Does it fit okay? Problems with condom use as a function of self-reported poor fit.

OBJECTIVE: To identify associations between men's self-reports of ill-fitting condoms and selected condom use problems, using an event-specific analysis. METHODS: A convenience sample of men was recruited via advertisements in newspapers (two urban and one small town) and a blog on the website of a condom sales company. Men completed a questionnaire posted on the website of The Kinsey Institute for Research in Sex, Gender, and Reproduction. Inclusion criteria were: at least 18 years old, used condoms for penile-vaginal intercourse in the past 3 months and the ability to read English. RESULTS: In controlled, event-specific, analyses of 436 men, those reporting ill-fitting condoms (44.7%) were significantly more likely to report breakage (adjusted odds ratio (AOR 2.6), slippage (AOR 2.7), difficulty reaching orgasm, both for their female partners (AOR 1.9) and for themselves (AOR 2.3). In addition, they were more likely to report irritation of the penis (AOR 5.0) and reduced sexual pleasure, both for their female partner (AOR 1.6) and for themselves (AOR 2.4). Furthermore, they were more likely to report that condoms interfered with erection (AOR 2.0), caused erection loss (AOR 2.3), or became dry during sex (AOR 1.9). Finally, they were more likely to report removing condoms before penile-vaginal sex ended (AOR 2.0). CONCLUSIONS: Men and their female sex partners may benefit from public health efforts designed to promote the improved fit of condoms.

Is phosphodiesterase type 5 inhibitor use associated with condom breakage?

We tested the hypothesis that phosphodiesterase type 5 inhibitor (PDE5i) use would be associated with increased likelihood of condom breakage using an event-specific analysis. A convenience sample of 440 men completed an internet-based questionnaire that assessed variables pertaining to the last time they used condoms for penile-vaginal intercourse (PVI). A bivariate (screening) analysis was performed to identify covariates for a multivariate analysis using logistic regression. Altogether, 5.9% of the men reported breakage and 9.5% reported PDE5i use during the last time a condom was used for PVI. Among men who had used PDE5i during the last condom-protected occasion of PVI, 11.9% reported breakage compared with 5.3% of those not reporting PDE5i use. Adjusting for men's age, ethnic minority status, marital status, reported duration of PVI and alcohol use at last PVI, those using PDE5i were about four times more likely to also report condom breakage (AOR 4.02; 95% CI 1.20 to 13.48; p = 0.04). Of note, duration of PVI was independently associated with breakage (AOR 1.36; CI 1.02 to 1.83; p = 0.04). Findings suggest that PDE5i use may potentially be associated with increased odds of condom breakage among some men.

Two heads are better than one: the association between condom decision-making and condom use errors and problems.

OBJECTIVES: This exploratory study compared the frequency of condom use errors and problems between men reporting that condom use for penile-vaginal sex was a mutual decision compared with men making the decision unilaterally. METHODS: Nearly 2000 people completed a web-based questionnaire. A sub-sample of 660 men reporting that they last used a condom for penile-vaginal sex (within the past three months) was analysed. Nine condom use errors/problems were assessed. Multivariate analyses controlled for men's age, marital status, and level of experience using condoms. RESULTS: Men's unilateral decision-making was associated with increased odds of removing condoms before sex ended (adjusted odds ratio (AOR) 2.51, p = 0.002), breakage (AOR 3.90, p = 0.037), and slippage during withdrawal (AOR 2.04, p = 0.019). Men's self-reported level of experience using condoms was significantly associated with seven out of nine errors/problems, with those indicating less experience consistently reporting more errors/problems. CONCLUSIONS: Findings suggest that female involvement in the decision to use condoms for penile-vaginal sex may be partly protective against some condom errors/problems. Men's self-reported level of experience using condoms may be a useful indicator of the need for education designed to promote the correct use of condoms. Education programmes may benefit men by urging them to involve their female partner in condom use decisions.

Breakage, slippage and acceptability outcomes of a condom fitted to penile dimensions.

