ORIGINAL STUDY

Type of Primary Education Is Associated With Condom

Use at Sexual Debut Among Chilean Adolescents
Andrea Huneeus, MD, MPH,* Julianna Deardorff, PhD, Maureen Lahiff, PhD,
and Sylvia Guendelman, PhD
Background: Although condom use in adolescence is related to higher
lifetime educational attainment, the association between primary education (from kindergarten to eighth grade) and adolescent sexual behavior
is not well understood. This study examined the association between type
of school in which primary education was completedVpublic, charter, or
privateVand condom use at sexual debut among Chilean adolescents.
Methods: Drawing on the 2009 Chilean National Youth Survey, a
population-based sample of general community youth aged 15 to 29 years,
we conducted a study of the 4217 participants who reported onset of sexual activity during adolescence. Bivariate and multple logistic regression
was used to examine the relationship between type of primary school
attended (60.1% public, 30.3% charter, and 9.6% private) and condom use
at sexual debut while controlling for sociodemographic characteristics
and sexual behavior.
Results: Compared with students who completed their primary education in private or charter schools, students who completed their primary education in public schools had 1.85 (95% confidence interval,
1.12Y3.04) and 1.67 (95% confidence interval, 1.26Y2.23) higher odds,
respectively, of not using condoms at sexual debut. Odds were similar
for students living in urban settings, whereas there were too few students
attending private schools in rural areas to allow meaningful estimates.
Conclusions: Independent of household income, primary schooling is
associated with sexual health behaviors among Chilean adolescents living
in urban areas and can serve as a target for public health interventions
designed to prevent sexually transmitted infections in adolescence.

ixty percent of all sexually transmitted infections (STIs)

worldwide occur in adolescents and young adults between
14 and 24 years of age.1,2 Condom use is associated with significant protection from multiple STIs.3 Adolescents who do not
use condoms at sexual debut are less likely to engage in subsequent protective behaviors and experience more infections;
therefore, condom use at sexual debut is a good proxy for STI
From the *Department of Obstetrics and Gynecology, Clnica Alemana de
Santiago, Universidad del Desarrollo, Chile; Maternal Child Health
Program, School of Public Health, University of California, Berkeley;
and Division of Biostatistics, School of Public Health, University of
California, Berkeley

All authors have stated no conicts of interest. There is no afliation,

nancial agreement, or other involvement of any author with any
company or other organization with a nancial interest in the subject
matter in the submitted manuscript
This research was conducted while the rst author was a student in the
Maternal and Child Health Program at the School of Public Health
at UC Berkeley. The Chilean National Scientic Research Committee
(CONICYT) and Clnica Alemana de Santiago, Chile, funded the
scholarship for the program but did not have any role in the design
of the study.
Correspondence: Andrea Huneeus, MD, MPH, Department of Obstetrics
and Gynecology, Clnica Alemana of Santiago, Vitacura 5951, Piso
14, Santiago, Chile. E-mail: ahuneeus@alemana.cl.
Received for publication August 19, 2013, and accepted March 3, 2014.
DOI: 10.1097/OLQ.0000000000000122
Copyright * 2014 American Sexually Transmitted Diseases Association
All rights reserved.

