Teaching Condom Use Skills: Hands on Practice is Superior to Observation Donald Calsyn, Ph.D. 1,2, Mary Hatch-Maillette, Ph.D. 1, Suzanne R. Doyle, Ph.D. 1, Sarah Cousins, M.A. 3, TeChieh Chen, B.A. 4 1 Alcohol & Drug Abuse Institute and 2 Department of Psychiatry & Behavioral Sciences, University of Washington, Seattle, WA 3 Matrix Institute, Rancho Cucamonga, CA 4 University of California San Francisco

Abstract Objectives: HIV/STI prevention efforts with substance abusers usually include a condom use skills component. We hypothesized that participants exposed to a “hands on” practice exercise would perform better on condom use skills measures than those exposed only to a demonstration of correct condom use. We predicted that both groups would perform better than participants exposed to neither intervention. Methods: Men in substance abuse treatment who enrolled in a randomized comparison of a five session (over 3 weeks), gender-specific HIV prevention intervention with a single-session HIV education intervention, were administered male and female condom use skills measures (MCUS, 14 items, FCUS, 11 items). Measures were given at pre-intervention and at two weeks post- intervention. This report focuses on men exposed to the demonstration only (DO, n=141), men exposed to the demonstration plus a “hands on” exercises (HO, n=104), and enrolled men who attended no sessions (NS, n=109). Outcome variables were post-intervention MCUS and FCUS total scores, with baseline MCUS and FCUS scores as covariates. Results: Analyses of covariance on the post-intervention scores (baseline scores served as covariates) comparing DO, HO, and NS groups on the MCUS (F=68.05, p<.0001) and the FCUS (F=60.24, p<.0001) were significant. Post hoc analyses (Bonferonni corrected) indicated that at post intervention, the HO group scored significantly higher on the MCUS (M=10.88, SD=2.14) than the DO (M=8.94, SD=2.33) and NS (M=7.72, SD=2.29) groups. Post hoc analyses also indicated that at post intervention, the HO group scored significantly higher on the FCUS (M=8.68, SD=2.05) than the DO (M=6.84, SD=2.07) and NS (M=5.38, SD=2.02) groups. The DO group scored significantly higher than the NS group on both the MCUS and FCUS. Conclusion: A “hands on” practice of condom use was superior in teaching condom use skills than a condom use demonstration, which in turn was superior to no intervention.

Background HIV/STI prevention programs with substances abusers routinely emphasize the importance of using condoms. To achieve maximum protection condoms need to be used correctly. Incorrect application and use can lead to condom failure. Some HIV/STI prevention programs emphasize the importance of using condoms without demonstrating their correct usage. Some programs demonstrate correct condom use by having a facilitator demonstrate the correct way to apply a condom to a model. Some programs have participants practice applying the condoms to models. Lindemann et al. (2005) demonstrated that with college students condom use skills improved after watching a demonstration on correct condom use compared to no intervention. Condom use skills improved more if the demonstration was accompanied by practice sessions. In the NIDA Clinical Trials Network Protocol 0018, “HIV/STD safer sex skills groups for men in methadone maintenance or drug free outpatient treatment programs” we were able to assess whether similar results could be found for men attending substance abuse treatment. Hypothesis 1. Men attending a single session HIV prevention intervention during which the correct use of condoms is demonstrated (demonstration only) will perform better on a condom use skills measure than men attending no intervention sessions. Hypothesis 2. Men attending the two sessions (of a five session HIV prevention intervention), during which the correct use of condoms is demonstrated and the correct use of condoms is practiced (hands on) will perform better on a condom use skills measure than men attending the one session intervention with the demonstration only. References. Lindemann, D.F., et al. (2005). Towards errorless condom use: A comparison of two courses to improve condom use skills. AIDS and Behavior, 9, 451,457.

