceptualize the intervention, with four studies using the information, motivation, and behavioral skills (IMB) model (Kiene & Barta, 2006; Moore & Harris, 2014; Norton et al., 2012; O’Grady et al., 2009). The IMB model, proposed by Fisher and Fisher, was initially developed to guide HIV prevention interventions; however, it has been adapted for various STI and pregnancy prevention interventions (Anderson et al., 2006; Fisher & Fisher, 1992; Fisher, Fisher, Williams, & Malloy, 1994; Walsh, Senn, Scott-Sheldon, Vanable, & Carey, 2011; Zhang et al., 2011). The IMB model consists of three constructs that influence behavioral adherence: information, motivation, and behavioral skills (Fisher & Fisher, 1992). The IMB model suggests that the aforementioned are (1) key components of sexual risk behavioral change, (2) determinants of preventative behavior, (3) indicative of whether behaviors will actually be performed, and (4) needed to understand and change an individual’s health behaviors (Kiene & Barta, 2006; Moore & Harris, 2014; Norton et al., 2012; O’Grady et al., 2009). Based on this behavior theory, it can be posited that providing college students with (1) information about STIs and condoms, (2) motivation to implement STI prevention behaviors including condom use, and (3) behavioral skills, such as condom application, will result in increased condom use or intention to use condoms.

Kiene and Barta (2006) conducted a randomized control trial to study the effectiveness of an individually tailored, computer-driven intervention that incorporated all three constructs of the IMB model. To evaluate the impact of the intervention, participants were scored on condom information, attitude, social norms, behavioral intention, and behavioral skills. Additionally, behavior outcomes were evaluated, which included keeping a condom available, using a condom, and persuading their partner to use a condom. Kiene and Barta (2006) found that, unlike the control group, participants in the intervention group had a significant increase in condom information, keeping a condom available, and condom use. They concluded that the other constructs of IMB model (i.e., motivation and behavioral skills) did not change significantly because of the high baseline scores for those constructs.

Moore and Harris (2014) used a one-group, pre-/posttest to examine the effectiveness of an STI prevention workshop developed using the three constructs of the IMB model. The workshop provided information (STI transmission, STI symptoms, and oral sex), motivation (STI prevalence, condom demonstration, and partner discussion), and behavioral skills (methods of prevention and condom demonstration, STI testing methods/costs/locations, and partner discussion) training. Evaluation of the workshop focused only on the motivation construct, and participants were asked about their motivation to (1) use a condom/dental dam the next time they had oral, vaginal, and anal sex; (2) get tested for chlamydia and gonorrhea; and (3) get vaccinated for human papillomavirus (HPV). After the workshop, motivation to use a condom for all forms of sex significantly increased. Participants were also significantly more motivated to get tested for STIs and vaccinated for HPV. Information and behavioral skills were not evaluated.

Norton et al. (2012) used a randomized control trial to compare the effectiveness of three separately focused but content-matched sexual risk–reduction interventions designed to increase condom use and reduce risky sexual behavior. The three interventions were developed using all constructs of the IMB model, and the intervention foci included a (1) pregnancy prevention intervention, (2) STI prevention intervention, and (3) HIV prevention intervention. Information presented in the DVD interventions included where to obtain condoms on campus and the prevalence rates that matched the intervention type (pregnancy, STIs, HIV). The motivation component focused on attitudes and social norms around condom use and risky sexual behaviors. The behavioral skills component addressed objective skills and increasing self-efficacy regarding condom use and safer sex behaviors. Norton et al. (2012) reported only the outcome for the primary objective of condom use and risky behaviors, and they found that participants in the STI and pregnancy prevention interventions had significant increases in condom use and decreases in risky behaviors compared to the HIV prevention intervention. This indicates that the focus of the intervention affected the behavior outcomes even though the interventions were all developed using the constructs of the IMB model.

