Crosby, Richard PhD*†‡; DiClemente, Ralph J. PhD§∥¶#; Yarber, William L. HSD‡**; Snow, Gregory*; Troutman, Adewale MD††‡‡
From the *College of Public Health at the University of Kentucky, Lexington, Kentucky; †Department of Applied Health Science, Indiana University; ‡Rural Center for AIDS/STD Prevention at Indiana University, Bloomington, Indiana; §Rollins School of Public Health at Emory University; ∥Emory Center for AIDS Research; ¶Department of Pediatrics, Division of Infectious, Diseases, Epidemiology, and Immunology, Emory University School of Medicine; #Department of Medicine (Infectious Diseases), Emory University School of Medicine, Atlanta, Georgia; **Department of Applied Health Science at Indiana University, Bloomington, Indiana; ††Louisville Metropolitan Department of Health and Wellness, Louisville, Kentucky; and ‡‡University of Louisville School of Public Health and Information Sciences
The authors thank the assistance of the Clinic Director (Deborah Snow) and the clinic staff members.
Supported by a grant from NIMH (R21 MH066682-01A1) (to R.C.).
Correspondence: Richard Crosby, PhD, College of Public Health, 121 Washington Ave. Lexington, KY 40506-0003. E-mail: firstname.lastname@example.org.
Received for publication February 20, 2007, and accepted August 10, 2007.
IN THE UNITED STATES acquired immunodeficiency syndrome case rates are approximately 8 times greater among African American men compared with their white counterparts.1,2 African American men have the highest prevalence and incidence rates of acquired immunodeficiency syndrome relative to other demographic classifications of US residents.3–5 African American men are also disproportionately affected by sexually transmitted diseases (STDs). In 2004, for example, the rate of gonorrhea was nearly 20 times greater for African Americans compared with whites.6 Given these health disparities, an improved understanding of African American men’s sexual protective behaviors is a public health imperative. This is true for African American men who have sex with men and those having sex with women. Less research, however, has been devoted to the latter population.7–9
A critically important aspect of men’s sexual protective behavior is their consistent and correct use of male condoms.10–12 One facet of this behavior is the multiple errors that people may make when using condoms and the relationship of these errors to condom breakage.13–24 However, only 2 studies specifically investigated these issues among African American men.19,20 One was a qualitative investigation (clinic based) suggesting that tight-fitting and poorly lubricated condoms may be prone to breakage.19 The other was a quantitative investigation (also clinic based) that identified 3 significant behavioral correlates of breakage: condoms contacting sharp objects, problems with the fit of condoms, and not squeezing air from the tip. Unfortunately, the study did not use an event-specific analysis, thereby detracting from the strength of evidence. An event-specific analysis is important because condom-use errors are assessed for the same sexual encounter used to assess breakage. This design feature provides the ability to link user errors to breakage.
Accordingly, the purpose of this study was to identify the prevalence and behavioral correlates (user errors) of condom breakage, using an event-specific analysis, among a clinic-based sample of young, heterosexual African American men.
Materials and Methods
Participants and Procedure
Baseline data from an human immunodeficiency virus prevention trial were utilized. Recruitment occurred at a public STD clinic (located in the southern United States) from September 2004 to April 2006. Men were recruited after clinical diagnosis of any STD. Additional eligibility criteria were self-identification as African American, 18 to 29 years of age, English speaking, reporting that a male condom had been used in the past 3 months for sexual intercourse (defined as “penis in the vagina”), and indicating they were not knowingly human immunodeficiency virus positive. Study procedures were approved by the Office of Research Integrity at the University of Kentucky.
After providing written informed consent, men completed a brief self-administered questionnaire. To minimize problems with poor literacy, the questions were recorded to a compact disk that men could play using a portable headset. Men were compensated $40 for this assessment.
The outcome measure was assessed by asking men, “The last time you had sex using a condom, did the condom you were using break?”
Six forms of user error were assessed. Each question began with the stem: “The last time you had sex using a condom …” Errors were (a) reusing condoms during the same sexual encounter; (b) letting condoms contact sharp jewelry, fingernails, or teeth; (c) use of an oil-based lubricant such as Vaseline; (d) needing to add a water-based lubricant but not doing so; (e) attempting condom application without full erection; and (f) completely unrolling the condom before putting it on the penis. To assure that men understood the item pertaining to oil-based lubrication, several examples other than Vaseline were provided: mineral oil, baby oil, cooking oil, body lotions, and massage oil. The item pertaining to adding a water-based lubricant when needed has not been asked in previously published studies; however, this study was preceded by qualitative research that clearly informed us about experiences reported by young African American men with condoms becoming dry and uncomfortable during coitus.19 Thus, this item assessed whether men experiencing this problem resolved it by adding lubrication.
