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Abstract
Objective To determine whether any of four condom use errors/problems occurred more frequently when condom application was ‘rushed’ among a clinic-based sample from three US states.
Methods A convenience sample (n=512) completed daily electronic assessments including questions about condom use being rushed and also assessed condom breakage, slippage, leakage and incomplete use.
Results Of 8856 events, 6.5% (n=574) occurred when application was rushed. When events involved rushed condom application, the estimated odds of breakage and slippage were almost doubled (estimated OR (EOR)=1.90 and EOR=1.86). Rushed application increased the odds of not using condoms throughout sex (EOR=1.33) and nearly tripled the odds of leakage (EOR=2.96). With one exception, all tests for interactions between gender and rushed application and between age and rushed application were not significant (p values>0.10).
Conclusions This event-level analysis suggests that women and men who perceive that condom application was rushed are more likely to experience errors/problems during the sexual event that substantially compromise the protective value of condoms against disease and pregnancy. Educational efforts emphasising the need to allow ample time for condom application may benefit this population.
- CONDOMS
- SEXUAL HEALTH
- SEXUAL BEHAVIOUR
- PREGNANCY
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Introduction
Evidence supports the efficacy of the male latex condom for reduction of sexually transmitted disease incidence, HIV incidence and unintended pregnancy.1 However, condom effectiveness is greatly compromised by user errors.1–3 Among the most common errors are condom breakage, slippage, leakage and incomplete use of condoms.1–3 Condom use errors/problems are common across different populations (eg, clinic-based samples,1 ,3 ,4 university students3 ,5), across both genders and across sexual orientation and ethnic groups.3 ,6 Missing key steps in condom application may be problematic. Correct condom application involves several steps that may require the couple to take ample time to properly perform each one.7 Research suggests that couples perceive condom application to disrupt sexual mood8 ,9 and, as a result, they may rush the process.
Unfortunately, the question of whether couples allowing adequate time for application have fewer condom errors/problems is underinvestigated, with only one such study being published to date and that study involved a non-clinical sample.7 Accordingly, the purpose of this event-level investigation was to determine whether any of four condom use errors/problems occurred more frequently when condom application was ‘rushed’ among a clinic-based sample of female and male adolescents and adults from three US states.
Methods
Study design
The study was based on the collection of daily ‘event reports’ from a cohort of patients recruited from sexually transmitted infection (STI) clinics in the USA. Only event reports that involved condom use were used for this study, and these reports constituted the unit of analysis (as opposed to a person-level unit of analysis used in traditional cohort studies).
Study sample
Data were collected from December 2007 through April 2011 as part of a National Institute of Health (NIH)-funded study of condom effectiveness.1 Patients were recruited on a consecutive basis from five clinics in three US cities (Louisville, Kentucky; Cincinnati, Ohio; and Boston, Massachusetts). Each clinic was a well-established location for the diagnosis and treatment of STIs, with clinics in two cities being exclusively designated for this purpose. All recruitment activities were initiated in the clinic waiting rooms. Eligibility criteria included being 15 years of age or older, reporting penile–vaginal intercourse in the preceding 3 months; speaking English; willing to provide contact information; and providing written informed consent. A research assistant explained the study, verbally summarised the consent document and then obtained written informed consent. Of 1297 eligible and invited to participate, 794 enrolled, yielding a participation rate of 61.2%. Institutional review boards at the participating universities approved the study protocol with a waiver of parental consent for adolescents <18 years of age.
Participants were trained in the use of an electronic diary report using a password-protected personal digital assistant (PDA) programmed with the Configurable Electronic Real-Time Assessment System (Personal Improvement Computer Systems, Reston, Virginia, USA). Each day, participants were prompted to answer the question of whether they had sex in the past 24 h. If participants responded affirmatively, they were asked questions about each instance of sexual intercourse. They were also asked to enter a report about their sexual behaviour directly into the PDA after each time that they had sex to maximise capture of data on every sex event. These PDA diaries were kept by participants for up to 180 days postenrolment; however, due to attrition and lack of condom use (non-use throughout the period meant that no data on condom use were collected), completed diaries for the current study were only available for 512 participants.
Measures
The primary event-level question used in this analysis was, ‘Was enough time available to put the condom on without being rushed?’ Event-level questions also assessed condom breakage, slippage, leakage and incomplete condom use as these are the primary errors that reduce condom effectiveness.1 Evidence suggests that women are well aware of, and commonly report, these condom use errors and problems.2 The Condom Use Errors/Problems Survey10 was used as the basis for question wording.
Data analysis
Contingency tables were used to describe events where the person reported rushed application versus events that were not rushed, relative to the four condom use errors/problems. Because the event-level data were correlated within individual, generalised estimating equation (GEE) models were used for multivariate analyses. GEE models account for within-individual correlation of observation intervals.11 These analyses controlled for gender and age (dichotomised as 21 or younger vs 22 and older) and investigated interactions of rushed application with these two demographic variables. We selected the age of 21 or lower to represent the NIH definition of ‘children’. Significance was defined by an α level of 0.05.
Results
Valid data were provided by 512 participants reporting 8856 events of condom use during penile–vaginal sex. Most participants (58.7%) were women; 80.8% were over 21 years of age. Average age of the sample was 29.1 years (SD=11.3, range was 15 through 65). Most (59.2%) reported unemployment at baseline; 43.3% reported having a high school degree or less education. Three-quarters (74.1%) of participants reported having at least 10 sex partners in their lifetime; 41.7% reported ever being diagnosed with an STI.
