Experiences of condom fit and feel among men in five European nations.
Article Type: Report
Subject: Health promotion (Management)
Condoms (Surveys)
Condoms (Usage)
Men (Health aspects)
Men (Surveys)
Authors: Dodge, Brian
Reece, Michael
Herbenick, Debby
Schick, Vanessa
Pub Date: 09/22/2010
Publication: Name: International Journal of Men's Health Publisher: Men's Studies Press Audience: Academic; Professional Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2010 Men's Studies Press ISSN: 1532-6306
Issue: Date: Fall, 2010 Source Volume: 9 Source Issue: 3
Topic: Event Code: 200 Management dynamics Computer Subject: Company business management
Product: Product Code: 3069770 Prophylactics & Diaphragms NAICS Code: 326299 All Other Rubber Product Manufacturing SIC Code: 3069 Fabricated rubber products, not elsewhere classified
Geographic: Geographic Scope: Slovenia; Spain; France; Germany; Netherlands Geographic Code: 4EXSL Slovenia; 4EUSP Spain; 4EUFR France; 4EUGE Germany; 4EUNE Netherlands
Accession Number: 241277014
Full Text: Findings from recent studies in the United States indicate that some men report they perceive problems with the fit and feel of condoms and that these perceptions are associated with lack of consistent condom use. However, little research has explored how men outside the U.S. feel about the fit and feel of condoms. The research project was conducted by researchers in the U.S. in collaboration with a range of community partners in France, Germany, the Netherlands, Slovenia, and Spain. A total of 2,921 men completed The Condom Fit and Feel Scale and other items via Internet-based surveys available in six languages. Men from each nation were compared using descriptive and multivariate techniques to assess condom fit and feel. Although most men reported they generally perceived condoms to fit fine and feel comfortable, there were differences across men in different countries with regard to specific issues they experienced with condom fit and feel. In particular, men in the Netherlands were least likely to report that condoms fit fine and most likely to report that condoms felt too tight and/or too short. Men from Slovenia were most likely to report that condoms were too loose. The fit and feel issues that men identified may be among those that are associated with their likelihood of using, or not using, condoms consistently and correctly. A better understanding of fit and feel perceptions in this study will be beneficial to both condom manufacturers and health professionals.

Keywords: men, sexual health, Europe, men's health, condoms

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Previous research has explored relationships between penis size and a wide range of sexual health issues (Reece et al., 2007; Reece, Herbenick, & Dodge, 2009; Reece et al., 2008). Complaints about the fit and feel of condoms have often been used by some men to rationalize their lack of correct and consistent condom use (Reece et al., 2009). Although studies to date have identified that most men report they perceive condoms to fit fine and feel comfortable, these studies have also documented that some men perceive condoms to be too tight, too loose, too long, and/or too short. These perceptions have been associated with men's actual penile dimensions (Reece et al., 2009) as well as difficulty in the application of condoms, loss of erection when applying and using condoms, and an increased likelihood of condom failure among samples of men in the United States (Reece et al., 2008). However, previous studies on condom fit and feel have not focused on settings outside the U.S.

Several studies have noted that significant differences in some sexual health indicators exist among young adults in the U.S. and European nations, in particular the Netherlands, Germany, and France (Berne & Huberman, 2000; Lottes, 2002; Santelli, Sandfort, & Orr, 2009). In recent decades, scientists have noted that Northern European nations, in general, seem to differ dramatically from the U.S. in the development of an "egalitarian and permissive sexuality" in their societies (Ketting & Visser, 1994; Lottes; Weinberg, Lottes, & Shaver, 2000). Researchers have suggested that young persons in the Netherlands may be more likely to use condoms and other contraceptive methods more consistently than their American counterparts as a result of their more tolerant societal views regarding sexuality (de Vroome, Paalman, Dingelstad, Kolker, & Sandfort, 1994; Dodge, Sandfort, Yarber, & De Wit, 2005). However, few studies have explored men's perceptions of the structural properties of condoms among European nations. Additionally, although studies have documented numerous reasons why men in these contexts (the Netherlands, in particular) may be more likely to use condoms, few have explored factors related to condom non-use, including condom fit and feel.

