Condom-use errors and problems: A neglected aspect of studies assessing condom effectiveness

doi:10.1016/S0749-3797(03)00015-1

American Journal of Preventive Medicine

Volume 24, Issue 4, May 2003, Pages 367-370

https://doi.org/10.1016/S0749-3797(03)00015-1 Get rights and content

Abstract

Objective

To assess and compare condom-use errors and problems among condom-using university males and females.

Methods

A convenience sample of 260 undergraduates was utilized. Males (n=118) and females (n=142) reported using condoms in the past 3 months for at least one episode of sex (penis in the mouth, vagina, or rectum) with a partner of the other sex. A questionnaire assessed 15 errors and problems associated with condom use that could be observed or experienced by females as well as males.

Results

About 44% reported lack of condom availability. Errors that could contribute to failure included using sharp instruments to open condom packages (11%), storing condoms in wallets (19%), and not using a new condom when switching from one form of sex to another (83%). Thirty-eight percent reported that condoms were applied after sex had begun, and nearly 14% indicated they removed condoms before sex was concluded. Problems included loss of erection during condom application (15%) or during sex (10%). About 28% reported that condoms had either slipped off or broken. Nearly 19% perceived, at least once, that their condom problems necessitated the use of a new condom. Few differences were observed in errors and problems between males and females.

Conclusions

Findings suggest that condom-use errors and problems may be quite common and that assessment of errors and problems do not necessarily need to be gender specific. Findings also suggest that correcting “user failure” may represent an important challenge in the practice of preventive medicine.

Introduction

R ecently the U.S. Department of Health and Human Services issued a review regarding the effectiveness of male condoms for the prevention of sexually transmitted infections (STIs).1 Although the report noted the existence of strong evidence suggesting that condoms prevent transmission of the human immunodeficiency virus and female-to-male transmission of gonorrhea, it concluded that evidence was insufficient to evaluate the effectiveness of condoms against chlamydia, syphilis, chancroid, trichomoniasis, genital herpes, and human papillomavirus. One important recommendation called for substantially more research addressing condom effectiveness against STIs.

To test hypotheses about condom effectiveness, several design issues must be addressed: measurement of condom use, protocols for establishing infection-free cohorts, and measurement of incident infections. A neglected issue is whether study participants reporting condom use actually used condoms correctly.2, 3, 4 For example, a recent clinic-based study of women suggested that condom failure was primarily a function of user errors.5 Other clinic-based investigations of condom use errors and problems have been reported4, 5, 6, 7; however, it is important to acknowledge that studies of persons attending clinics may not generalize to the majority of condom users. Although two studies investigating condom-use errors and problems sampled university undergraduates, each included only males.8, 9

To date, studies have not been published that report condom-use errors and problems in a nonclinic male and female sample. Given that questions about condom effectiveness apply to both males and females, studies that address similarities (or differences) in condom errors and problems between males and females are warranted. Accordingly, this study assessed and compared the occurrence of condom use errors and problems among a sample of condom-using males and females attending a large midwestern university.

Section snippets

Study sample

From September 2001 through April 2002, research assistants enrolled 483 Indiana University undergraduates in an anonymous, cross-sectional survey of condom-use errors and problems. Undergraduates were solicited from courses that had not included instruction regarding correct condom use; other eligibility criteria were not applied. The Institutional Review Board approved the study protocol, and no incentives for participation were provided.

For analyses, only those undergraduates who reported

Results

Average age of the sample (N=260) was aged 19.5 years (range = 18–29; standard deviation [SD]=1.6 years). The majority (88.0%) self-identified as white, 6.6% self-identified as black or African American, and the remainder self-identified as members of other racial or ethnic minorities. Fifty-five percent were female. Most (85.7%) had received some form of instruction about correct condom use (e.g., from clinic brochures, friends, high school health classes).

Table 1 displays the observed

Discussion

Findings suggest that condom use errors and problems may be quite common, even among well-educated individuals who were not recruited through clinic-based venues. Indeed, errors and problems were common, even though most undergraduates reported receiving some form of instruction about correct condom use. Also, few differences between males and females were found. Thus, these findings support the idea that prevention messages should emphasize the correct use of condoms in addition to the current

References (14)

R.A. Crosby et al.
Correct condom application among African American adolescent femalesthe relationship to perceived self-efficacy and the association to confirmed STDs
J Adolesc Health
(2001)
United States Department of Health and Human Services. Workshop Summary: Scientific evidence on condom effectiveness...
R.A. Crosby
Condom use as a dependent variablemeasurement issues relevant to HIV prevention programs
AIDS Educ Prev
(1998)
M. Fishbein et al.
Evaluating AIDS prevention interventions using behavioral and biological outcome measures
Sex Transm Dis
(2000)
M. Macaluso et al.
Mechanical failure of the latex condom in a cohort of women at high STD risk
Sex Transm Dis
(1999)
K.J. Mertz et al.
Gonorrhea in male adolescents and young adults in Newark, New Jerseyimplications of risk factors and patient preferences for prevention strategies
Sex Transm Dis
(2000)
A. Spruyt et al.
Identifying condom users at risk for breakage and slippagefindings from three international sites
Am J Public Health
(1998)

There are more references available in the full text version of this article.

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Citation Excerpt :
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Brief reportCondom-use errors and problems: A neglected aspect of studies assessing condom effectiveness

Abstract

Objective

Methods

Results

Conclusions

Introduction

Section snippets

Study sample

Results

Discussion

J Adolesc Health

Condom use as a dependent variablemeasurement issues relevant to HIV prevention programs

AIDS Educ Prev

Evaluating AIDS prevention interventions using behavioral and biological outcome measures

Sex Transm Dis

Mechanical failure of the latex condom in a cohort of women at high STD risk

Sex Transm Dis

Gonorrhea in male adolescents and young adults in Newark, New Jerseyimplications of risk factors and patient preferences for prevention strategies

Sex Transm Dis

Identifying condom users at risk for breakage and slippagefindings from three international sites

Am J Public Health

Brief report
Condom-use errors and problems: A neglected aspect of studies assessing condom effectiveness