Influence of Sex Education on Condom Knowledge and Condom Use Skills Among Texas College Students



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The Journal ­— October 2015

Tex Med. 2011;111(10):e1.

By Jessica Clifton, MD; Lindsay Penrose, PhD; Sam Prien, PhD; and Naghma Farooqi, MD 

From the Department of Obstetrics and Gynecology, Texas Tech University Health Sciences Center, Lubbock, Texas. Send correspondence to Sam Prien, PhD, Department of Obstetrics and Gynecology, TTUHSC, 3601 4th St, Lubbock, TX 79430; email: samuel.prien[at]ttuhsc[dot]edu.

Presented in part at the 2nd annual meeting of ACOG District XI.

Abstract

Condoms have proven effective when used correctly; however, few studies have examined the relationship between a student's previous sex education and his or her general condom knowledge and ability to use a condom correctly. Educational systems in Texas provide a myriad of types of sexual education to their student populations. The objective of the present study was to compare the type of previous sex education with the condom knowledge and condom use skills among students attending college. Participants were recruited at health fairs conducted at a major Texas university during October 2010 and March 2011. Students were first asked to complete a computerized questionnaire and then participated in a condom demonstration. Of 180 students who completed both the questionnaire and the condom demonstration, 67% failed to apply the condom correctly. Further, the results were equally poor regardless of previous sex education format.  The results of this study suggest that none of the current training mechanisms provide adequate information to ensure the proper use of condoms by college students and that alternatives need to be considered to protect the health and well-being of this important segment of the state's population.

Introduction

The male condom is a popular form of contraception among teens and young adults (aged 15-24 years), likely due to its low cost and wide availability in comparison with other forms of contraception. Obviously, condoms must be used consistently and correctly to be effective.1 When used properly, condoms have been shown to be effective at preventing sexually transmitted infections (STI). The typical use failure rate of condoms is 15%; when used perfectly, the failure rate is only 3%. 

Data from the CDC show that young adults are at a higher risk of acquiring an STI than any other age group.2 Young adults account for approximately half of all new cases of STI, despite the fact that they constitute only 25% of the sexually experienced population.2 The 2011 Youth Risk Behavior Surveillance reported that of the 33.7% of high school students who self-reported being sexually active, only 60.2% used a condom during their last sexual encounter and only 18% of students reported the use of birth control pills.3

Previous research has outlined reasons for condom failure. A review by Sanders in 2012 classified condom use errors into 4 general categories: incomplete use, problems with breakage, leakage, or slippage (condom-associated erection problems, and other technical use errors).4 A study of condom use errors among college men highlighted common errors associated with incomplete condom use, which was defined as not using a condom during the entire act of intercourse.5 Forty-three percent of participants reported putting condoms on after initiating sexual intercourse and 15% of participants reported removing condoms before ending sexual activities. 

The study further reported that the participants demonstrated common technical errors that may lead to condom use failure; 40% did not leave space at the tip of the condom, and 30% applied the condom with the wrong side up. A large percent of the participants (81%) reported not changing condoms between different sexual behaviors. These rates were similar among college age women, where 46% of the women reportedly did not leave space at the tip of the condom, and 30% placed it with the wrong side up.6

Additional studies have reported other issues with proper condom use. Crosby et al reported an association between incorrect lubricants and increased condom failure.7 Yarber et al reported an association between breakage and slippage and a lack of condom education among college-aged students.8 A study by Crosby et al suggested that participants who scored lower on a knowledge based questionnaire were more likely to experience condom breakage and slippage.5  Further, a review by Sanders et al found a number of reports where condom slippage was directly related to condom-associated erection problems (reports ranging from 6% to 20%).6

Sex education is another factor thought to influence condom knowledge. In a study by Dodge et al in 2009, men who had received school-based instruction on STI's were less likely to be diagnosed with an STI and were more likely to be tested for an STI.9 Lindemann et al also demonstrated that comprehensive sex education correlated with improved correct condom usage.10, Likewise, Crosby et al reported a trend between receiving condom instruction and lower reported error scores on a condom knowledge examination.11 However, general education level itself has not been found to correlate with correct condom knowledge.12  

While previous studies have examined condom knowledge or usage abilities independently, no single study appears to have examined the relationship between sex education combined with both condom knowledge and condom use skills. The goal of the present study was to determine how previously received sex education affects condom knowledge and the ability to demonstrate proper condom use among Texas college students, a population merging the diverse cultural and sex educational experiences of young adults from across the state.

