Condom Use Errors/Problems Survey

Condom Use Errors/Problems Survey

RICHARD A. CROSBY,University of Kentucky CYNTHIA A. GRAHAMUniversity of Oxford ROBIN R. MILHAUSENUniversity of Guelph STEPHANIE A. SANDERS AND WILLIAM L. YARBER,Indiana University

For sexually active persons wanting to prevent sexually transmitted infections (STIs) and pregnancy, condom use for all sexual episodes is necessary. Consistent use of the male, latex condom is an effective method of reducing the risk of transmitting and acquiring many STIs, including HIV infection, and unintended pregnancy (Centers for Disease Control and Prevention [CDC], 2009; Holmes, Levine, & Weaver, 2004). However, consistently using condoms is not sufficient—condoms must also be used correctly (CDC, 2009; Crosby, DiClemente, Holtgrave, & Wingood, 2002; Steiner, Cates, & Warner, 1999). Indeed, evidence suggests that condom failure typically stems from user error rather than product defect (Graham, Crosby, Sanders, & Yarber, 2005). Thus, identifying prevalent user errors and problems can be a valuable starting point toward the goal of promoting improved quality of condom use (Crosby, Yarber, Sanders, Graham, & Arno, 2008).‌

Description

The Condom Use Errors/Problems Survey (CUES) is a comprehensive assessment of errors and problems that people may experience when using male condoms that may lead to condom failures. Errors such as forms of incorrect use (e.g., putting condom on after starting sex) and problems such as breakage or slippage, erection difficulties, and discomfort are assessed using the CUES. The questionnaire has been refined through use in several studies involving samples of adolescent and adult men and women recruited from STI clinics, college students, rural men from a random telephone sampling, and participants from an online survey (e.g., Crosby, Milhausen, Sanders, Graham, & Yarber, 2008; Crosby, Sanders, Yarber, Graham, & Dodge, 2002; Graham et al., 2006; Sanders et al, 2003; Sanders, Milhausen, Crosby, Graham, & Yarber, 2009; Yarber, Graham, Sanders, & Crosby, 2004; Yarber et al., 2005). We have two versions: (a) Condom Use Errors/Problems— Men (M-CUES), for men who placed the condom on them- selves, and (b) Condom Use Errors/Problems—Women (W-CUES), for women who placed condoms on their male partners. Both versions are presented in the Exhibit.

The CUES assesses the last three times a condom was used during the past 3 months as the recall period. The CUES has also been used to assess use errors and problems the last time the condom was used or during all occasions of condom use during a specified time period. We used a limited event and time frame because accuracy of recall is considered vital (Graham et al., 2005). However, researchers are encouraged to adopt a recall period that reflects their study goals and objectives.

The survey can be used to measure condom use errors and problems during either penile-vaginal or penile-anal sexual intercourse. As seen in the CUES versions presented below, a blank space is provided before the word “inter- course” so that researchers can tailor the measure to assess the specific behavior of interest (i.e., penile-vaginal inter- course or penile-anal intercourse).

Response Mode and Timing

Respondents indicate whether or not each condom use error or problem occurred during the last three times they used and applied a male condom and, if so, if it occurred on one, two, or three occasions. The survey takes an average of 10 minutes to complete.

Scoring

Although analysis of individual items provides greater insight, summative scores of error items and problem items can be calculated. Error Items are 1, 2, 3, 4, 6, 7, 9, 10, and 11. Problem Items are 5, 8, 12, 13, 14, 15, and 16. For a recall period based on the last three times a condom was used, the summative error score indicates the total number of times errors were reported (minimum 0, maximum 27 [9 errors × 3 occasions]). Items 1, 3, and 4 are reversed scored such that a no response is scored as 3, one occasion scored as 2, two occasions scored as 1, and all three occasions scored as 0 (for an example of this scoring, see Crosby, Milhausen, et al., 2008). Alternatively, an error occurring during any of the last three occasions or that occurred at least once during a specific time period could be scored a 1 and a correct condom use or no problem is scored as 0 (Crosby, Sanders, et al., 2002; Milhausen et al., 2009).

