ONE CITED PROBLEM IN THE design of studies of condom effectiveness has been the emphasis on frequency of condom use but not correct condom use.1,2 This and other inadequacies in the research literature led to questions about the effectiveness of condoms in preventing sexually transmitted infections (STIs) when the National Institutes of Health (NIH) reviewed this subject in 2000.1 Since then, several studies have been published that show that consistent and correct use of condoms does provide protection against STIs and human immunodeficiency virus (HIV).3
Crosby et al found that college-aged men and women commonly reported condom errors2,4 and that sexually active adolescent males aged 15 to 20 years had limited knowledge about correct use.5 Lindemann and Brigham noted many mistakes when they evaluated condom use skills by direct observation of males and females aged 18 to 23 years.6 We found no study that assessed the prevalence of errors and problems with condom use in younger adolescents.
An extensive literature describes how adolescents acquire their knowledge about sex.7–9 However, we found no studies that focused specifically on where and how adolescent males learn to use condoms.
The purpose of this study was to determine how often incarcerated males used condoms incorrectly. We also evaluated where, how, and from whom they learned to use a condom. If we can better understand the common condom use errors and problems in these adolescents and gain knowledge of where information on condom use is obtained, we can better tailor health education programs for this population, which is at high risk for STIs.10–13
We conducted this study at the Harris County (Houston) Juvenile Detention Center (HCJDC). Between October 2003 and January 2004, one of 3 experienced adolescent medicine clinicians administered a 20-question survey to consecutive adolescent males aged 12 to 17 years during their intake physical examination in a standard examination room. The questions on the survey were based on reviews of the literature and were pilot-tested. The survey assessed demographic variables and included 8 questions about the details of condom use, both during the last sexual encounter and during usual use. Sex was defined as putting the penis in the vagina or rectum. Answers were based on self-reported technical efficacy; condom use models were not used. We also asked the participants to describe how, where, and by whom they were taught how to use condoms.
As part of standard care at the HCJDC, a urine specimen is collected at the time of the intake physical to test for chlamydia (Gen-Probe amplified Chlamydia trachomatis assay; Gen-Probe, San Diego, CA). We determined the proportion of subjects in this study who were infected.
We used descriptive statistics to summarize the demographic data; the prevalence of condom errors at the last sexual encounter and during usual use; and the information on how, where, and from whom subjects learned how to use condoms. We coded the latter answers for common themes. We used the statistical package STATA (STATA Corp., College Station, TX) to analyze the data.
We also evaluated the reproducibility of the participants’ responses. One investigator repeated the questionnaire on 38 subjects that had been interviewed by the other 2 clinicians (19 subjects for each clinician) at least 1 week previously. Cohen’s κ coefficient was used for measuring the degree of agreement between each set of raters.
This study was approved by the Committee for the Protection of Human Subjects of the University of Texas–Houston Health Sciences Center and by the administration of the HCJDC.
The survey was administered to 209 males, 207 of whom completed the survey. Mean age was 15.3 years (standard deviation [SD], 1.1 year). Forty-three percent (89 of 207) were Hispanic, 38% (78 of 207) black, 14% (29 of 207) white, and 5.3% (11 of 207) other.
Of the 207 males, 180 (87%) had engaged in sexual intercourse; 81% had had sex in the previous 3 months. All males defined themselves as heterosexual. The mean age of initiating sexual intercourse was 12.9 years (SD, 1.6 years; range, 6–16 years). The mean number of lifetime partners was 6 (SD, 8.8; range, 1–100). Nine males (5%) had a history of an STI. The prevalence of chlamydia in this sample at the time of the survey was 8.3% (13 of 157).
At last sexual intercourse, 73% (132 of 180) said that they had used a condom. When asked about frequency of condom use in general, 93% (167 of 180) reported previously using a condom: 52% (94 of 180) always, 30% (53 of 180) most of the time, and 11% (20 of 180) occasionally. All subjects with a positive chlamydia test reported using a condom always or most of the time.
The prevalence of condom errors and problems at both the last sexual intercourse and during usual use is shown in Table 1. The most common error reported was failure to secure a condom on the penis on withdrawal both at the last sexual intercourse and in usual use. The errors and problems in condom use were similar between last use and usual use. Having condoms break and slip as well as flipping over after placing them incorrectly occurred, if at all, no more than twice in any one subject.