306

risk in adolescence.4,5 Sexually transmitted infections have numerous lifelong health consequences, which can prove more deleterious for females than males, and include infertility, cervical
cancer, pelvic inflammatory disease, or STI transmission from
mother to child during childbirth.1,2 However, many teens initiate
sex using condoms inappropriately or not using them at all.6,7
Female adolescents, especially, seem to be at risk for STIs, in part,
because of their inability to negotiate condom use with males.6,8,9
Education is an important structural determinant of sexual health. Educational attainment, the highest degree of education an individual has completed, is a known protective factor
against vulnerability to STIs and condom use.10,11 As educational
attainment increases, rates of STI diagnoses decline.12,13 High
school performance also influences sexual health.10 Academic
difficulties and lower grades in high school are associated with
not using condoms at sexual debut.14,15 Higher high school grades
have been associated with fewer STI diagnoses.16 Furthermore,
youth who drop out of high school are less likely to use condoms
and are more likely to have STIs compared with those who stay
in school.17 Evidence further shows that adolescents who attend
private schools are more likely to use condoms and less likely to
report STIs than adolescents who attend public schools.18Y20
The extent to which there is a link between the types of
school attended before adolescence (i.e., primary school) and
sexual risk behavior during adolescence has not been examined.
Chiles universal primary kindergarten through eighth grade
educational system offers an ideal opportunity to examine these
issues because the law that mandated sex education in schools was
enacted in 2010, so differentials observed in sexual risk-taking
behaviors by school types before this time are not confounded
by school-based sex education.21
The Chilean educational system comprises 3 sectors: free
public schools that are widespread throughout the country and serve
53% of students; subsidized charter schools that are privately run,
share limited financing with families, are free to establish admission policies, and serve 40% of students; and private schools that
serve an additional 7% of students. Public schools serve mostly
lower and lower middle-class students; charter schools are predominant among middle and upper middle-class students; private
institutions charge high tuition and therefore attract the Chilean
economic elite.22,23 Not surprisingly, there is a generalized concern
about the educational inequalities linked to a students economic
resources because substantial differences in academic performance
exist across sectors in terms of standardized test scores. All students take a yearly standardized test of math, language, and science
in fourth and eighth grades. Test results show that, on average,
charter schools score 12% lower than private schools and public
schools score 20% lower than private schools.24
The aim of this population-based study was to examine
whether primary education is associated with sexual health. We
examined the association between having attended public, charter,
or private primary schools and condom use at sexual debut
among Chilean adolescents. We hypothesized that students, independent of their socioeconomic status (SES), who completed their

Sexually Transmitted Diseases

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Condom Use at Sexual Debut in Chilean Adolescents

kindergarten through eighth grade education in public schools

would be less likely to use condoms at sexual debut than students
who completed primary education in charter or private schools.

MATERIALS AND METHODS

Sample
Data were drawn from the 2009 Chilean National Youth
Survey.25 This survey used a multistage probability sampling
design to select participants who were representative of Chilean
youth aged 15 to 29 years. Census estimates indicated that there
were 4,024,452 adolescents in this age group. After stratifying by
region and urban/rural residence, a complex sampling approach
was used to randomly select households, and 1 eligible individual
from each household was selected to complete an in-person home
interview. Questions regarding sexual behavior were read and
answered by the participant in a private room. Of the 7570 participants who answered the survey, 4319 reported onset of sexual
activity between the ages of 10 and 18 years and were initially
included in the study sample. After excluding individuals who
had experienced sexual abuse during sexual debut (n = 31), which
were missing data on primary education (n = 39), or on contraceptive use at sexual debut (n = 32), our analytic sample consisted
of 4217 participants.

Measures
The outcome of interestVcondom use at sexual debutVwas
obtained from 2 survey questions: Was any method of protection used at first intercourse? Participants who answered yes
were asked: What method of protection did you use during

sexual debut? Respondents could select 1 or more options including condoms.

The key independent variable was type of primary school
attended by each participant. The survey question In what type
of school did you complete your primary education? was answered: public, charter, or private, by 99.2% of the survey respondents, reflecting the universality of the Chilean primary
education system.
The potential confounders considered a priori were demographic characteristics (gender, age at survey, SES, urban/rural
residence, and Catholic religion) and sexual behaviors at the
time of sexual debut (age of sexual debut, whether the encounter
involved a romantic or a casual partner, and whether the age
difference with the partner was G3 years or Q3 years more). Age
at survey was categorized into 3 groups: 15 to 19, 20 to 25, and
26 to 29 years. Social class (low, middle, and high SES) was
defined in the survey according to the World Association Market
Research classification and is based on the highest level of educational attainment obtained in the household and type of employment of the main provider.26 For participants who had a
non-economically active provider, a scale of assets was used that
included car, computer, microwave oven, hot shower, and cable
TV. Religion was assessed using 2 survey questions: Do you
identify with any religion? and To what religion do you identify? Participants were dichotomized as being Catholic or not.

Statistical Analysis
All analyses were weighted to reflect a nationally representative sample using survey estimation commands in Stata
version 12.1 that account for complex study design.27

TABLE 1.