Reliability

Reliability refers to the consistency of a measure within the same subject under the same conditions. It is usually measured in terms of internal consistency and test-retest reliability. Behavioral measures such as the CUES do not easily lend themselves to such evaluations, as they are not measuring a trait or construct assessed with multiple questions. Instead, the items are designed to measure distinct behavioral experiences. Making one type of error is not assumed to correlate with making other errors. Relative to test-retest, the same person may have different behavioral experiences over time; test-retest assessments may not be highly correlated over time unless the person has the same behavioral experiences. Although it is possible that a per- son who reports a specific error or problem at “test” may also be inclined to the same error/problem in the future “retest” (assuming that taking the CUES does not alter the behavior), this has not been evaluated longitudinally with the CUES.

Validity

The survey items have evidence of content and face valid- ity because they were informed by widely cited condom use guidelines (CDC, 1998; Warner & Hatcher, 1999). Our studies have found, for example, that respondents who reported previous instruction on correct condom use were found to have lower error scores than those who had not had such instruction (Crosby, Sanders, et al., 2002), and correlations have been reported between errors and specific problems, such as incomplete use and erection difficulties (Graham et al., 2006) and using sharp objects to open the package and condom breakage (Yarber et al., 2004).

Condom Use Errors/Problems Survey—Men (M-CUES)

Directions: The questionnaire is designed for a man who has used male condoms at least three times in the past three months for [Researchers choose penile-vaginal (penis in vagina) or penile-anal (penis in rectum/butt)] intercourse and who put the condom on his penis all of the three times. Thinking about the last three times you (not your partner) put the condom on your penis, indicate whether or not you engaged in the behavior or if the event happened and, if so, how often it occurred.

  1. For the last three times you used a condom for         [Researchers choose: penile-vaginal or penile-anal] intercourse, did you check for visible damage before having         intercourse?

         no

         if yes, did you do it on 1 occasion, on 2 occasions, or on all 3 occasions?

         I did it on 1 occasion

         I did it on 2 occasions

         I did it on all 3 occasions

  2. For the last three times you used a condom for         intercourse, did you put it on the wrong side up and have to flip it over?

         no

         if yes, did you do it on 1 occasion, on 2 occasions, or on all 3 occasions?

         I did it on 1 occasion

         I did it on 2 occasions

         I did it on 3 occasions

  3. For the last three times you used a condom for         intercourse, did you leave space at the tip of the condom when putting it on?

         no

         if yes, did you do it on 1 occasion, on 2 occasions, or on all 3 occasions?

         I did it on 1 occasion

         I did it on 2 occasions

         I did it on 3 occasions

  4. For the last three times you used a condom for         intercourse, did you squeeze the air out after putting it on?

         no

         if yes, did you do it on 1 occasion, on 2 occasions, or on all 3 occasions?

         I did it on 1 occasion

         I did it on 2 occasions

         I did it on 3 occasions

  5. For the last three times you used a condom for         intercourse, did you lose or start to lose your erection while putting it on?

         no

         if yes, did you do it on 1 occasion, on 2 occasions, or on all 3 occasions?

         I did it on 1 occasion

         I did it on 2 occasions

         I did it on 3 occasions

  6. For the last three times you used a condom for         intercourse, did you use a condom without a water-based lubricant such as K-Y jelly or spermicidal cream (meaning the condom did not have lubricant on it and you or your partner did not put any on it)?

         no

         if yes, did you do it on 1 occasion, on 2 occasions, or on all 3 occasions?

         I did it on 1 occasion

         I did it on 2 occasions

         I did it on 3 occasions

  7. For the last three times you used a condom for         intercourse, did you also use an oil-based lubricant, such as Vaseline or baby oil, with the condom?

         no

         if yes, did you do it on 1 occasion, on 2 occasions, or on all 3 occasions?