In addition to age, we examined frequency of condom use as a potential important covariate. We speculated that men using condoms more frequently may be more adept at averting breakage. To assess this, men were asked how many times they had used condoms for vaginal or anal sex with women in the past 3 months.
First, we examined the statistical association between the covariates and condom breakage by using independent groups t-tests. Next, bivariate associations were assessed by prevalence ratios, their 95% confidence intervals, and respective P values. Correlates achieving a screening level of significance (P <0.10) were entered into a hierarchal logistic regression model using a forward entry procedure. The first block entered into the model contained the covariate (age) and the second contained the user errors.
Characteristics of the Sample
Two hundred ninety-six eligible men were identified. Of these, 271 (91.5%) participated. Upon excluding from the analyses men recently having sex with men (n = 7), the remaining analytic sample was 264 men having sex exclusively with women in the past 3 months.
Average age was 23.2 years (SD = 3.3). The majority (70.4%) reported earning less than $1000 per month after taxes, with 26.3% earning between $1000 and $2000 per month. Nearly one-half of the men (46.6%) reported that they were currently in an exclusive, monogamous sexual relationship. Just over one-third of the men (35.2%) indicated that they had not experienced any of the 6 assessed errors the last time they used a condom. Slightly fewer men (30.7%) reported 1 error, 20.5% reported 2 errors, 6.1% reported 3 errors, 4.2% reported 4 errors, 1.9% reported 5 errors, and 1.5% reported making all 6 errors.
Prevalence of Errors and Breakage
More than one-fifth of the sample (21.2%) reported breakage the last time they used a condom. Men reporting breakage (n = 56) were compared with those not reporting breakage (n = 208) with regards to the 6 types of user error. Of the 56 men reporting breakage, 7 (12.5%) had not used a new condom, and 7 had allowed condoms to contact sharp objects. Also, 15 (26.8%) used an oil-based lubricant, and 15 did not add a water-based lubricant when needed. Nineteen men (33.9%) had attempted application without a full erection, and 26 (46.4%) had completely unrolled condoms before application.
Frequency of condom use in the past 3 months did not differ between men indicating breakage had or had not occurred [t = 0.38 (df = 262), P = 0.70]. However, age approached significance as a covariate. Men reporting condom breakage were about 1 year younger (mean = 22.5 years) than those not reporting breakage (mean = 23.4 years) [t = 1.93 (df = 262), P = 0.05]. To control for this potential source of confounding, age-adjusted odds ratios (AOR) were calculated.
Table 1 displays the observed bivariate associations. Breakage occurred among 46.7% of the men indicating that they had reused a condom compared with 19.7% among those not reusing condoms. Just over one-third of the men (36.8%) indicating contact of condoms with sharp objects reported breakage compared with 20.1% not indicating this contact. About 1 of every 4 men (40.5%) reporting use of an oil-based lubricant experienced breakage compared with 18.4% among those not using oil-based lubrication. About 35% of those not adding a water-based lubricant when needed reported breakage compared with 18.6% among the remaining men. Of men indicating that they tried to apply condoms without a full erection, 34.5% reported breakage compared with a 17.8% breakage rate among men not having this difficulty. Finally, 36.1% of the men unrolling condoms before application experienced breakage compared with 18.6% among those not making this error.
Using the data from Table 1, the number of breakage events attributable to each of the 6 errors was calculated. Four cases of breakage could have been averted by not reusing condoms. Three breaks would have been averted by not contacting sharp objects and 8 by not using oil-based lubricants. Further, 7 breaks would have been averted by using water-based lubricants, 9 by applying condoms when the penis was fully erect, and about 14 (14.25) by unrolling condoms as they are applied to the penis.
The model was significant (χ2 with 3 df = 25.3, P <0.0001), and achieved a satisfactory fit with the data (goodness of fit χ2 with 8 df = 6.61, P = 0.58). Age was the only variable entered in the first block of the model. Each year of advancing age decreased the odds of breakage by 10% (AOR = 0.90, 95% confidence interval = 0.81–0.99, P = 0.028).