Sociodemographic and Sexual Behavior Characteristics of Chileans 15 to 29 Years Old With Sexual Debut in Adolescence
by Type of Primary Schooling* (2009)

Private
Characteristic
Sociodemographic
Gender
Male
Female
SES
High
Medium
Low
Urban/Rural
Urban
Rural
Catholic religion
Yes
No
Sexual behavior
Age of sexual debut
10Y13
14Y16
17Y18
Romantic or casual 1st partner
Romantic
Casual
Age difference with 1st partner
G3
Q3

Charter

Public

Weighted
Percents

Weighted %

Weighted %

Paired
Comparisons

144
111

(64.9)
(35.1)

542
558

(54.7)
(45.3)

1329
1533

(51.8)
(48.2)

0.004

66
144
45

(31.0)
(56.9)
(12.1)

77
680
343

(7.3)
(65.9)
(26.8)

71
1271
1520

(2.8)
(48.1)
(49.1)

G0.001

244
11

(98.2)
(1.8)

1004
96

(94.0)
(6.0)

2269
593

(81.9)
(18.1)

G0.001

101
154

(36.1)
(63.9)

502
586

(44)
(56)

1391
1450

(45)
(55)

0.080

18
121
116

(7.5)
(38.2)
(54.3)

58
556
476

(4.6)
(50.0)
(45.5)

194
1535
1133

(7.2)
(50.5)
(42.3)

0.006

222
32

(84.7)
(15.3)

937
160

(84.5)
(15.5)

2436
415

(84.0)
(16.0)

0.950

183
70

(75.1)
(24.8)

752
328

(70.7)
(29.3)

1825
953

(65.3)
(32.1)

0.008

*Primary schooling from kindergarten to eighth grade.

Significant difference between private and charter.

Significant difference between private and public.

Significant difference between public and charter.

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Huneeus et al.

Bivariate analysis using Rao-Scott adjustment for W2 test

on weighted samples was used to examine the association between the type of primary schooling and the sociodemographic
and sexual behavior covariates and condom use.27 A multiple logistic regression was then used to examine the association between
type of primary schooling and condom use at sexual debut while
controlling for covariates.
All covariates were retained for the multiple logistic models
because they had a P value smaller than 0.2 and changed the main
outcome coefficient by more than 10%. Age of sexual debut
was modeled as a categorical variable because lowess plots of
log odds were not linear or quadratic. The nine participants who
were 10 years old did not use condoms and were excluded from the
models because of a serious concern of unrevealed sexual abuse
where no volition for condom use exists.
Demographic characteristicsVgender, SES, and Catholic
religionVwere identified in the literature as variables that may
modify the association between type of primary schooling and
condom use at sexual debut. Wald tests were performed using
cross products of sex, SES, Catholic religion, and type of primary
education in restricted versus full models. Only interaction terms
for Catholic religion were significant (P 9 0.10) and were retained
in the final model.

RESULTS
Sixty percent of the participants had attended a public
primary school; 30.3%, a charter primary school; and 9.6%, a
private primary school. As shown in Table 1, private school attendees were more likely than charter or public school attendees

to be males, have a higher SES, and have urban residence. They

were also less likely to identify as Catholic compared with public
school attendees. Compared with public school attendees, charter
school attendees were more likely to have a higher SES and an
urban residence. Regarding sexual debut characteristics, private
school attendees were more likely than both public and charter
school attendees to be older at sexual debut. Across types of primary schools, there were no differences in whether the first sexual partner was romantic or casual. Public school attendees were
more likely than private and charter school attendees to debut with
a partner with an age difference of 3 or more years.
Although condoms were used at sexual debut by 60% of
participants who had attended private schools, only 52% and
37% of those who had attended charter schools and public schools,
respectively, used a condom at sexual initiation (P G 0.001; data
not shown). Condom use was higher among males than females,
among those who were 15 to 19 years old at the time of responding
to the survey, among those who had higher SES, and among those
who resided in urban centers (Table 2). There were no differences
in condom use by Catholic identification. Although condom use
increased with age of sexual debut, overall, condoms were used less
than 50% of the time at sexual debut in all age groups. Furthermore,
condom use at sexual debut was more likely among adolescents
engaging in sex with a romantic partner than with a casual partner
and among those who had an age difference less than 3 years.
Results from multiple logistic regression analyses (Table 3)
showed that, when adjusting for key covariates including SES,
participants who completed their education in public schools
had 1.85 (95% confidence interval [CI], 1.12Y3.04) higher odds of