The purpose of this study was to assess the psychometric properties of The Condom Fit and Feel Scale in a large sample of men from five nations within the European Union (France, Germany, the Netherlands, Slovenia, and Spain). We also assessed the perceptions of fit and feel across men in these five nations and compared them with one another.

METHODS

Participant Recruitment

The five countries of interest were selected based on ongoing research partnerships with the study team. After convening a community advisory meeting in Amsterdam, the Netherlands, study partners determined the most feasible and effective methods for recruiting participants and collecting data (i.e., Internet and card distribution).

Internet

The research team posted recruitment messages on Europe's three largest condom retail and condom information websites. Recruitment messages were also placed on sexuality and sexual health websites that community partners have identified as leading sources for people seeking information related to sexuality throughout the six nations of interest. Recruitment scripts appeared in English as well as the official language of each country under study.

Card Distribution

The research team distributed recruitment cards at a large condom retailer located in central Amsterdam that attracts visitors from the Netherlands as well as a number of different countries. The recruitment card was given to all male visitors to this store during the period May 15-June 30, 2008. This card was distributed in English and Dutch, but included a link to the study website for those who desired to complete the survey in one of the other four languages.

Instrument Development

The development and translation of the data collection tool involved a multi-step process to ensure the validity and reliability of the instrument. Specifically:

1. The research team conducted a formative evaluation of the instrument (including The Condom Fit and Feel Scale) in English.

2. Certified translators with fluency in the official language of each nation translated the scale items (French, German, Dutch, Slovenian, and Spanish).

3. The research team pilot-tested the instrument in English, French, German, Dutch, Slovenian, and Spanish versions with a small group of monolingual individuals.

4. Based on recommendations, the study team and translators revised each instrument.

5. Each foreign language instrument was back-translated to English to ensure accuracy.

After these steps were followed for each version of the survey, the study team met to identify and resolve any discrepancies with the translators. All study procedures and protocols were approved by the authors' institution.

Total Sample

A total of 2,921 men participated in the study. As is common in online recruitment, a much wider degree of variation than anticipated was observed in the geographical location of respondents (including participants from over twenty countries worldwide). It is also important to note that, as in the U.S. and other national cultures, there was diversity in terms of which country participants were born in relative to their current geographical location. For example, 7% in the Netherlands were not born in the Netherlands but rather Suriname, Indonesia, North Africa, the former Yugoslavia, and so forth. The greatest diversity in terms of country of origin was found in France and the least in Slovenia. In the total sample, small numbers of "other" gender individuals and men who reported an age of under 18 (regardless of the extent to which they had previously agreed that they were 18 or over during consent procedures) also responded to the survey. For the following analyses, respondents were removed if they lived outside the five nations of interest (n = 571), reported a gender other than male (n = 12), and reported that their age was less than 18 (n = 98). This resulted in a sample of 2,350 participants.

Data Analysis

Analyses of the data included descriptive and bivariate statistical techniques. Specifically, we used analyses of variance (ANOVA) to determine if differences were present among men in terms of their mean scores on The Condom Fit and Feel Scale. The alpha level was set at p < 0.05.

RESULTS

Demographic Characteristics

Age and geographical location. The mean age of the 2,350 participants was 33.8 years (SD = 11.7) with a range from 18-88 years old. In terms of geographical location, approximately one half of the participants (50.4%, n = 1184) currently resided in the Netherlands, due in large part to the multiple and intensive methods of recruitment utilized in this nation. Over a quarter of the participants (28.7%, n = 674) lived in France. Nearly equal numbers of participants responded to the survey from Slovenia (7.7%, n = 181) and Germany (7.6%, n = 176). The least number of respondents lived in Spain (5.7%, n = 135).

Sexual orientation/identity. The majority of men (80%, n = 1880) self-identified as heterosexual/straight. Additionally, 9.8% (n = 231) identified as gay and 7.7% (n = 181) identified as bisexual. Smaller numbers of men identified as questioning (2%, n = 46) and "other" (0.5%, n = 12).