Methods

Students at a major Texas university were offered the opportunity to complete a computerized questionnaire and live condom demonstration at three health and STI education fairs held at the university in the fall of 2010 and the spring of 2011. Informed consent was obtained, and the students were given a unique identifier to maintain anonymity throughout the study. The students were first asked to complete the computerized questionnaire regarding their demographic data, past sexual history, history of condom use, previous type of sex education received, and an 11-question examination of condom knowledge. The examination contained questions on proper storage, lubricant use, reuse, and potential replacements for the condom. 

Condom Knowledge Questions Used in the Survey of College Students to Assess Their Knowledge Versus Their Ability to Properly Apply a Condom to a Wooden Demonstrator  

  1. Can you reuse a condom? (Yes or No)
  2. True or false: A condom can be used after it has been in your wallet for 6 months.
  3. What type of lubricant can you use in combination with a condom? (water based or oil based)
  4. When is the proper time to put on a condom during intercourse? (Before erection, before vaginal penetration, after penetration, just before ejaculation)
  5. True or false: Condoms cannot protect against 100% of sexually transmitted diseases.
  6. True or false: You should change condoms between vaginal and anal intercourse.
  7. True or false: All condoms are made of latex, so a person with a latex allergy cannot use a condom.
  8. True or false: Condoms should be worn tightly fitted with no space left at the tip.
  9. True or false: Using two condoms at once is more effective than using one condom.
  10. True or false: A female can get pregnant the first time she has sex, so a virgin female needs to use a condom.
  11. True or false: Saran wrap or a balloon is a suitable replacement for a condom.  

After completing the questionnaire, students were escorted to a separate room where they were asked to apply a condom to a wooden demonstrator while being scored by a trained observer. The students were graded on a pass/fail basis by a 4-step criteria derived from Lindemann et al.13 In brief, the criteria involved correctly opening the condom package, applying the condom to the model right side out, "pinching" the tip during application, and applying the condom all the way to the base of the penis model. Resulting data were analyzed by using chi-square test, the Student t test, or analysis of variance (ANOVA) with mean separation, as appropriate. Only data from students who completed both the survey and the condom demonstration were analyzed. 

Results

A total of 202 students participated in the study; 183 completed both the survey and the condom demonstration. Responses from 3 students were removed for inconsistences in data reported or extreme exaggerations in reported numbers of sexual partners.  Of the remaining 180 participants, 37.8% were male and 62.2% female, and all had permanent address ZIP codes identifying them as Texas residents. On average, male respondents tended to be slightly older than female respondents (21.3 years versus 20.7 years, respectively). Male respondents also self-reported a higher number of lifetime sexual partners (7.5 versus 5.1 for female respondents, P<0.031). Overall, 88.3% of respondents reported previous or current participation in oral, vaginal, and/or anal intercourse. Furthermore, 85.6% of the study respondents reported using some type of contraception, with 72% using condoms for contraception (Figure 1). Focusing specifically on condom use, 27.8% of participants reported never using a condom, while 24.4% reported always using a condom during intercourse. Ten percent of the respondents reported a history of STI; all were female. 

Eighty-one percent of the participants answered 9 or more of the 11 condom questions correctly, indicating a good overall knowledge base. No difference was found in pass rate based on gender (P=0.215) but a trend toward a statistical difference (P=0.071) was seen for previous form of sex education (Figure 2). Interestingly, and maybe to be expected, the questions regarding condom knowledge were answered similarly both by students with no formal sex education and those with an abstinence-only education. However, only 33% of the 180 students participating in the condom demonstration passed all four parts of the condom demonstration. Figure 3 and Figure 4 show that males and females had equal pass rate (P=0.664) and no difference in type of previous sex education (P=0.889). Of those students who performed the exercise incorrectly, only 1 ripped the condom while removing it from the package (0.6%), and 5 failed to roll the condom completely to the bottom of the model (2.7%). Forty-eight students attempted to apply the condom upside-down (26.7%). However, the most common mistake (62.2%) was failing to leave space at the condom tip. Furthermore, 37 students (20.7%) made two or more mistakes, with the most common combination being failure to leave space at the top of the condom while applying it upside-down.