         I did it on 1 occasion

         I did it on 2 occasions

         I did it on 3 occasions

  8. For the last three times you used a condom for        intercourse, did you lose or start to lose your erection after         intercourse had begun while using the condom?

         no

         if yes, did you do it on 1 occasion, on 2 occasions, or on all 3 occasions?

         I did it on 1 occasion

         I did it on 2 occasions

         I did it on 3 occasions

  9. For the last three times you used a condom for         intercourse, did you let it contact sharp jewelry, fingernails, piercings, or teeth anytime before or during         intercourse?

         no

         if yes, did you do it on 1 occasion, on 2 occasions, or on all 3 occasions?

         I did it on 1 occasion

         I did it on 2 occasions

         I did it on 3 occasions

  10. For the last 3 times you used a condom for         intercourse, did you start having         intercourse without the con- dom and then put it on later and continued                  intercourse?

         no

         if yes, did you do it on 1 occasion, on 2 occasions, or on all 3 occasions?

         I did it on 1 occasion

         I did it on 2 occasions

         I did it on 3 occasions

  11. For the last time you used a condom for         intercourse, did you start having intercourse with it on and then take it off and continue having         intercourse without it on?

         no

         if yes, did you do it on 1 occasion, on 2 occasions, or on all 3 occasions?

         I did it on 1 occasion

         I did it on 2 occasions

         I did it on 3 occasions

  12. For the last three times you used a condom for         intercourse, did it break during         intercourse?

         no

         if yes, did it do it on 1 occasion, on 2 occasions, or on all 3 occasions?

         it did it on 1 occasion

         it did it on 2 occasions

         it did it on 3 occasions

  13. For the last three times you used a condom for         intercourse, did it slip off during         intercourse?

         no

         if yes, did it do it on 1 occasion, on 2 occasions, or on all 3 occasions?

         it did it on 1 occasion

         it did it on 2 occasions

         it did it on 3 occasions

  14. For the last three times you used a condom for        intercourse, did it slip off as you were taking your penis out of the

                      [vagina or anus/rectum/butt]?

         no

         if yes, did it do it on 1 occasion, on 2 occasions, or on all 3 occasions?

         it did it on 1 occasion

         it did it on 2 occasions

         it did it on 3 occasions

  15. For the last three times you used a condom for         intercourse, did you have any problems with the way it fit?

         no

         if yes, did I on 1 occasion, on 2 occasions, or on all 3 occasions?

         I did on 1 occasion

         I did on 2 occasions

         I did on 3 occasions

  16. For the last three times you used a condom for         intercourse, did you or your partner have any problems with the way it felt?

     no

     if yes, did it happen on 1 occasion, on 2 occasions, or on all 3 occasions?

     it happened on 1 occasion

     it happened on 2 occasions

     it happened on 3 occasions

Condom Use Errors/Problems Survey—Women (W-CUES)

Directions: The questionnaire is designed for a woman who has used a male condom at least three times in the past three months for

                 [Researchers choose penile-vaginal (penis in vagina) or penile-anal (penis in rectum/butt)] intercourse and who put the condom on her partner’s penis all of the three times. Thinking about the last three times you (not your partner) put the condom on his penis, indicate whether or not you engaged in the behavior or if the event happened and, if so, how often it occurred.

  1. For the last three times you used a condom for         [Researchers choose: penile-vaginal or penile-anal] intercourse, did you check for visible damage before having        intercourse?

         no

         if yes, did you do it on 1 occasion, on 2 occasions, or on all 3 occasions?

         I did it on 1 occasion

         I did it on 2 occasions

         I did it on all 3 occasions

  2. For the last three times you used a condom for         intercourse, did you put it on the wrong side up and have to flip it over?

         no

         if yes, did you do it on 1 occasion, on 2 occasions, or on all 3 occasions?

         I did it on 1 occasion

         I did it on 2 occasions

         I did it on 3 occasions

  3. For the last three times you used a condom for         intercourse, did you leave space at the tip of the condom when putting it on?

         no

         if yes, did you do it on 1 occasion, on 2 occasions, or on all 3 occasions?