TABLE 2. Sociodemographic and Sexual Behavior Characteristics of Chileans 15 to 29 Years Old With Sexual Debut in Adolescence by
Condom use in Sexual Debut (2009)
Condom Use
Yes
Characteristic
Sociodemographic:
Gender
Male
Female
Age
15Y19
20Y24
25Y29
SES
High
Medium
Low
Urban/Rural
Urban
Rural
Catholic religion
Yes
No
Sexual behavior
Age of sexual debut
10Y13
14Y16
17Y18
Romantic or casual 1st partner
Romantic
Casual
Age difference with 1st partner
G3
Q3

308

No

Weighted %

Weighted %

1011
871

(49.4)
(37.1)

1004
1331

(50.6)
(62.9)

G0.001

863
710
309

(53.7)
(45.6)
(33.7)

755
897
683

(46.3)
(54.5)
(56.2)

G0.001

140
1028
714

(71.3)
(46.5)
(43.8)

74
1067
1194

(28.7)
(53.5)
(56.2)

G0.001

1625
257

(45.1)
(34.5)

1892
443

(54.9)
(65.5)

G0.001

898
971

(43.6)
(43.9)

1096
1219

(56.4)
(56.1)

0.88

66
967
849

(25.5)
(41.6)
(48.8)

204
1255
876

(74.5)
(58.4)
(51.2)

G0.001

1669
208

(46.0)
(32.2)

1926
399

(54.0)
(67.8)

G0.001

1347
495

(48.4)
(34.2)

1413
856

(51.6)
(65.8)

G0.001

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Condom Use at Sexual Debut in Chilean Adolescents

TABLE 3.

Odds of No Condom Use at Sexual Debut by Type

of Primary Schooling From Logistic Regression Models in Chileans
15 to 29 Years Old With Sexual Debut in Adolescence (2009)

Characteristic
Type of school
Public vs. private
Public vs. charter
Private vs. charter
Sociodemographic
Gender
Male
Female
Age at survey
15Y19
20Y24
25Y29
SES
High
Medium
Low
Urban rural residence
Urban
Rural
Catholic religion
Yes
No
Sexual debut behavior
Age
11
12
13
14
15
16
17
18
Type of partner
Romantic
Casual
Age difference, y
G3
Q3

Crude
Odds
Ratio

95%
CI

Adjusted
Odds
Ratio*

95%
CI

2.50
1.82
1.37

1.78Y3.51
1.50Y2.20
0.96Y1.97

1.85
1.67
1.02

1.12Y3.04
1.26Y2.23
0.66Y1.85

DISCUSSION
Reference
1.97
1.60Y2.42
Reference
1.72
1.40Y2.12
2.99
2.34Y3.83
Reference
2.47
1.61Y3.78
3.49
2.24Y5.45
Reference
1.22
0.94Y1.58
Reference
0.82
0.78Y1.16
26.94
7.43
2.76
2.23
1.87
1.47
1.30
Reference

3.01Y241.8
2.70Y20.44
1.60Y4.78
1.57Y3.17
1.36Y2.56
1.09Y1.98
0.97Y1.75

Reference
1.85
1.38Y2.48
Reference
1.16
0.94Y1.43

*Controlling for gender, age at survey, SES, urban/rural, Catholic religion, age of sexual debut, casual or romantic first partner, and age difference with first partner.

not using condoms at sexual debut compared with participants

who completed primary education in a private school and 1.67
(95% CI, 1.26Y2.23) higher odds compared with participants
who completed primary education in charter schools. Participants
who attended charter schools did not differ in condom use with
participants from private schools. Because there were few participants living in rural areas that attended private schools and/or
had high SES, we further restricted the analysis to the 3383 urban
participants. Compared with urban students who completed their
primary education in private or charter schools, urban students
who completed their primary education in public schools had 1.56
(95% CI, 1.06Y2.30) and 1.56 (95% CI, 1.25Y1.96) higher odds,
respectively, of not using condoms at sexual debut. Urban participants who attended charter school also did not differ in condom
use with urban participants form private schools.
Females had 1.97 (95% CI, 1.60Y2.42) higher odds than
males of not using a condom at sexual debut. Participants who
were older at the time of the survey had lower SES, reported a
Sexually Transmitted Diseases

younger age at sexual debut, and had their first sexual encounter
with a casual partner had increased odds of not using condoms
at sexual debut (Table 3).
There was a significant interaction between Catholic identification and type of primary school attended with condom use at
sexual debut (P = 0.0014). Non-Catholic private school attendees
were more likely to use condoms at sexual debut than Catholic
private school attendees (Fig. 1). This was not the case for charter
and public school attendees for whom Catholic identification was
not associated with condom use.