OBJECTIVE: This study compared failure rates of a standard-sized condom and a condom fitted to a man's penile length and circumference and assessed users' perceptions of condom acceptability and confidence in the efficacy of both condoms. METHOD: Using an experimental crossover design with Internet-based daily diaries, 820 men who wore at least one of each condom type reported outcomes and perceptions of condoms used during vaginal and anal intercourse events for which they were the insertive partner. RESULTS: Breakage for fitted condoms (0.7%) was significantly less than for standard-sized condoms (1.4%). When assessed by penile dimensions, significantly less breakage of fitted condoms than standard-sized condoms was observed among men in the middle circumference category (12-13 cm) during anal intercourse (1.2% versus 5.6%), men in the larger circumference category (> or =14 cm) during vaginal intercourse (0.6% versus 2.6%), and men in the longer length category (> or =16 cm) for both vaginal (0.5% versus 2.5%) and anal (3.0% versus 9.8%) intercourse. More slippage upon withdrawal after vaginal intercourse occurred with fitted condoms among men in the middle penile length (1.9% versus 0.9%) and circumference (2.2% versus 0.7%) categories. CONCLUSIONS: Fitted condoms may be valuable to sexually transmitted infection prevention efforts, particularly for men with larger penile dimensions. That fitted condoms slipped more for some men provides insights into the need for unique educational materials to accompany such products. Findings also highlight the need for participatory approaches between public health, condom manufacturers, and the retail industry to integrate fitted products into our work successfully.

Assessment of condom use in men and women.

Self-reported condom use is a key variable in surveys of sexual behavior and in studies evaluating interventions to reduce the risk of sexually transmitted infections. This article provides a review of how male condom use has been assessed in research. We critically review a number of methodological issues, including the length of the recall period, terminology, specification of partner variables, validity and reliability of condom use, and use of newer data collection methods such as daily diaries and computer-assisted and online technologies. Assessment of condom use errors and problems, and the role of women in condom use are discussed. Finally, we offer recommendations for improving assessment of condom use in future research.

Perceived versus actual knowledge about correct condom use among U.S. adolescents: results from a national study.

PURPOSE: To assess the prevalence of three misconceptions about correct condom use and determine whether prevalence of these misconceptions varied by gender, sexual intercourse experience, experience using condoms, and the relationship between adolescents' actual and perceived knowledge about correct condom use. Variables that predicted misconceptions about correct condom use were also identified. METHODS: Data from the National Longitudinal Study of Adolescent Health were analyzed to determine prevalence of misconceptions among 16,677 adolescents. Misconceptions were: (a) no space at the tip of the condom, (b) Vaseline can be used with condoms, and (c) lambskin protects against the acquired immunodeficiency virus better than latex. Chi-square analyses determined differences in prevalence of misconceptions between male and female adolescents based on their sexual and condom use experience as well as their level of perceived knowledge about correct condom use. Logistic regression models identified predictors of reporting misconceptions. RESULTS: Depending on intercourse experience and experience using condoms, about one-third to one-half believed the first two misconceptions and about one-fifth believed the latter one. Perception of knowledge about correct condom use was infrequently related to actual knowledge. Misconceptions were less likely among older adolescents, those ever having intercourse, those reporting four or more lifetime intercourse partners, those who had used condoms, females, and those not reporting a religious affiliation. CONCLUSIONS: Misconceptions about correct condom use are common among adolescents. Sexually active adolescents need more complete information about correct condom use.

Instructional emphasis in family life and sex education: viewpoints of students, parents, teachers and principals at four grade levels.

This study was conducted to assess and compare the opinions of four population groups -- students, parents, teachers and principals -- concerning the amount of teaching emphasis that should be given to family life and sex education at school grades three, six, nine and twelve. The population was derived from a large, county school corporation in north central Indiana. A large proportion of each population at each grade supported at least some instructional emphasis about the topic, with nearly a majority or more of the subjects of most of the 16 populations favoring major teaching emphasis. Some differences in endorsement among the populations and sub-populations (male vs. female students) at each grade and among the four grades were found.

The relationship between the sexual attitudes of parents and their college daughters' or sons' sexual attitudes and sexual behavior.

This study determined if three selected sexual attitudes of parents were related to similar sexual attitudes of their college daughters or sons and to five sexual behaviors. Only never married, college freshmen (N = 83) with both parents participating were utilized. A self-report questionnaire was administered to students at a large midwestern university and distributed to and returned from parents by mail. The Pearson product-moment correlation and the stepwise and multiple regressions were used to test four hypotheses. Mothers' sexual attitudes had a stronger relationship than fathers' attitudes with offspring sexual attitudes and behaviors, particularly for daughters. Generally, mothers with the most positive attitudes toward sexual-self had daughters who were more responsive relative to personal sexual expression (masturbation frequency and orgasmic experience), but who were not any more involved heterosexually (frequency of coitus and number of coital partners). Fathers' sexual attitudes had little relationship to offspring sexual attitudes and behavior. None of the male students' sexual behaviors were related strongly to parent sexual attitudes. Implications for school and parent sexuality education programs are briefly discussed.

