Condoms are the only form of contraception that prevent both sexually transmissible infections (STI) and pregnancy, but little information is available on condom use by women attending general practice, which is where most women seek contraceptive advice and prescriptions.1 In Australia, in the past decade, reported cases of gonorrhoea have almost doubled, syphilis has tripled and chlamydia has increased by 43%,2,3 despite the sustained public health efforts in Australia to combat this trend. Used alone, condoms are not as effective in preventing pregnancy as other modern contraceptive methods because they require active use for every act of sexual intercourse, they can break or slip off and might not be used correctly. Therefore, for the purpose of pregnancy prevention, it is recommended that they be used correctly and consistently in conjunction with another form of contraception.4
Consistent and correct condom use is affected by a number of factors. These include age and relationship type (whether long term or casual) and number of current partners.5,6 Low confidence in the ability to negotiate condom use in challenging situations (low condom use self-efficacy) has also been identified as a factor relating to inconsistent or incorrect condom use.7 The Contraceptive CHOICE project,8 using challenging hypothetical situations, found that lower condom use self-efficacy, as well as lower partner willingness, was correlated with higher risk of incorrect or inconsistent condom use.7 In some studies, male preference for condom use was found to be more influential than female preference.9–11
In an Australian telephone survey of more than 5000 women, condom use was reported by approximately 30% of women aged 16–49 years.12 The important role of general practitioners (GPs) in primary care in providing advice and prescriptions for contraception is described by Temple-Smith and Sanci.13 Despite this, there is a paucity of information regarding condom use among women attending general practice, possibly because condoms are available without prescription, with women accessing condoms through retail outlets or pharmacies. Other studies examining condom use focus on women from the community at large,6–8,12 women using specialised sexual health services14 and adolescent females.15 Understanding condom use in the context of general practice will inform practitioners regarding their contraceptive counselling. Within the Australian literature, there is little information on condom use self-efficacy. The aim of this study was to describe the use of condoms by women attending general practice and their perception of their ability to negotiate condom use.
Methods
Study design and setting
In this secondary analysis, the authors used data collected from the Australian Contraceptive ChOice pRoject (ACCORd) study (a cluster randomised controlled trial investigating the effect of a complex intervention aimed at increasing the uptake of long-acting reversible contraception [LARC]) in the general practice setting.16 Data were collected between April 2016 and July 2018 from 720 women attending 56 general practices in metropolitan Melbourne, Australia.
Participants
Eligible women were aged between 16 and 45 years, neither pregnant nor planning a pregnancy in the subsequent 12 months, had been sexually active in the previous six months or anticipating sexual activity in the following six months, had not undergone tubal sterilisation (and partner had never had a vasectomy), proficient in English and interested in discussing contraception with their GP. They were recruited from general practices by either GPs or reception staff; potential participants were handed an iPad to complete an eligibility form.
Data
All eligible women were contacted by ACCORd researchers, and those who agreed to participate provided informed consent and completed a 30-minute telephone interview. This involved collection of demographic information, including age, level of education, country or birth, marital status and socioeconomic status. Current condom use was self-reported. Participants were asked whether they currently used condoms, and those selecting ‘yes’ were included in this analysis. Participants were able to select more than one form of contraception in order to identify the use of dual methods of contraception.
Using Likert scales with a validated self-efficacy model,17 women currently in a relationship rated their perception of their partner’s willingness to use condoms (not at all willing/not very willing/somewhat willing/extremely willing), their perception regarding who had the final say of condom use (partner has more say/equal say/woman has more say/not discussed) and their confidence in negotiating condom use with male partners during various hypothetical and challenging situations (when alcohol or drugs were used, when partner was annoyed, if sexually excited, if depressed or if the risk of contracting STI or pregnancy was low).7
Analysis
The characteristics of the women were summarised using counts and percentages. Using descriptive statistics, the authors reported the women’s level of satisfaction and frequency of condom use, as well as perceived partner’s willingness and whether the woman or her partner had had final say in the use of condoms. The authors calculated the percentage of women reporting varying levels of certainty of using condoms in various hypothetical situations and compared the odds of being certain across the situations using a proportional odds model, which was adjusted across situations for each woman. Logistic models were fitted to assess the relationship between participant characteristics and being unsure of using a condom and whether the effect of the characteristics differed according to the situation. In the single proportional-odds model and logistic models, the authors adjusted parameter estimates to allow for the multiple responses per woman, as each woman contributed a separate response for each of the hypothetical situations.