Table 2 displays the age AORs for the 2 correlates achieving multivariate significance in the model. Men who reported using oil-based lubrication were about 3.2 times more likely to report breakage, and men indicating that they had completely unrolled the condom before application were about 3.3 times more likely to report breakage. The concept of attributable risk was then used to estimate the breakage that would be averted had the 2 errors not occurred. Eight cases of breakage (14%) would have been averted if men had not used oil-based lubricants and just over 14 breaks (25%) would have been averted if men had not unrolled condoms before application. Thus, the combined attributable risk was 39%.
In this study of 264 young, African American men newly diagnosed with an STD, we observed that condom breakage rate was high, with 21.2% self-reporting condom breakage the last time a condom was used. The observed condom breakage rate far exceeds national estimates of 3% to 425 and 8.3% among African Americans26 and exceeds rates (ranging from 2.3% to 7.3%) reported from clinic-based samples of persons from other populations.13,15,27 The observed rate also exceeds nonrate values reported in studies using multiple events to aggregate the percent of men experiencing one or more episodes of breakage.14,18,20 For example, a clinic-based study of African American men found that 15% reported breakage at least once during their last 3 sexual encounters.20 Prevalence of condom-use errors was also quite high given that only a single event was used as the recall period. For example, 5.6% of the men reported reuse of condoms during this one event and 28.1% reported unrolling the condom before application. In contrast, the corresponding values of 3.3% and 23.4%, for a 30-day recall period, were reported from a sample of men attending an STD clinic.23
The study also observed that breakage declined with advancing years of age. In addition, we identified 2 user errors that independently contributed to breakage after adjusting for age. First, men using oil-based lubrication such as Vaseline were more than 3 times as likely to report breakage. Although the deteriorating effect of oil-based lubricants on latex condoms is well known, it is noteworthy that nearly 1 of 7 men (14.0%) applied an oil-based lubricant the last time they used a condom. Second, men (n = 72; 27% of the sample) who reported they had completely unrolled the condom before application were also more than 3 times as likely to report breakage. Although the mechanics of this finding should be explored in detail, perhaps using qualitative investigations, it is reasonable to speculate that men may excessively stretch and pull an unrolled condom in an effort to place it on their penis. It is also reasonable to suspect that the previously unrolled condom is misapplied and the result is an ill-fitting condom (perhaps with air pockets) that is prone to undue friction and thus breakage. Regardless, however, of the reason that previously unrolled condoms are prone to breaking, the finding represents an intervention opportunity that can easily be incorporated into postdiagnostic counseling protocols. The process of using a penile model to show men how to correctly unroll a condom as it is being applied should consume only a brief amount of time during the clinical encounter.
These findings suggest an ideal clinical opportunity for prevention counseling and education may exist. Clearly, the diagnosing clinician can inform men that oil-based lubricants can significantly destroy latex during coital activity and then describe various examples of such lubricants (e.g., baby oil, Vaseline, chocolate syrup). Given that 14% of the sample reported use of oil-based lubricants and that 27% reported unrolling condoms before application, it is conceivable that effective intervention for these 2 errors could substantially reduce breakage rates. To illustrate this point, we calculated breakage rates for men indicating: (a) both errors, i.e., use of an oil-based lubricant and unrolling the condom before application (11 men); (b) either error (87 men); and (c) neither error (164 men). Breakage rates were 54.5%, 33.3%, and 12.8%, respectively.
As is true for most sexuality research, findings are limited by the validity of retrospective self-report. In particular, the ability of men to accurately recall condom-specific events is critical to the validity of the study findings. The use of a convenience sample means that our findings may not be generalizable to other populations of young, African American men newly diagnosed with an STD. Finally, it should be noted that we assessed a limited number (i.e., 6) of user errors that may plausibly relate to breakage; thus other potentially important errors may have been neglected.
Condom breakage among this sample of men newly diagnosed with an STD was common. This problem could be mitigated by counseling African American men attending STD clinics to avoid the use of oil-based lubricants and by teaching correct condom application skills such as how to unroll it down the shaft of the penis. Even in time-restricted clinical encounters the modest requirements of these 2 prevention messages make their implementation feasible.
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