Relationship status and sexual relationship status. Nearly half of the sample (41.6%, n = 978) reported currently being in a "partnered" relationship. Approximately one third of the sample (30.9%, n = 725) reported being single. A quarter of participants were currently married (25.7%, n = 603).

In terms of sexual relationships during the previous three months, the majority of men (61.7%, n = 1449) reported being in a sexual relationship with only one person. Sixteen percent of participants (n = 377) reported being in a sexual relationship with more than one person. Approximately equal numbers of men reported being sexually active but not in any relationship (11.3%, n = 265) or reported they were not sexually active (11.0%, n = 258).

Sexual Behaviors and Condom Use

Female partners. Participants were asked to describe their sexual behaviors with women during the previous three months. Nearly three quarters of the participants (76.2%, n = 1584) reported engaging in sexual intercourse with women, including vaginal intercourse (74.2%, n = 1550) and anal intercourse (19.5%, n = 405). Additionally, over one half of the men (52.6%, n = 1092) engaged in vaginal intercourse without a condom and a small number of men (10.7, n = 251) engaged in anal intercourse without a condom. Overall, however, over half of the sample (56.2%, n = 1168) used a condom with a female partner during the previous three months.

Male partners. Participants were also asked to report their sexual behaviors with men during the previous three months. Overall, 17.7% (n = 366) had engaged in sexual intercourse with another male partner, including receptive anal intercourse (10.3%, n = 214) and insertive anal intercourse (13.2%, n = 272). In terms of condom use, 3.9% (n = 81) engaged in receptive anal intercourse without a condom and 4.4% (n = 91) engaged in insertive anal intercourse without a condom. Overall, 11.9% (n = 246) used a condom with a male partner during the previous three months.

The Condom Fit and Feel Scale. Men completed The Condom Fit and Feel Scale, a 14-item Likert type scale on which men report experiences with the fit and feel of condoms (Reece et al., 2007; Reece et al., 2009; Reece et al., 2008). The scale has five subscales, including that condoms fit fine, or are too loose, too tight, too long and too short. An overall score of "condom fit and feel problems" is calculated by reverse scoring the two positive items in the "condoms fit fine" subscale and creating a summed score. In this sample, reliability coefficients of the subscales ranged from 0.70 (in the Spanish version) to 0.89 (in the Dutch version), which is slightly higher than ranges reported in other studies (0.60-0.89) (Reece et al., 2007; Reece et al., 2009; Reece et al., 2008).

Perceptions of condom fit and feel. Table 1 presents overall perception of condom fit and feel within the sample. As in other samples (Reece et al., 2007; Reece et al., 2009; Reece et al., 2008), the majority of men endorsed the notion that condoms fit properly and felt fine. However, notable numbers of men (between 7-36%) also reported that they perceived issues with condoms being too long, too short, too tight, and too lose.

The individual sub-scales of The Condom Fit and Feel Scale were compared across the five nations in order to explore potential relationships among these perceptions and national culture. In order to adjust for unequal sample sizes in subsequent comparisons across these five countries, Scheffe's post-hoc test was used (Harmonic Mean Sample Size = 209.925).

Interestingly, Analyses of Variance (ANOVA) revealed that participants from the Netherlands and Slovenia were most likely to report perceived problems with the fit and feel of condoms within the sample. Overall, Dutch men were least likely to report that condoms fit fine (M = 2.68, SD = .90, p < .0001) and significantly more likely to report that condoms felt too tight (M = 2.12, SD = 0.76, p < .0001) or too short (M = 1.71, SD = .82, p < .0001) on the penis. Inversely, Slovenian men were most likely to report that condoms felt too loose (M = 1.48, SD = .57, p < .01) and fit too long (M = 1.93, SD = .77, p < .0001) on the penis.

DISCUSSION

Thus far, reports of men's perceptions of condom fit and feel and their relations to condom-related behavior have only been assessed in the United States. This study sought to explore issues related to condom fit and feel among men in five European nations. Similar to the United States, the majority of men in these nations reported no perceived problems with the fit and feel of condoms; however, Dutch and Slovenian men, in particular, did express that they had experienced challenges with fit or feel in the past.