         I did it on 1 occasion

         I did it on 2 occasions

         I did it on 3 occasions

  4. For the last three times you used a condom for         intercourse, did you squeeze the air out after putting it on?

         no

         if yes, did you do it on 1 occasion, on 2 occasions, or on all 3 occasions?

         I did it on 1 occasion

         I did it on 2 occasions

         I did it on 3 occasions

  5. For the last three times you used a condom for         intercourse, did your partner lose or start to lose his erection while you were putting it on his penis?

         no

         if yes, did he do it on 1 occasion, on 2 occasions, or on all 3 occasions?

         he did it on 1 occasion

         he did it on 2 occasions

         he did it on 3 occasions

  6. For the last three times you used a condom for        intercourse, did you use a condom without a water-based lubricant such as K-Y jelly or spermicidal cream (meaning the condom did not have lubricant on it and you or your partner did not put any on it)?

         no

         if yes, did you do it on 1 occasion, on 2 occasions, or on all 3 occasions?

         I did it on 1 occasion

         I did it on 2 occasions

         I did it on 3 occasions

  7. For the last three times you used a condom for         intercourse, did you also use an oil-based lubricant, such as Vaseline or baby oil, with the condom?

         no

         if yes, did you do it on 1 occasion, on 2 occasions, or on all 3 occasions?

         I did it on 1 occasion

         I did it on 2 occasions

         I did it on 3 occasions

  8. For the last three times you used a condom for        intercourse, did your partner lose or start to lose his erection after

                      intercourse had begun while using the condom?

         no

         if yes, he did on 1 occasion, on 2 occasions, or on all 3 occasions?

         he did it on 1 occasion

         he did it on 2 occasions

         he did it on 3 occasions

         not sure

  9. For the last three times you used a condom for         intercourse, did you let it contact sharp jewelry, fingernails, piercings, or teeth anytime before or during         intercourse?

         no

         if yes, did you do it on 1 occasion, on 2 occasions, or on all 3 occasions?

         I did it on 1 occasion

         I did it on 2 occasions

         I did it on 3 occasions

  10. For the last three times you used a condom for         intercourse, did you start having         intercourse without the condom and then put it on later and continued                  intercourse?

         no

         if yes, did you do it on 1 occasion, on 2 occasions, or on all 3 occasions?

         I did it on 1 occasion

         I did it on 2 occasions

         I did it on 3 occasions

  11. For the last time you used a condom for         intercourse, did you start having intercourse with it on and then take it off and continue having         intercourse without it on?

         no

         if yes, did you do it on 1 occasion, on 2 occasions, or on all 3 occasions?

         I did it on 1 occasion

         I did it on 2 occasions

         I did it on 3 occasions

  12. For the last three times you used a condom for         intercourse, did it break during         intercourse?

         no

         if yes, did it do it on 1 occasion, on 2 occasions, or on all 3 occasions?

         it did it on 1 occasion

         it did it on 2 occasions

         it did it on 3 occasions

         not sure

  13. For the last three times you used a condom for         intercourse, did it slip off during         intercourse?

         no

         if yes, did it do it on 1 occasion, on 2 occasions, or on all 3 occasions?

         it did it on 1 occasion

         it did it on 2 occasions

         it did it on 3 occasions

         not sure

  14. For the last three times you used a condom for         intercourse, did it slip off while your partner was taking his penis out of your         [vagina or anus/rectum/butt]?

         no

         if yes, did it do it on 1 occasion, on 2 occasions, or on all 3 occasions?

         it did it on 1 occasion

         it did it on 2 occasions

         it did it on 3 occasions

         not sure

  15. For the last three times you used a condom for         intercourse, did your partner have any problems with the way it fit?

         no

         if yes, did he on 1 occasion, on 2 occasions, or on all 3 occasions?

         he did on 1 occasion

         he did on 2 occasions

         he did on 3 occasions

         not sure

  16. For the last three times you used a condom for         intercourse, did you or your partner have any problems with the way it felt?

     no

     if yes, did it happen on 1 occasion, on 2 occasions, or on all 3 occasions?

     it happened on 1 occasion

     it happened on 2 occasions

     it happened on 3 occasions

Address correspondence to William L. Yarber, Department of Applied Health Science, Indiana University, Bloomington, Indiana 47405; e-mail: [email protected]

References

Centers for Disease Control and Prevention. (1998). Facts about condoms and their use in preventing HIV infection and other STDs. Atlanta, GA: U.S. Department of Health and Human Services.