Ethics
This trial is registered with the Australian New Zealand Trials Registry (ACTRN12615001346561). The ACCORd study was approved by the Monash University Human Research Ethics Committee (CF14/3990-2014002066 and CF16/188-2016000080).
Results
The eligibility survey was completed (or partially completed) by 2256 women, of whom 720 were eligible and participated in the ACCORd study. Of the 698 women who completed the questions regarding contraception in the baseline questionnaire, 43% (325/698) reported current condom use. This article reports the results of the analyses of data from these 325 women. Eighty-one per cent (263/325) reported having a regular partner in the past 30 days. Most of these women were born in Australia and aged less than 35 years (Table 1). Women were more likely to cite STI prevention as their reason for using condoms if they reported having casual sex in the previous 30 days (92% versus 42%, P <0.001). Over half of the condom users (58%, 188/325) used them in combination with another method (dual contraception). Women frequently used condoms with oral contraception (n = 123, 36%), whereas fewer than 20% used them with intrauterine devices or contraceptive implants (Table 2). Most condom users (72%, n = 233/325) reported being very satisfied with them. Of those who reported being dissatisfied with condom use, the most common reason given was that they were too hard or inconvenient to use (n = 64, 41%). Reduced sexual pleasure was reported by 32% (n = 105), and 17% (n = 54) reported that their partners disliked using them. Three women currently using only condoms, but who were dissatisfied with them, reported that this method had previously failed, with a resulting pregnancy.
| Table 1. Demographics of ACCORd participants26 |
| Characteristic |
Those using
condoms (n = 325)
n (%) |
Those not using condoms (n = 415)
n (%) |
| Age (years) |
| <25 |
128 (39) |
139 (34) |
| 25–34 |
129 (40) |
155 (37) |
| >35 |
68 (21) |
121 (29) |
| Highest level of education |
| University |
197 (60) |
238 (57) |
| Certificate/diploma |
25 (8) |
37 (9) |
| Year 12 or below |
103 (32) |
140 (34) |
| Country of birth |
| Australia |
263 (81) |
324 (78) |
| Other |
61 (19) |
90 (22) |
| Data missing |
1 (<1) |
1 (<1) |
| Marital status |
| Married/de facto* |
114 (35) |
203 (49) |
| Not married/de facto |
210 (65) |
212 (51) |
| Data missing |
1 (<1) |
0 (0) |
| Socioeconomic status |
| Low† |
86 (27) |
114 (28) |
| Not low |
239 (73) |
301 (72) |
*De facto: living with partner
†Low socioeconomic status: difficulty paying for housing/food/transport/healthcare card holder26
ACCORd, Australian Contraceptive ChOice pRoject |
| Table 2. Current dual contraception in ACCORd16* |
| |
Condoms
n (%) |
Oral
contraception
n (%)† |
Contraceptive implant
n (%) |
Intrauterine devices
n (%) |
Injectable
n (%) |
Contraceptive
ring‡
n (%) |
Natural§
n (%) |
| Total number reporting method |
325 (47) |
342 (49) |
79 (11) |
68 (9) |
11 (2) |
6 (<1) |
10 (1) |
| Used in combination with condoms |
137‖ (42) |
123 (36) |
13 (17) |
13 (19) |
5 (45) |
3 (50) |
3 (30) |
*Contraceptive patch and contraceptive sponge are not used in Australia, and no women reported using the diaphragm
†Combined oestrogen/progestogen or progestogen only
‡Combined oestrogen/progestogen
§Fertility awareness–based methods
‖Condoms used alone for contraception
ACCORd, Australian Contraceptive ChOice pRoject |
Willingness to use condoms
Among current condom users with a regular partner, most (72%, 190/261) perceived that their partners were extremely willing to use condoms, including those using dual protection (Table 3). Where condoms were used as the sole form of contraception, 76% (88/155) reported their current partner to be extremely willing (Table 3). Of the women who reported only using condoms for contraception, and who also reported having sex in the previous 30 days (n = 119), 90 (76%) reported using condoms every time, with the remainder using them almost every time (13%), sometimes (8%) or rarely (3%). There was no difference in reported willingness to use condoms between those who used condoms alone for contraception and/or STI protection and those who used dual methods.