As with any national culture, it is difficult to pinpoint exactly what would characterize these men as distinctive in their experiences of using condoms and perceptions of issues related to fit and feel. The Netherlands is lauded for maintaining a record of positive sexual health indicators, often the lowest rates of unintended pregnancy and abortion among Western nations (Ketting & Visser, 1994; Lottes, 2002). In comparing the nations sexual health indicators, Delbanco and colleagues claim that "(w)hile subgroups within each country may differ in their views about sexuality and contraception, the Dutch tend to have a more open, liberal attitude; as a result, sexual health topics may be discussed more freely and pragmatically and in a less moralistic manner in the Netherlands than they are in the United States" (Delbanco, Lundy, Hoff, Parke, & Smith, 1997). It was interesting to us, therefore, that Dutch men reported more concerns with the fit and feel of condoms than men in other nations in this study. Several factors may underlie this. Since rates of condom use tend to be highest among Dutch men compared to men in other nations, they may be more accustomed to using condoms, in general, and thus may be more in line with how condoms fit and feel. Additionally, the wide range of options for men in the Netherlands in terms of types of condoms and progressive retail establishments may present men with a broader experience of different types of sexual health products that may involve issues of fit and feel.

The issues reported by participants in Slovenia are innovative, in that (as yet) very little research on sexuality has been conducted in this nation (Klavs, Rodrigues, Wellings, Weiss, & Hayes, 2009). A small body of epidemiological literature has described rates of sexually transmitted infections and HIV in former Yugoslavia, however no previous studies to date were identified that focus on men's sexual health in Slovenia. The finding that men in this nation were significantly more likely than others to report specific issues related to the fit and feel of condoms warrants further investigation since little is known about the range of condom products available to men in this country.

Given that little information exists on men's perceptions of condom fit and feel, in general, the descriptive results of men's experiences in the other three countries under study that did not stand out in terms of statistical significance (France, Germany, and Spain) are open for interpretation. Future research should investigate men's experiences of using condoms in these, and other, settings in order to determine if these findings have any potentially positive or negative implications.

Limitations

This study is not without its limitations. Similar to other studies in this area, we used convenience sampling, and findings therefore have limited generalizability. Recruitment via the Internet includes unique benefits and limitations, including the inability to sample individuals without Internet access. Additionally, the use of a community-based partnership approach to sampling with an internet-based survey across five distinct national cultures was complex. However, one of the major insights from this study was the experience gained from the partnership perspective. Europe is fortunate to have retail establishments (e.g., Condomerie) in which individuals can go to "experts"/"peer educators" to seek advice on condoms, in general. This model has not yet been fully explored in the U.S. and may be of interest to sexual health researchers and practitioners in the future.

Implications

Since the promotion of condom use is a core component of many sexual health promotion efforts, a deeper understanding of perceived condom fit and feel will be useful to those who manufacture and promote the use of condoms in numerous contexts, including those that were the focus of the present study. As the global condom marketplace continues to evolve and more diverse products are introduced, those who promote condoms globally may be able to facilitate men's ability to find condoms that they will perceive as better fitting or more comfortable, which may subsequently increase the likelihood that these men will use condoms more consistently and correctly.

DOI: 10.3149/jmh.0903.175

REFERENCES

Berne, L.A., & Huberman, B.K. (2000). Lessons learned: European approaches to adolescent sexual behavior and responsibility. Journal of Sex Education & Therapy, 25(2/3), 189-199.

de Vroome, E.M., Paalman, M.E., Dingelstad, A.A., Kolker, L., & Sandfort, T.G.M. (1994). Increase in safe sex among the young and non-monogamous: Knowledge, attitudes and behavior regarding safe sex and condom use in The Netherlands from 1987 to 1993. Patient Education And Counseling, 24(3), 279-288.

Delbanco, S., Lundy, J., Hoff, T., Parke, M., & Smith, M.D. (1997). Public knowledge and perceptions about unplanned pregnancy and contraception in three countries. Family Planning Perspectives, 29(2), 70-75.