O’Grady et al. (2009) used a randomized control trial to evaluate a single-session, peer-led safer sex intervention developed based in the three constructs of the IMB model. The intervention session consisted of five modules with module one highlighting common sexual relationships and sexual situations that college students encounter; Module 2 providing information about STIs, STI prevalence on college campuses, STI transmission, and STI prevention; Module 3 focusing on motivation included attitude, intention, and subjective norms; Module 4 providing behavioral skills for safer sexual behaviors; and Module 5 presenting behavioral skills for condom use. The control session only included HIV/STIs information (similar to Module 2) followed by videos about HIV. O’Grady et al. (2009) measured information (knowledge), motivation (subjective norms and intention), and behavioral skills (perceived effectiveness and self-efficacy). They found that participants in the intervention group had significantly greater prevention knowledge, and women in the intervention group had significantly higher subjective norms for prevention behaviors. Both the control and intervention sessions increased intentions to perform preventative behaviors, such as keeping condoms available and using condoms.

Health Belief Model and Social Cognitive Theory

The health belief model (HBM) posits that human disease prevention behaviors are influenced by constructs including (1) perceived susceptibility, (2) perceived severity, (3) perceived benefits, (4) perceived barriers, (5) cues to action, and (6) self-efficacy (Green & Murphy, 2014). A person is more likely to engage in disease prevention behaviors, such as using a condom, if he or she perceives that there is a high likelihood of getting the disease and that the disease will be severe, if the perceived benefits are high and the barriers are low, if there are cues to do the behavior, and if he or she has high self-efficacy or the belief he or she can successfully perform the behavior. The social cognitive theory (SCT) postulates that constructs within the person (knowledge, self-efficacy, outcome expectations, and goals) and within the person’s environment (social and built environment) influence behavior (Bandura, 1994, 2004). One study used constructs of both the HBM and SCT to reduce risky sexual behaviors, which was evaluated through a randomized control trial. (Calloway et al., 2014). Specific components of each behavioral theory were used to create a peer-led workshop. Constructs of the HBM used in this intervention included perceived susceptibility, perceived severity, cues to action, and self-efficacy, while constructs of the SCT included knowledge, social influences, and the environment (Bandura, 1994, 2004). This workshop had four modules. The first module provided basic information about HIV/AIDS and other STIs, and the second addressed risk behaviors and social influences. The third and fourth modules focused on cues to action, self-efficacy, beliefs, and later, skill building. Participants were taught how to use a condom, how to negotiate condom use, and they were able to build skills through role play. In this study, HIV prevention self-efficacy in having discussions with a partner about intravenous drug use, condom negotiation, and HIV testing were measured (Calloway et al., 2014). After the workshop, students in the intervention group were less embarrassed to put a condom on themselves or on their partner, were more likely to use a condom, and ask their partner if they had ever been tested for HIV than the control group. Pre-/posttest in the intervention group showed a significant increase in HIV prevention self-efficacy scores.

Behavioral Affective Associations Model

The behavioral affective associations model developed by Kiviniemi and Klasko-Foster (2018) incorporates the construct of affective associations, or feelings associated with health behaviors, such as using condoms, as influencers of health decision making. Cognitive beliefs about a health behavior work together with affective associations (feelings) about the behavior to determine the likelihood of engaging in that behavior (Kiviniemi & Klasko-Foster, 2018). Ellis et al. (2015) used a randomized control trial to evaluate an intervention developed based on the behavioral affective associations models. Affective associations, or feelings, were used to influence decision making in condom selection. To do this, images of condoms were paired with positive or neutral stimuli, and then at the end of the intervention, participants selected condoms. Ellis et al. (2015) found that participants in the positive condition had a more positive association when compared to the neutral condition, and among participants who regularly used condoms at baseline, those in the positive condition also selected significantly more condoms.

No Theoretical Framework

One article did not explicitly state which behavioral theory was used (Helion et al., 2008). In their study, Helion et al. (2008) used a randomized trial to determine the effectiveness of HIV/STI prevention DVDs recorded using Black, White, or combinations of Black and White presenters. Although not stated, the intervention seems similar to those that used the IMB model including the studies by Moore and Harris (2014), Norton et al. (2012), and O’Grady et al. (2009). Similar to the three studies mentioned, the 12 topics included in the DVDs focused on information, motivation, and behavioral skills needed for condom use. HIV/STI prevention topics included STI risks and severity (information), the effectiveness and importance of condom use (motivation), and how to get and carry condoms, and partner communication (behavior). The intervention was effective for increasing intentions to use condoms with a current partner across the follow-up period (After DVD, 2-week follow-up, 4-week follow-up). The race of the presenter did not affect the outcomes.