Adolescents and sexually transmitted diseases.

Sexually transmitted diseases (STDs) are a serious health problem for adolescents, occurring in an estimated one-quarter of sexually active teen-agers. Many of the health problems--including STDs--result from specific risk-taking behaviors. Determinants of STD risks among adolescents include behavioral, psychological, social, biological, institutional factors. Education is an important component in STD control in adolescents. The goal of education is to increase adolescent self-efficiency in practicing STD prevention and risk-reduction. A comprehensive approach including quality, theory-based education, accessible and effective health clinics, and improved social and economic conditions has the most promise of controlling STDs in adolescents.

PIP: The US Department of Health and Human Service reported that 25% of sexuality active teenagers have had a sexually transmitted disease (STD). In school, youth are reported to have a lower STD prevalence of 4% based on Centers for Disease Control high school surveys. The seriousness of the problem is approached through discussion of the prevalence and health impact, the determinants (behavioral, social, biological, institutional), control strategies, and educational strategies. STD educational strategies can be effective only when part of a larger health education program (human sexuality and family life education) rather than including HIV infection instruction in a biology class. Populations particularly affected are young women and low income, urban minority youth. The adolescent risk of STDs is higher than in other age groups. Unfortunately severe consequences may involve reproductive health, i.e., tubal infertility from pelvic inflammatory disease and ectopic pregnancies from, for instance, chlamydia and gonorrhea. Females suffer more damage than males, although more males die of AIDS. Behavioral factors are sexual behavior, drug use, and health care behavior. Psychological factors such as self-esteem and locus of control are associated with STD risk behavior. Sexual activity is possible earlier due to a decrease in the average age of menarche. Access to services is a critical factor in prevention. Effective intervention programs should take into account risk factors and adolescent development. Adolescent clinical services need to be improved through better diagnosis, treatment, and counseling; research and education are needed also. The goal of STD education is to provide adolescents with an increased self-sufficiency in practicing STD prevention and risk reduction. Programs must be sensitive to youth subcultures and include messages about HIV and AIDS. School and community programs are essential to reach all teenagers. The optimum conditions for controlling STDs are an improved social and economic environment, accessible and effective health clinics, and quality education.

Instructional units of death education: the impact of amount of classroom time on changes in death attitudes.

The present study sought to provide a better understanding of the impact instructional time devoted to death education had on death attitudes. The study incorporates a three-group experimental research design with repeated measures. Three experimental groups of college students randomly were assigned to one of three short units of death education. The groups varied in terms of the amount of instructional time they were given. One group received three class sessions of death education, while the other two groups received six and nine classes, respectively. Only in the group that received nine class sessions of death education were death attitudes changed significantly. Such changes occurred on one dimension of death attitudes. Results suggest that very brief units of death education are not effective in changing attitudes. When attitude change is deemed important, the most rational length of time to devote to death education is roughly nine class sessions. Even then, attitudes related to death may be affected only partially.

STD content in school health textbooks: an evaluation using the worth assessment procedure.

Classroom education is a key strategy to controlling sexually transmitted diseases in young persons. Textbooks are the major or sole source of STD information for many students. Thirteen secondary level health science textbooks and five sex education textbooks were reviewed to assess their potential contribution to STD control objectives. Worth assessment, a decision analysis tool for helping decision makers choose among complex or maltiattributed alternatives, was used to evaluate the STD content. The review indicated that sex education textbooks are more likely to contribute to STD control objectives than are health science textbooks. Health science textbooks failed to incorporate information on preventive health behaviors. Both types of textbooks present biomedical information primarily, which is generally free of significant errors. The worth assessment method proved to be a useful tool for evaluating the quality of textbook treatment in a specific content area.

Teacher characteristics and the inclusion of sex education topics in grades 6-8 and 9-11.

PIP: The project purpose was to determine whether selected personal characteristics of health science teachers of school grades 6-8 and 9-11 were related to 1 measure of sex education teaching performance--the inclusion of topics within the instructional unit. The study population was limited to 269 health science teachers in public schools in Indiana, with 94 teaching within grades 6-8 and 175 teaching in grades 9-11. Some significant relationships were established between the teacher characteristic variables and the 60 sex education topics. None of the teacher characteristics variables were consistently related to the inclusion of the topics when considering the topics as a group, although significance was found more frequently at the 9-11 grade than at the 6-8 grade level. More significant relationships were established for the variable erotophila-erotophobia (persons who associate primarily positive emotions with sexuality are considered erotophilics, and individuals associating primarily negative emotions with sex are classified as erotophobics) than for any other teacher characteristic. Erotophilic individuals more often included the birth control topics within sex education instruction. For the teachers in grades 9-11, those with the master's degree in health education were more likely than those without the advanced degree to include sexual behavior-related topics.^ieng

Negative perceptions about condom use in a clinic population: comparisons by gender, race and age.