Dodge, B., Sandfort, T.G.M., Yarber, W.L., & De Wit, J. (2005). Sexual health among male college students in the United States and the Netherlands. American Journal of Health Behavior, 29(2), 172-182.

Ketting, E., & Visser, A.P. (1994). Contraception in The Netherlands: The low abortion rate explained. Patient Education And Counseling, 23(3), 161-171.

Klavs, I., Rodrigues, L.C., Wellings, K., Weiss, H.A., & Hayes, R. (2009). Sexual behaviour and HIV/sexually transmitted infection risk behaviours in the general population of Slovenia, a low HIV prevalence country in central Europe. Sexually Transmitted Infections, 85(2), 132-138.

Lottes, I.L. (2002). Sexual health policies in other industrialized countries: Are there lessons for the United States? Journal of Sex Research, 39(1), 79-83.

Reece, M., Dodge, B., Herbenick, D., Fisher, C., Alexander, A., & Satinsky, S. (2007). Experiences of condom fit and feel among African-American men who have sex with men. Sexually Transmitted Infections, 83(6), 354-357.

Reece, M., Herbenick, D., & Dodge, B. (2009). Penile dimensions and men's perceptions of condom fit and feel. Sexually Transmitted Infections, 85(2), 127-131.

Reece, M., Herbenick, D., Sanders, S.A., Monahan, P., Temkit, M., & Yarber, W.L. (2008). Breakage, slippage and acceptability outcomes of a condom fitted to penile dimensions. Sexually Transmitted Infections, 84(2), 143-149.

Santeili, J., Sandfort, T.G.M., & Orr, M. (2009). U.S./European differences in condom use. The Journal of Adolescent Health: Official Publication of the Society for Adolescent Medicine, 44(3), 306-306.

Weinberg, M.S., Lottes, I., & Shaver, F.M. (2000). Sociocultural correlates of permissive sexual attitudes: A test of Reiss's hypotheses about Sweden and the United States. Journal of Sex Research, 37(1), 44-52.

Brian Dodge (a), Michael Reece (a), Debby Herbenick (a), and Vanessa Schick (a)

(a) Center for Sexual Health Promotion, Indiana University at Bloomington.

The authors sincerely appreciate the time, insight, and collaboration of Theodoor van Boven of Condomerie Amsterdam and our other European community partners, without whom this study would not have come to fruition. We would also like to thank the reviewers of this manuscript for their constructive feedback on earlier drafts of this manuscript.

Correspondence concerning this article should be addressed to Brian Dodge, Ph.D., Indiana University, Department of Applied Health Science, Center for Sexual Health Promotion, HPER 116, Bloomington, IN, 47405. Email: bmdodge@indiana.edu
Table 1
Proportion of Participants Strongly Endorsing * Items on The
Condom Fit and Feel Scale (N = 2350)

Scale items by subscale                                      n (%)

Condoms fit fine

Condoms feel comfortable once I have them on my penis     1433 (68.0)
Condoms fit my penis just fine                            1097 (52.0)

Condoms are too long

Condoms are too long for my penis                          364 (17.3)
I have some unrolled condom left at the base of my penis
  after I unroll it                                        630 (29.9)

Condoms are too short

Condoms are too short for my penis                         294 (13.9)
Condoms will not roll down far enough to cover
  my penis completely                                      350 (16.6)

Condoms feel too tight

Condoms are too tight on my penis                          764 (36.2)
Condoms fee too tight along the shaft of my penis          622 (29.5)
Condoms feel too tight on the head of my penis             492 (23.3)
Condoms feel too tight around the base of my penis         621 (29.5)

Condoms feel too loose

Condoms are too loose on my penis                          175 (8.3)
Condoms feel too loose along the shaft of my penis         169 (8.1)
Condoms feel too loose around the head of my penis         186 (8.8)
Condoms feel too loose around the base of my penis         159 (6.8)

* Proportion of participants responding "often applies or always
applies" to each scale item.
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