Methods Subjects. Men enrolled in one of 14 substance abuse treatment programs across the US were recruited to take part in an HIV/STI prevention project specifically tailored for men (NIDA Clinical Trials Network Protocol 0018). Inclusion criteria included age of 18 or more, engagement in unprotected vaginal or anal intercourse in the prior 6 months, willingness to attend HIV/STI prevention groups and complete assessments at baseline and at 2 wk., 3 mo., 6 mo. post intervention. Exclusion criteria included having a primary partner planning to get pregnant or a Mini Mental Status Exam Score< 25. This report focuses on men who completed the baseline assessment and the 2 wk. post intervention assessment and who: 1) attended the single session HIV- Ed (demonstration only) group (n=141), 2) attended sessions 1 and 2 of the Real Men are Safe (hands on) group (n=104) and men who were randomized to one of the two interventions, but attended no sessions (n=109). Demographics for the sample are provided in Table 1.

Table 1

Methods (cont.) Procedures. The study schema is presented in Figure 1. This report focuses on data regarding condom use skills measured at the baseline assessment and at the 2 wk. post-intervention assessment. Presented in Table 2 are the items for the male condom use skills measure (MCUS, 14 items) and the female condom use skills measure (FCUS, 11 items.) For the MCUS five types of condoms and four types of lubricant are placed on a table in front of the participant along with a penile model like the one in Figure 2. Participants are asked to apply and remove the condom from the model, verbalizing what they are doing as they do it. Participants receive a point for each step they demonstrate correctly. For the FCUS a female condom and a pelvic model like the one in Figure 2 are placed on the table. The application/removal instructions are repeated. Scoring proceeds as above. A limitation to the scoring method was using an equal weight for each item. Some items such as “getting all the air out,” maybe more salient for preventing condom failure than others such as “check date.” Data Analysis. The three attendance groups are compared on the 2 wk. post- intervention MCUS and FCUS scores by means of separate analyses of covariance with baseline MCUS and FCUS serving as covariates, respectively. Post hoc analyses, consisting of pair-wise comparison of adjusted group means with Bonferonni correction, were conducted to address the limitation of using equal weights in scoring the MCUS and FCUS.

Figure 1: Study Schema Advertise Study Availability  Consent to Screen for Inclusion/Exclusion & Screening Assessment  Obtain Informed Consent from Eligible Participants  Conduct Baseline Assessment → Place in Waiting Cohort  Randomly Assign Cohort to Intervention   Standard HIV Education Gender Specific Intervention (one session) (five sessions)   Conduct Post Intervention Assessment  Conduct Three Month Follow Up Assessment  Conduct Six Month Follow Up Assessment

Figure 2: Condom Demonstration and Practice Materials

Table 2: Condom Skills Measures Male condom skill list Chose a latex condom Chose a water-based lubricant Expiration date on package is checked Package is opened carefully Condom checked for damage Determined direction in which condom rolls Condom rolled correctly downward Condom rolled to base of penis Air removed from condom Space left at tip of condom Lubricant added to inside tip of condom or penis Turned to the side and withdrew condom Took care to avoid spilling Tied off condom and disposed of in trash Female condom skill list Expiration date on package is checked Package is opened carefully Condom checked for damage Condom unrolled and the two rings separated Condom rubbed gently to evenly spread the lubricant Inner ring squeezed between fingers Inner ring pushed into vaginal canal while squeezed Inner ring placed against cervix so that it is completely covered Outer ring covers outside of vagina End of condom is twisted and removed by pulling, with care taken not to spill its contents Condom disposed of in a trash can

Table 3: Outline of the HIV/STI Prevention Interventions HIV Education (one session) I. Group Introductions. Goals and Guidelines 5 Min II. HIV/AIDS Update10 Min III. HIV Risky Behaviors, injection practices5 Min IV. HIV Risky Behaviors, sexual practices10 Min V. Healthy Options 10 Min VI. Condom demonstrations 10 Min VII. Overcoming Barriers to Condom Use10 Min Real Men are Safe Session 1. HIV/AIDS Update: Identifying Risks I. Group Introductions. Goals and Guidelines10 Min II. Getting Started10 Min III. HIV Risky Behaviors Exercise 15 Min IV. HIV/AIDS Update15 Min V. HIV Risky Behaviors, injection practices10 Min VI. HIV Risky Behaviors, sexual practices10 Min VII. Condom demonstration10 Min VIII. Revisit Risky Behaviors Exercise10 Min Real Men are Safe Session 2. HIV/AIDS Update: Planning Prevention I. Welcome, redo introductions 5 Min II. Healthy Options 10 Min III. Barriers to Condom Use10 Min IV. Condom Practice 20 Min V. Identifying Triggers25 Min VI. Risk Reduction Problem Solving20 Min