&

In this population-based study of Chilean adolescents, we

found that less than half of the youth reported using condoms
at sexual debut. Although this study corroborates evidence that
condom use is strongly associated with SES, our findings underscore the relationship between primary education and sexual behaviors independently of SES. We found that students who
completed their primary education in public schools were less
likely to use condoms at sexual debut than those who completed
their primary education in private or charter schools. These disparities persisted after controlling for sociodemographic and sexual behavior characteristics at the time of sexual debut. Because
there were few respondents living in rural areas who had attended
private primary schools and/or were affluent, our findings may
only be generalizable to urban Chilean youth. Neither gender nor
SES modified the association between type of primary education
and condom use, which suggests that this association operates
similarly for males and females and across varying social classes.
Previous studies have reported an association between
education and adolescent condom use and STIs; however, most
assessed educational status during adolescence14Y20 or after high
school.12,13 To our knowledge, this is the first study to examine
an educational measure before adolescence and before the onset
of sexual activity. Our findings suggest the importance of focusing upstream and prompt future studies to test the hypothesis
that primary education is associated with sexual behaviors.
What might explain the association between type of primary school (whether private, charter, or public) and condom
use at sexual debut? A potential pathway lies in the quality of
education, which may differ by school type. Students who receive
a higher-quality education are more likely to have higher educational aspirations, which in turn might influence their perceptions of
the cost of risky sexual behaviors.10,28 Moreover, it is possible that
higher quality schools equip students with more tools to acquire
knowledge and skills to negotiate condom use and prevent STIs.19
The role of quality of education on sexual behaviors has not received sufficient attention and merits further research.

Figure 1. Stratied analysis of condom use at sexual

debut by Catholic identication in types of primary
schools in Chileans 15 to 29 years old with sexual debut
in adolescence (2009).

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Huneeus et al.

Other risk factors for not using condoms at sexual debut

were being female, belonging to the older cohorts of youth, lower
SES, and being younger and having a casual partner at sexual
debut. Our results corroborate previous studies showing that males
use condoms more than females.6,8,20 This could be explained by
less condom inhibition, more effective condom negotiation practices, and the fact that condoms are ultimately under physical
control of the male partner. The striking magnitude of the sex
differences reported here, where females report 96% less condom
use than males at sexual debut, requires further investigation.
The finding that older participants were less likely to use
condom at sexual debut, a birth cohort effect, reflects a worldwide
trend that has been attributed to the success of condom education
among newer generations.6,8,25 Since 1991, the Chilean Ministry
of Health has undertaken yearly HIV prevention media communication campaigns that include TV, radio, street signs, and volunteers to raise awareness of HIV risk and disseminate sexual
transmission prevention strategies like condom use. Socioeconomic status inequality in condom use could be strongly affected
by economic access. Chile does not distribute free condoms in
schools, and the average price of a condom is as expensive as
US$1. In our sample, 14% of the condoms used at sexual debut
were provided by health clinics, and the remaining 86% were
bought in drugstores.25 The younger the age adolescents experience sexual debut, the less likely they are to use condoms, especially if younger than 14 years. This underscores the extremely
vulnerable conditions in which sexual encounters with minors
occur.6,13 Furthermore, sexual debut with a casual partner may
account for lower condom use due to lack of planning.8,17
Although the Chilean school system may not be generalizable to other settings, many countries (including the United
States) have introduced charter schools in addition to having
open access public schools and paid private schools. We had
no information whether participants attended a religious school.
By law, no public school can impart religious education, and
37% of private and charter schools in Chile are Catholic.29 We
found that Catholic identification was associated with lower
condom use only in private schools. This finding suggests that
Catholic students in private schools might be exposed to more
abstinence only messages, which may inhibit condom use and
negotiation practices at the time of sexual debut.
Our study had several limitations. In this cross-sectional
study, causality cannot be established. There was limited SES variability within school settings, and few rural students attended private schools, which might reflect selection bias. Because SES was
measured at the time of the survey, misclassification may have occurred if participants changed their SES status after leaving their
parental home. Self-reported measures of the exposure and outcome reflect recall of such events by participants. Nonetheless,
sexual debut is likely to be a salient experience, which is usually
recalled accurately.7 Study participants may have overestimated
condom use because of social desirability bias. However, students
answered questions about sexual behaviors in private, therefore
ensuring confidentiality and reducing bias. Unmeasured covariates like parental and family factors could affect the observed
differences. We lacked information on the number of students
who may have switched between types of schools during their
primary schooling years. Estimates from other studies, however,
show that the number of switchers is low (5%Y7%).23
Our study has several strengths. Data were drawn from a
large population-based survey conducted in 2009. A unique
natural experiment allowed us to examine the association between primary school type and sexual health before the implementation of sex education curricula in 2010. It is unlikely that
schools were providing sex education before the mandate.