We sought to elucidate the associations of 13 items assessing negative perceptions about condom use with gender, age and race in a sample of clinic attendees. Patients from four clinics, in three US cities, were recruited (N = 928). Data were collected using audio-computer-assisted self-interviewing. The primary measure was a 13-item adapted version of the Condom Barriers Scale. Logistic regression and chi-square tests were employed to relate the 13 items to gender, age and race. Gender, race and age all had significant associations with negative perceptions of condoms and their use. A primary finding was a large number of significant differences between men and women, with negative perceptions more common among women than among men. For African Americans, especially women, negative perceptions were more common among older participants than among younger participants. In conclusion, important demographic differences regarding negative perceptions may inform the tailoring of intervention efforts that seek to rectify negative perceptions about condoms and thus promote condom use among individuals at risk for sexually transmitted infections (STIs) in the USA. On the other hand, our findings also suggest that the majority of STI clinic attendees may hold positive perceptions about condoms and their use; maintaining and building upon these positive perceptions via education, counselling, and access is also important.

A comparison of condom use errors and problems for heterosexual anal and vaginal intercourse.

Condom use errors and problems were compared for anal and vaginal intercourse among a convenience sample of heterosexual men aged 18-66 years (n = 757). Men completed an online questionnaire for the last male condom use event for penile-anal (10.4%) or penile-vaginal (89.6%) intercourse. The prevalence of condom use errors and problems was similar regardless of intercourse type with a few exceptions; those reporting anal intercourse were significantly more likely to report using water-based (P < 0.001) and oil-based (P = 0.037) lubricant and to remove condoms before sex was finished (P < 0.001). The large majority of the sample (93.8%) reported at least one of the nine errors assessed and almost half (46.2%) reported at least one of the seven problems, indicating that many adults may need assistance with these issues. Condom use promotion programmes designed for heterosexual adults are needed that address condom use errors and problems for penile-anal as well as penile-vaginal intercourse.

Men with broken condoms: who and why?

OBJECTIVES: To identify (1) the prevalence of condom breakage, and demographic and sexuality-related differences among young men who have sex with women reporting and not reporting this event; (2) condom-specific behaviours associated with breakage. METHODS: Young men (n = 278) attending a clinic for treatment of sexually transmitted infections (STIs) responded to an anonymous questionnaire aided by a CD recording of the questions. The samples were screened to include only men who had used a condom during penile-vaginal sex at least three times in the past 3 months. Condom-specific behaviours (including breakage) were assessed using these last three acts of condom use as the recall period. Correlates achieving bivariate significance were subjected to multivariate analysis. RESULTS: Nearly one third (31.3%) of the men reported recent breakage. The breakage rate was 15%. Three correlates significantly distinguished between men who did and did not report breakage. Men who had past STIs were more likely to report breakage (adjusted odds ratio (AOR) 2.08), as were men who also reported condom slippage (AOR 2.72). Less self-efficacy for correct condom use was also significantly associated with breakage (AOR 1.07). Further, three condom-specific behaviours were significantly associated with breakage: allowing condoms to contact sharp objects (AOR 2.6), experiencing problems with the "fit or feel" of condoms (AOR 2.3) and not squeezing air from the receptacle tip (AOR 2.0). CONCLUSIONS: Breakage may be common and may occur in a larger context of difficulties with condoms. STI clinics could potentially benefit some men by providing instructions on the correct use of condoms.

Country watch: USA.

PIP: Educators responsible for selecting and/or developing curricula for teaching HIV/STD school programs do not have adequate professional preparation and are unclear about the goals of such education. They know neither what is the best content nor which methodological approach to use. Professor William Yarber of Indiana University has therefore developed a model of performance standards which can be used to evaluate existing curricula as well as develop new materials. Educators may use this framework to assess the comparative worth of various elements in curricula. The model is based upon Centers for Disease Control guidelines and a curriculum on AIDS education for the young. It assumes that the most effective curriculum includes both student and teacher guides. A checklist of 73 criteria and performance standards is included against which educators may assess the worth of various discussion topics and behaviors promoted by a curriculum. The checklist may, however, require revision and/or expansion to accommodate other criteria particular to specific settings and needs.^ieng