Descriptive findings
Table 1 displays descriptive findings. Of 8856 events, 6.5% (n=574) occurred when application was rushed. As shown in table 1, 209 cases of breakage were reported. During 574 events when a lack of adequate condom application time was reported, breakage occurred 27 times (4.7%). In contrast, during 8190 events when adequate condom application time was reported, breakage occurred 182 times (2.2%). The table shows similar frequencies for slippage and leakage, while incomplete condom use was more common. However, for all four condom use errors, a relative difference of at least 50% was found.
Frequency of selected condom use errors by rushed compared with unrushed condom application and estimated ORs (EOR) of event-level errors
Multivariate findings
Table 1 also displays results from the four GEE models used to estimate adjusted ORs for the effect of rushed condom application on condom use errors. In each model, rushed application was significantly associated with the assessed, event-level, condom use error. When events involved rushed condom application, the estimated odds of breakage were almost doubled (estimated OR (EOR)=1.90). For women versus men, no effect was found for breakage (EOR=1.10; 95% CI 0.68 to 1.77; p=0.70). Also, for younger versus older ages no main effect was found with breakage (EOR=1.55; 95% CI 0.94 to 2.54; p=0.085).
When events involved rushed application, the estimated odds of condoms slipping off during sex were almost doubled (EOR=1.86). Neither gender (EOR=1.57; 95% CI 0.97 to 2.56; p=0.07) nor age group was significantly associated with slippage (EOR=0.99; 95% CI 0.60 to 1.61; p=0.96). Additionally, when events involved rushed condom application, the estimated odds of not using the condom throughout sex increased by one-third (EOR=1.33). Gender was not significantly associated with incomplete use (EOR=0.88; 95% CI 0. 66 to 1.17; p=0.38). However, age was significantly associated with incomplete use, with those aged 21 years or younger being more likely to report this error (EOR=1.38; 95% CI 1.03 to 1.85; p=0.03).
Finally, when events involved rushed application, the estimated odds of reporting that condoms leaked nearly tripled (EOR=2.96). Neither gender (EOR=1.19; 95% CI 0.57 to 2.48; p=0.64) nor age was a significant predictor of leakage (EOR=1.31; 95% CI 0.61 to 2.80; p=0.49).
With one exception, all tests for interactions between gender and rushed application and between age and rushed application were not significant (p values>0.10). The exception pertained to the interaction between rushed application and age with respect to breakage (p=0.045). Among persons aged 21 years or younger, there was a 10.2% breakage rate during rushed events versus 2.5% during unrushed events (EOR=3.03; 95% CI 1.01 to 9.11; p=0.048). Among persons aged 22 years or older, there was a 3.1% breakage rate during rushed events compared with 2.2% during unrushed events (EOR=0.33; 95% CI 0.11 to 0.99; p=0.048).
Discussion
This event-level study supports results from a previous study of a non-clinical sample and extends them to a clinical sample of adolescent and adult women and men. The previous study included only men and found that odds of breakage were about three times greater, and odds of slippage were about 2.4 times greater when condom use was perceived as rushed.7 The current findings suggest a less dramatic influence of rushed application, but one that is, nonetheless, significant and substantial. In particular, women and men who perceive that condom application was rushed may be more likely to experience errors/problems that compromise the protective value of condoms against disease and pregnancy.
This novel finding is important because clinic-based and community-based condom education programmes can design interventions that encourage both women and men to include adequate time for condom application as part of their sexual repertoire. In turn, individuals can find methods of eroticising condom application; this may yield fewer errors and problems. Such a sex-positive approach to disease and pregnancy prevention can be included as a component in larger behavioural intervention programmes, condom social marketing programmes or even individualised, clinic-based, safer sex counselling programmes.12
As is true for most sexuality research, findings are limited by the validity of self-report; however, this problem is greatly mitigated by daily reporting. The participation rate of 61.2% is also a potential limitation of this study. Notwithstanding this limitation and the fact that generalisation beyond clinic populations is not possible with these data, rushed application may be a common aetiology of user errors that detract from condom effectiveness. Indeed, evidence suggests that the gap between effectiveness of condoms used correctly versus effectiveness under typical, imperfect use is quite large.1
In contrast to strategies that close the gap between correct and typical use by providing preferred condoms and lubricants in clinics, teaching men and women to take their time during condom application is not resource intensive. An important adjunct to this intervention message is that clinical providers and educators may also need to instruct their clients in the process of correct condom application, as is done in many of the safer sex programmes endorsed by the US Centers for Disease Control and Prevention.12 For persons who cannot find more time to apply condoms, an alternative counselling strategy may be to teach them how to efficiently and correctly apply condoms to avoid mistakes that may otherwise occur when rushing. If condom application is performed correctly and care is taken to overcome a feeling of being rushed to perform this task, users will likely have fewer concerns about condom use spoiling the mood and thus experience fewer errors and problems.
References
Footnotes
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Handling editor Jackie A Cassell
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Contributors RC and LAS obtained funding for the study and provided oversight of all study activities. RC conceived the study design and analytic, also analysed the data and drafted the manuscript. CG, RM, SS and WY provided refinements to the initial analysis and finalised the draft manuscript.
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Funding Support for this project was provided by a grant to the first author from the National Institutes of Allergies and Infectious Diseases, grant # 5 R01 AI068119.
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Competing interests None.
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Patient consent Obtained.
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Ethics approval University of Kentucky.
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Provenance and peer review Not commissioned; externally peer reviewed.