310

Describing the association between the type of primary

school and condom use in sexual debut is an important step in
identifying structural determinants of health that impact adolescent condom use. Public health STI interventions should be
combined with larger efforts tailored to address structural factors that are associated with protective sexual health behaviors,
such as condom use. One way in which this prevention might be
accomplished is by improving the quality of primary education.
Further prospective research using quasi-experimental methods
or randomized controlled designs (perhaps through lottery
methods to offer charter schooling) is needed to determine
whether type of primary school education affects sexual behaviors as well as other health-related outcomes in adolescence,
such as teenage pregnancy and drug or alcohol use, and if so,
whether these effects can be modified by offering higher educational quality to lower SES youths. It is worth considering that
by optimizing primary education, we might achieve improvements in youth health.
REFERENCES
1. Shrier L. Sexually transmitted infections: Chlamydia, gonorrhea,
pelvic inflammatory disease, and syphilis. In: Emans SJ, Laufer
MR, Goldstein DP, eds. Pediatric and Adolescent Gynecology.
Philadelphia, PA: Lippincott Williams & Wilkins, 2012: Kindle
Location 12667.
2. CDC. STD Surveillance, 2010. CDC Web site. Available at: http://
www.cdc.gov/std/stats10/. Accessed August 16, 2013.
3. Holmes KK, Levine R, Weaver M. Effectiveness of condoms in
preventing sexually transmitted infections. Bull World Health Organ 2004; 82:454Y461.
4. Shafii T, Stovel K, Holmes K. Association between condom use at
sexual debut and subsequent sexual trajectories: A longitudinal
study using biomarkers. Am J Public Health 2007; 97:1090Y1095.
5. Shafii T, Stovel K, Davis R, et al. Is condom use habit forming?
Condom use at sexual debut and subsequent condom use. Sex Transm
Dis 2004; 31:366Y372.
6. Centers for Disease Control and Prevention (CDC). Trends in HIV- and
STD-related risk behaviors among high school studentsVUnited States,
1991Y2007. MMWR Morb Mortal Wkly Rep 2008; 57:817Y822.
7. Gebhardt W, Kuyper L, Dusseldorp E. Condom use at first intercourse with a new partner in female adolescents and young adults:
the role of cognitive planning and motives for having sex. Arch Sex
Behav 2006; 35:213Y219.
8. Feldman BS, Shtarkshall RA, Ankol OE, et al. Diminishing gender
differences in condom use among a national sample of young Israeli
men and women between 1993 and 2005. J Adolesc Health 2012;
50:311Y314.
9. Tschann JM, Flores E, de Groat CL, et al. Condom negotiation
strategies and actual condom use among Latino youth. J Adolesc
Health 2010; 47:254Y262.
10. Bradley BJ, Greene AC. Do health and education agencies in the
United States share responsibility for academic achievement and
health? A review of 25 years of evidence about the relationship of
adolescents academic achievement and health behaviors. J Adolesc
Health 2013; 52:523Y532.
11. Zuilkowski SS, Jukes MH. The impact of education on sexual
behavior in sub-Saharan Africa: A review of the evidence. AIDS
Care 2012; 24:562Y576.
12. Painter JE, Wingood GM, Di Clemente RJ, et al. College graduation reduces vulnerability to STIs/HIV among African-American
young adult women. Womens Health Issues 2012;22:e303Ye310.
13. Annang L, Walsemann KM, Maitra D, et al. Does education matter?
Examining racial differences in the association between education and STI diagnosis among black and white young adult females
in the U.S. Public Health Rep 2010; 125(suppl 4):110Y121.
14. Marsiglio W. Adolescent males orientation toward paternity and
contraception. Fam Plann Perspecti 1993; 25:22Y31.