Nonsignificant Findings

Although it was not the purpose of this article to report studies with nonsignificant findings, there were two studies that did not result in significant increases in condom use or intention to use condoms, which we thought were worth summarizing. Jackson, Ingram, Boyer, Robillard, and Huhns (2016) used constructs from the theory of reasoned action and trans-theoretical model of behavior change to develop a “Sex 101” mobile app intervention that consisted of four modules (condom use, contraceptive use, sexual partner relationships, and alcohol use). No significant differences were seen in condom self-efficacy scores or reporting of consistent condom use when comparing pre- and postintervention scores. This may be because the participants had a high base line level of condom use self-efficacy (4.27 on a 5-point scale) prior to the study. Additionally, postevaluation of the intervention was conducted 3-months postintervention. The condom use question asked about consistent condom use over the past 6 months. Three months postintervention, the answer to this question probably did not change since it was asking the participants to reflect back on the past 6 months.

Blanton, Gerrard, and McClive-Reed (2013) conducted two experimental manipulation designed studies to determine the impact of the manipulations on condom use among college students. These two studies showed mixed results. In the first study, participants were split into three groups, an information-only group that served as a control group, a coping pessimism group, and a probability optimism group. Questionnaires were given to the participants to assess the likelihood of experiencing STIs or unwanted pregnancy, and they were worded to evoke the feelings that corresponded to each of the intervention groups. In the coping pessimism group participants were asked questions that determined how they would emotionally respond to or cope with being infected by an STI or an unwanted pregnancy. While the probability optimism group was asked about their perceived likelihood for getting an STI or having an unwanted pregnancy. Those who were in the coping pessimism group reported a significantly higher likelihood of having sex without a condom than the control group, especially among those with higher self-esteem, demonstrating a boomerang effect (a reduction in a healthy behavior postintervention).

In the second study, groups were divided into 2 × 2 groups based on the following categories: (1) vulnerability focus: coping pessimism versus probability optimism and (2) self-affirmation: affirmation versus control. The participants in the affirmation group wrote a positive affirmation about what was important to them and what made them feel proud. They were then given different questionnaires depending on their group. Each group was administered the same willingness to have unprotected sex questionnaire as in Study 1. Similar to Study 1, Study 2 found that attention to coping vulnerability triggered a boomerang effect among participants (a higher willingness to have unprotected sex). However, when attention to vulnerability was combined with a self-affirmation exercise, a greater commitment to using condoms was observed.

Discussion

Studies identified in this systematic review used multiple constructs of behavior theories to develop successful interventions to increase condom use among college students. Four of the interventions were developed using all three constructs of the IMB model, and all four found significant increases in condom use or condom use intentions. Interventions that provided information about STIs/pregnancy prevention, motivated participants by changing social norms and attitudes concerning condom use, and provided behavioral skills training, such as how to use a condom or negotiate use with a partner, were effective. However, it was noted that the focus of the intervention can impact its success. Norton et al. (2012) found that interventions focused on STI and pregnancy prevention were successful for increasing condom use while the intervention focused on HIV was not. They hypothesized that this finding was due to students being more concerned about STIs and pregnancy than HIV because STIs and pregnancy are more prevalent among this group. Because STIs and pregnancy are more prevalent, the students may perceive that they are more susceptible to them, which, in turn, may motivate the students to use condoms as a means of prevention. Although this intervention was based on the IMB model, this idea of perceived susceptibility also is a construct of the HBM.