Centers for Disease Control and Prevention. (2009). Condoms and STDs: Fact sheet for public health personnel. Retrieved May 18, 2009, from http://www.cdc.gov/condomeffectiveness/latex.htm

Crosby, R., Milhausen, R., Sanders, S., Graham, C., & Yarber, W. (2008). Two heads are better than one: The association between condom decision-making and condom use errors and problems. Sexually Transmitted Infections, 84, 196–201.

Crosby, R. A., DiClemente, R. J., Holtgrave, D. R., & Wingood, G. M. (2002). Design, measurement, and analytic considerations for testing hypotheses relative to condom effectiveness against nonviral STIs. Sexually Transmitted Infections, 32, 513–515.

Crosby, R. A., Sanders, S. A., Yarber, W. L., Graham, C. A., & Dodge, B. (2002). Condom use errors and problems among college men. Sexually Transmitted Diseases, 29, 552–557.

Crosby, R. A., Yarber, W. L., Sanders, S. A., Graham, C. A., & Arno, J. N. (2008). Slips, breaks and “falls”: Condom errors and problems reported by men attending an STD clinic. International Journal of STD and AIDS, 19, 90–93.

Graham, C. A., Crosby, R. A., Sanders, S. A., & Yarber, W. L. (2005). Assessment of condom use in men and women. Annual Review of Sex Research, 16, 1–33.

Graham, C. A., Crosby, R. A., Yarber, W. L., Sanders, S. A., McBride, K., Milhausen, R. R., et al. (2006). Erection loss in association with condom use among young men attending a public STI clinic: Potential correlates and implications for risk behavior. Sexual Health, 3, 255–260.

Holmes, K. K., Levine, R., & Weaver, M. (2004). Effectiveness of con- doms in preventing sexually transmitted infections. Bulletin of the World Health Organization, 82, 454–461.

Milhausen, R. R., Wood, J., Sanders, S. A., Crosby, R. A., Yarber, W. L. & Graham, C. A., (2009). A novel, self-guided home-based intervention to promote condom use among young men: A pilot study. Manuscript submitted for publication.

Sanders, S. A., Graham, C. A., Yarber, W. L., Crosby, R. A., Dodge, B., & Milhausen, R. R. (2003). Condom use errors and problems among women who put condoms on their male partners. Journal of the American Medical Women’s Association, 58, 95–98.

Sanders, S. A., Milhausen, R. R., Crosby, R. A., Graham, C. A., & Yarber, W. L. (2009). Do phosphodiesterase type 5 inhibitors protect against condom-associated erection loss and condom slippage? Journal of Sexual Medicine, 6, 1451–1456.

Steiner, M., Cates, W., & Warner, L. (1999). The real problem with male condoms in non-use. Sexually Transmitted Diseases, 26, 459–462.

Warner, D. L., & Hatcher, R. A. (1999). Male condoms. In R. A. Hatcher, W. Cates, Jr., J. Trussell, F. Stewart, F. Guest, G. K. Stewart, et al. (Eds.), Contraceptive technology (17th ed., pp. 325–352). New York: National Academy Press.

Yarber, W. L., Graham, C. A., Sanders, S. A., & Crosby, R. A. (2004). Correlates of condom breakage and slippage among university students. International Journal of STD and AIDS, 15, 467–472.

Yarber, W. L., Kennedy, J., Sanders, S. A., Crosby, R. A., Graham, C. A., Heckman, T. G., et al. (2005). Prevalence of condom use errors and problems among Indiana rural men: An exploratory telephone survey. The Health Education Monograph, 22(3), 36–38.