Conclusions

Previous studies have documented that male condoms, when used correctly and consistently, prevent STIs and unwanted pregnancies effectively in persons actively engaged in sexual practices.1-4,10,11

While previous studies suggested a relationship between a lack of condom knowledge and higher rates of condom failure,5 few studies have attempted to correlate general sex education and specific condom knowledge with proper condom use. Data from the present study seem to confirm earlier findings that condom knowledge is independent of formal sexual education.4,8,10,11 In the present study, general condom knowledge appeared to be a poor predictor of the ability to apply a condom correctly. While the data suggest a possible trend of slightly more correct answers among those who had received more formal condom training, fully 81% of the participants demonstrated a good base of condom knowledge. However, this knowledge did not translate well in practice, as 67% of the 180 participants failed one or more steps when they attempted to apply the condom to the trainer.

The study is somewhat limited by its dependence on a self-reporting survey format. Because the survey was self-reported and anonymous, it might have allowed overestimated or underestimated rates of contraceptive use or sexual behaviors, as best demonstrated by one of the removed surveys where a student aged 19 years reported more than 1500 different sexual partners, yet reported being a virgin until age 18. Also, a selection bias may exist in the study population as data collections took place during health fairs and sexual health awareness events; consequently, the study population might have included only those students who were more motivated to take an active role in their own health and their sexual health knowledge. 

The results of this study suggest a disconnect between training knowledge and practical application among Texas college students regarding condom use. If the current study truly reflects the ability of Texas college students to use a condom correctly and given the extremely high failure rate among participants and their self-reported use of condoms as a primary means of preventing STIs and unwanted pregnancy (72.8%), the need to develop an effective training method that teaches the proper application of a male condom is compelling. 

Acknowledgments

The authors wish to thank Dr. Linda Brice, Dr. Edwin Henslee, Dr. Jenny Wiggins-Smith, Ms. Sarah Tilford, and Ms. Liz Wagner for their assistance in data collection.

References  

  1. Langer LM, Zimmerman RS, Cabral RJ. Perceived versus actual condom skills among clients at sexually transmitted disease clinics. Public Health Rep. 1994;109(5):683-687.
  2. Centers for Disease Control and Prevention. Sexually transmitted disease surveillance 2009. http://www.cdc.gov/std/stats09/. Accessed June 28, 2010.
  3. Centers for Disease Control and Prevention. Youth risk behavior surveillance — United States, 2011. MMWR Surveill Summ. 2010;59(5):102-103.
  4. Sanders SA, Yarber WL, Kaufman EL, Crosby RA, Graham CA, Milhausen RR. Condom use errors and problems: a global view. Sex Health. 2012;9(1):81-95.
  5. Crosby RA, Sanders SA, Yarber WL, Graham CA, Dodge B. Condom use errors and problems among college men. Sex Transm Dis. 2002;29(9):552-557.
  6. Sanders SA, Graham CA, Yarber WL, Crosby RA. Condom use errors and problems among young women who put condoms on their male partners. J Am Med Womens Assoc. 2003;58(2):95-98. 
  7. Crosby RA, Yarber WL, Sanders SA, et al. Men with broken condoms: who and why? Sex Transm Infect. 2007;83(1):71-75. 
  8. Yarber W, Graham C, Sanders S, Crosby R. Correlates of condom breakage and slippage among University Undergraduates. Int J STD AIDS. 2004;15(7):467-472.
  9. Dodge B, Reece M, Herbenick D. School-based condom education and its relations with diagnoses of and testing for sexually transmitted infections among men in the United States. Am J Public Health. 2009;99(12):2180-2182. 
  10. Lindemann DF, Brigham TA, Harbke CR, Alexander T. Toward errorless condom use: a comparison of two courses to improve condom use skills. AIDS Behav. 2005;9(4):451-457.
  11. Crosby R, Diclemente RJ, Yarber WL, Snow G, Troutman A. An event-specific analysis of condom breakage among African American men at risk of HIV acquisition. Sex Transm Dis. 2008;35(2):174-177. 
  12. Norris A. Beaton M. Who knows more about condoms? A comparison between nursing students, education students, and at-risk adolescents. MCN Am J Matern Child Nurs. 2002;27(2):103-108.
  13. Lindemann DF, Brigham TA. A Guttman scale for assessing condom use skills among college students. AIDS Behav. 2003;7(1):23-27. 

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