Regardless of the behavior theory, interventions developed using multiple behavior theory constructs and modules that increased self-efficacy for condom use, taught participants where to get condoms and how to negotiate condom use with partners, established positive social norms toward condom use, and elicited positive associations (attitudes and feels) toward condoms saw increased condom use or intention to use condoms. Only providing information about the importance of condom use is not enough. Interventions must also target motivation, feelings, and skills (self-efficacy) to elicit behavior change.

Based on our findings, future researchers have several different intervention designs to choose from when developing an intervention to increase condom use. Interventions that used peer-educators to provide training through peer-led workshops were effective (Calloway et al., 2014; O’Grady et al., 2009) as were multimodular DVD trainings (Helion et al., 2008; Norton et al., 2012). Additionally, an individually tailored, computer-driven intervention that provided participants with only the information that they needed was effective for increasing condom information, availability, and use (Kiene & Barta, 2006).

Limitations

As with any study, limitations were identified in all the studies and in this review. There were significant concerns about overall generalizability of the studies reviewed, due to small sample sizes and lack of gender and racial diversity. Other limitations included lack of long-term follow-up, no lag time between intervention and follow-up, and inability to assess condom use behaviors. All the articles used self-reported data through questionnaires, assessments, pretest or posttest designs. Self-reported information is subject to inherent biases, such as social desirability bias.

There were also limitations encountered during this systematic review. The researchers selected databases that had a high likelihood of indexing articles relevant to the purpose of the study; however, some articles may have been missed because only three databases were used in the search, and potentially relevant gray literature and non–peer-reviewed articles were not included. Although all members of the research team and the university’s health sciences librarian contributed to a substantive list of search terms, this list may not have been exhaustive, potentially resulting in missed articles. The researchers also agreed on inclusion/exclusion criteria that aligned with the study purpose; however, these many have been too restrictive, leading to missed articles. Although the review of potential articles and quality assessment was conducted by two researchers, there is still the chance that articles may have been missed (Adams, Soumerai, Lomas, & Ross-Degnan, 1999). Additionally, there was the potential for researcher error in assessing the validity of the studies. Each article had its own limitations and potential biases and lack of external validity. Last, there were relatively few studies found in this review, and there was a lack of quantitative data.

Implications for Practice

Typical college students in the United States are among the age-group most affected by STIs. However, only half of the sexually active undergraduate college students report consistent condom use, and studies have found that consistent condom use decreases as students matriculate. Each of the articles included in this review used behavioral interventions that mitigated the risk of STIs and highlighted strategies that were effective for increasing condom use or intention to use condoms. Constructs of the IMB model can be particularly helpful in developing effective interventions with a behavioral skills component that focuses on practical skills such as condom application and use, negotiation and communication skills, which seek to build self-efficacy. In developing future interventions, use of technology and peer-educators for delivery of interventions should be considered as these were successful. Interventions reported in this review were also effective for decreasing some of the unique barriers to condom use among college students, particularly increasing the likelihood of having a condom accessible and increasing self-efficacy for using a condom and negotiating condom use with a partner. Additionally, this article provides a benefit for health care providers, as it presents a streamlined, comprehensive review that they can use to quickly understand the scope of the recent literature surrounding the topic.

Similar to previous systematic reviews that focused on intervention types such as social marketing or social networks, this review found significant increases in condom use with behavioral interventions (Sweat et al., 2012; Wang et al., 2011). However, similar to the other reviews, there were a limited number of studies identified in this review. The limited number of studies found in ours and other systematic reviews highlights the need for more evidence based, intervention studies to understand intervention components and theoretical constructs that increase condom use among college students. Because condoms are an effective way to prevent the spread of STIs among sexually active college students (when a vaccine is not available), these findings indicate that interventions to increase condom use among college students may result in a decrease in STIs among this subgroup of young adults (Lazarus et al., 2010).

Footnotes

Acknowledgements

The authors wish to acknowledge Ms. Xan Goodman, the Health Sciences Librarian at the University of Nevada, for her help in suggesting search terminology and more efficient ways to search databases.

Authors’ Note

This study was deemed exempt by the University of Nevada, Las Vegas Institutional Review Board as it was a systematic review.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Jennifer R. Pharr

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