Sexually Transmitted Diseases

&

Volume 41, Number 5, May 2014

Copyright 2014 by the American Sexually Transmitted Diseases Association. Unauthorized reproduction of this article is prohibited.

Condom Use at Sexual Debut in Chilean Adolescents

15. Doljanac RF, Zimmerman MA. Psychosocial factors and high-risk

sexual behavior: race differences among urban adolescents. J Behav
Med 1998; 21:451Y467.
16. Ford CA, Pence BW, Miller WC, et al. Predicting adolescents
longitudinal risk for sexually transmitted infection: Results from the
National Longitudinal Study of Adolescent Health. Arch Pediatr
Adolesc Med 2005; 159:657Y664.
17. Crosby RA, DiClemente RJ, Wingood GM, et al. The protective
value of school enrolment against sexually transmitted disease: A
study of high-risk African American adolescent females. Sex
Transm Infect 2007; 83:223Y227.
18. Upchurch DM, Mason WM, Kusunoki Y, et al. Social and behavioral determinants of self-reported STD Among adolescents.
Perspect Sex Reprod Health 2004; 36:276Y287.
19. Martins LB, da Costa-Paiva LH, Osis MJ, et al. Factors associated
with condom use and knowledge about STD/AIDS among teenagers in public and private schools in Sao Paulo, Brazil. Cad Saude
Publica 2006; 22:315Y323.
20. Oliveira-Campos M, Giatti L, Malta D, et al. Contextual factors
associated with sexual behavior among Brazilian adolescents [published online ahead of print]. Ann Epidemiol 2013 doi:10.1016/j.
annepidem.2013.03.009.
21. Chilean Law 20418 January 28, 2010. Chilean Congresss Library Web
site. Available at: http://www.leychile.cl/Navegar?idNorma=1010482.
Accessed August 16, 2013.

Sexually Transmitted Diseases

&

22. Mizala A, Torch F. School discipline in Chile. In: Arum R, Velez M,

eds. Improving Learning Environments: School Discipline and
Student Achievement in Comparative Perspective. Stanford, CA:
Stanford University Press, 2012:74Y103.
23. Raczynski D, Munoz G. Reforma Educacional Chilena: El Dificil
Equilibrio entre la Macro y la Micro Poltica. REICE 2007; 5:40Y83.
24. Chilean Standarized Test Results (SIMCE) 2010. Chileans Educational
Quality Agency Web site. Available at: http://www.agenciaeducacion.cl/
simce/resultados-simce/. Accessed August 16, 2013.
25. 2009 Chilean Youth Survey. Chilean Youth Institute Web site.
Available at: http://www.injuv.gob.cl/portal/wp-content/files_mf/
sextaencuestanacionaldejuventud.pdf. Accessed August 16, 2013.
26. Mendez R. World Association of Market Research Measurement for
Socioeconomic Status in Chile. Chilena Market Research Web site.
Available at http://www.microweb.cl/idm/documentos/ESOMAR.pdf.
Accessed August 16, 2013.
27. STATA 12.1. [computer program] Version 12.1. College Station
TX. StataCorp LP.
28. Harris KM, Duncan GJ, Boisjoly J. Evaluating the role of nothing
to lose attitudes on risky behavior in adolescence. Soc Forces
2002; 80:1005Y1039.
29. Passalacqua AL. Statistics of Chilean Catholic Education. Chilean
Observatory of Educational Policy Web site. Available at: http://
www.opech.cl/bibliografico/Doc_Financiamiento/cuantos_somos_
como_lo_hacemos.pdf. Accessed August 16, 2013.

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