Condom Use Knowledge
Table 2 lists how, where, and from whom these adolescents acquired knowledge about how to use a condom. Of note, 33% (9 of 27) of those who had not yet had sex had not yet learned.
Many subjects learned how to use a condom in more than one way. However, several learned in only one way. For example, 39 subjects learned only by reading the package insert, 27 only from an explanation in words, and 12 only by watching pornography. Of those who learned from the media, 44% (15 of 34) learned from pornography, 26% (9 of 34) from educational movies, 21% (7 of 34) from books or pictures, and 9% (3 of 34) from commercial television. Only 3 subjects received instruction at medical facilities (we did not ask from whom), and therefore, no more than these 3 learned from a physician.
When the questionnaire was repeated on 38 subjects by a different investigator, there was good agreement. Cohen’s κ coefficient was calculated to be 0.77 (95% confidence interval, 0.72–0.83) for one clinician and 0.81 (0.76–0.86) for the other clinician.
Seventy-three percent of the subjects in this study reported using a condom at last sexual intercourse. This is a greater percentage than has been found in other groups of incarcerated male adolescents (59.3%11 and 59.4%13) and in a representative sample of U.S. adolescent males (68.8%14).
Condom Errors and Problems
These adolescents reported relatively few problems in their use of condoms. Three other studies provide comparable information on adolescents and young adults: Crosby et al obtained self-reports of condom use from college-aged men4 and men and women2; and Lindemann and Brigham directly observed young men and females aged 18 to 23 years old while they put on a condom.6 Only 2% of our subjects reported failure to put on a condom before initiating vaginal intercourse, whereas college-aged men or their partners described this mistake 38% to 43% of the time.2,4 Only 14% of our participants reported failure to leave a space at the tip of the condom, compared with 40% of college men4 and 46% of the subjects in the study by Lindemann and Brigham.6 Slippage and breakage of condoms occurred at a similar rate in our study (9.2% and 23%, respectively) when compared with college-aged men and women (13–14% and 14–29%, respectively2,4). None of our subjects had had breakage or slippage occur more than twice.
At a similar rate compared with college-aged males and females (10–20%2,4), our subjects sometimes had lost some or all of their erection before removing the condom (18%). The most frequent error reported by our subjects was failure to secure the condom at the base of the penis before withdrawal (37%); Lindemann and Brigham found a similar prevalence of this problem.6 However, our participants denied spilling the contents of the condom because of these mistakes.
Condom Use Knowledge
Given their apparent knowledge about correct condom use, we were not surprised that most of our subjects (85%) said that they had learned how to use a condom in at least one way. We found no studies with comparable information, except for the frequency of school as a source of information: 23% of our subjects learned how to use a condom in that setting compared with 58% of adolescent males in a national survey.7 Unique to our population, 14% of subjects received instruction at a probation or detention facility. This was the result of teaching provided by health department staff in the detention center. However, this teaching was sporadic because funding for this program was intermittent.
Unexpectedly, nearly half of our subjects stated that they learned how to use a condom by reading the package insert. For approximately 23%, this was their only source of information. For 15%, movies (educational, commercial, or pornographic) provided education. This is not surprising, because adolescents often look to media for information on sex.8 Educators, counselors, and family members were creative in demonstrating how to put on a condom by using a variety of props (Table 2). Nine subjects received a demonstration from their girlfriends. No subject specifically mentioned a physician as his teacher.
There are limitations to this study. Findings are limited by the problems inherent to self-report. Recall bias and social acceptability bias is likely. For the information about condom errors, we tried to minimize this bias by asking participants specifically about their experience with condom use at the last sexual encounter in addition to their usual experience. Because we asked sensitive questions about condom use and sexual behavior, subjects may have been uncomfortable answering questions honestly. In addition, the survey was administered during a required physical examination; this may have affected accuracy of response in unknown ways.
The generalizability of the study results may be limited. Our results may not be applicable to other groups of adolescents who are not incarcerated or to incarcerated youth in other parts of the country.
Except for their failure to hold the condom securely on the penis before withdrawal, these incarcerated adolescents reported relatively few errors in condom use, suggesting that the ways that they had learned to use condoms were effective. Information about securing the condom on withdrawal should have greater emphasis in educational materials. All of the following methods may work: encouraging adolescents to read the instructions that come with condoms, telling them in words about the proper technique, and using a variety of models to provide direct demonstration. The first 2 methods are simple to implement. Their effectiveness can be evaluated in other groups of adolescents.
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