Results 1.The three attendance groups differed significantly on the Male Condom Use Skills (MCUS) measure at post intervention when the baseline MCUS is used as a covariate (Fmodel=68.05, p<.0001; Fgroups=68.21, p<.0001; Fcovariate=76.64, p<.0001). In post hoc analyses men attending demonstration + practice sessions scored higher than men attending a demonstration only session, who scored higher than men attending no sessions (for all comparisons, p<.001). Means scores at baseline and post intervention assessments are presented in Figure 3. 2.The three attendance groups differed significantly on the Female Condom Use Skills (FCUS) measure at post intervention when the baseline FCUS is used as a covariate (Fmodel=63.75, p<.0001; Fgroups=78.72, p<.0001; Fcovariate=47.21, p<.0001). In post hoc analyses men attending demonstration + practice sessions scored higher than men attending a demonstration session only, who scored higher than men attending no sessions (for all comparisons, p<.001). Means scores at baseline and post intervention assessments are presented in Figure 3.

Figure 3: Condom use skills at post-intervention as a function of intervention attendance ♂ ♂ condoms* ♀ ♀ condoms* * Hands On>Demo Only>None

Results (cont.) 3. Presented in Figure 4 are the percent responding correctly to each MCUS item as a function of attendance groups. The demonstration + practice group scored higher than the demonstration only and no attendance groups on the following items: Checking date, checking for damage, getting air pockets out avoiding spills upon removal, disposing in the trash. The demonstration + practice group scored higher than the no attendance groups on the following items: Choosing a water-based lube, leaving space in the tip adding lube, moving away from partner after removal. 4. Presented in Figure 5 are the percent responding correctly to each FCUS item as a function of attendance groups. The demonstration + practice group scored higher than the demonstration only and no attendance groups on the following items: Checking date, checking for damage, spreading the lube evenly. The demonstration + practice and the demonstration only groups scored higher than the no attendance groups on the following items: Squeezing the inner ring between finger for insertion, pushing inner ring into vaginal canal while squeezed, getting inner ring over cervix, twisting outer ring and pulling for removal, disposing in trash. The demonstration + practice group scored higher than the no attendance groups on the following items: Opening package carefully, separating the rings, ensuring outer ring covered vaginal opening.

Figure 4: Male Condom Use Skill Items as a Function of Group Attendance ♂ Condom Skill Item *Hands On>Demo Only>None * * * * ^Hands On>Demo Only # !Hands On>None #Hands On>Demo Only & None ^ ! ! ! !

Figure 5: Female Condom Use Skill Items as a Function of Group Attendance ♀ Condom Skill Item #Hands On>Demo Only & None *Hands On>Demo Only>None ^Hands On&Demo Only>None * # # ! ^ ^ ^ ! Hands On>None ^ ^ ! !

Conclusions  Men attending HIV/STI prevention interventions while in substance abuse treatment can effectively be taught correct condom use skills.  Teaching skills by demonstration was more effective than no intervention, but less effective than having participants perform “hands on” practice.  Differences observed included performance on items critical to preventing male condom failure such as “getting the air out,” “using water based lubricant,” leaving space in the tip” and “avoiding spills during withdrawal and removal.” Differences observed on critical female condom skill items included “spreading the lubricant evenly,” twisting outer ring and pulling for removal” and “ensuring outer ring covered vaginal opening.” Acknowledgements  Supported by NIDA (1 U10DA , Dennis Donovan, PI).  The authors wish to thank the CTN 0018/0019 lead node teams, the 23 RRTC and site PIs, the 15 site coordinators, the 21 research assistants, the 15 therapy supervisors, and the 29 therapists who worked on this project.

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