| Table 3. Perceived willingness of regular partner to use condoms* |
| Perceived partner response |
n (%) |
| If condoms used with other contraception |
| Not willing |
8 (5) |
| Somewhat willing |
32 (22) |
| Extremely willing |
102 (70) |
| Do not know |
4 (3) |
| Total |
146 (100) |
| If only condoms used for contraception |
| Not willing |
6 (5) |
| Somewhat willing |
21 (18) |
| Extremely willing |
88 (76) |
| Do not know |
1 (1) |
| Missing |
2 (0) |
| Total |
117 (100) |
| *Women reporting a male regular sexual partner. The number of women who reported casual partners (defined as a sexual partner apart from their regular partner in the past 30 days) and those who reported degree of willingness of partner (13%, 3/23) was too low for meaningful comparison. No women reported both a regular partner and a casual partner. |
Final say on condom use
Of the women currently using condoms and who had a regular partner, the majority (60%, 87/146) reported equal say in the use of condoms, and very few reported that their partner had more say (Table 4). Fewer women felt that they had more say in decision making regarding condom use if they were with a regular partner compared with those reporting a casual relationship. Compared with women using dual protection, fewer women using only condoms for contraception reported having more say than their partner (24% versus 37%, n = 29/123 versus n = 63/169, P = 0.02).
| Table 4. Who has final say on using condoms? |
| Partner response* |
Regular partner (n = 263)
n (%) |
Casual partner
(n = 29)*
n (%) |
| If condoms used with other contraception (ie dual contraception) |
n = 146 |
n = 23 |
| Partner has more say |
4 (3) |
0 (0) |
| Equal say |
87 (60) |
9 (39) |
| Woman has more say |
50 (34) |
13 (57) |
| Do not discuss |
3 (2) |
1 (4) |
| Do not know |
2 (1) |
0 (0) |
| If only condoms used for contraception |
n = 117 |
n = 6 |
| Partner has more say |
1 (0.85) |
1 (17) |
| Equal say |
85 (73) |
1 (17) |
| Woman has more say |
25 (21) |
4 (66) |
| Do not discuss |
5 (4) |
0 (0) |
| Do not know |
1 (0.85) |
0 (0) |
| *Some women did not answer this question (n = 33). The number of women who had casual partners and used condoms only for contraception was too low for meaningful comparisons. |
Women’s perceived ability to negotiate condom use in challenging situations
All women were asked whether particular hypothetical situations would affect their decision making, even if they knew that condoms were needed to prevent pregnancy or potential transmission of STI (Table 5). Women were more likely to report being unsure about being able to use a condom in a hypothetical situation where they were drunk or high compared with the other hypothetical situations (P <0.001). Thirteen per cent of women reported being unsure they would use a condom when drunk or high, compared with 8–10% reporting such uncertainty in the context of other situations.
| Table 5. Women’s perceived certainty of condom use according to situation |
| Women’s level of certainty with condom use |
Even if
drunk/high
n (%) |
Even if partner annoyed
n (%) |
Even if sexually excited
n (%) |
Even if
depressed
n (%) |
Even if risk seemed low
n (%) |
| Unsure |
41 (13) |
25 (8) |
27 (8) |
22 (7) |
33 (10) |
| Somewhat sure |
75 (14) |
41 (13) |
69 (21) |
39 (13) |
72 (23) |
| Very sure |
196 (63) |
247 (79) |
227 (71) |
252 (80) |
218 (67) |
| Total |
312 |
313 |
323 |
313 |
323 |
The hypothetical situation was associated with the level of certainty of using condoms in the multivariate model; however, other factors (age, education, marital status and economic status) were not associated with the level of certainty (Table 6).
| Table 6. Women who reported being unsure, by participant characteristic and hypothetical situations26 |
| Factor |
Even if drunk/high (%) |
Even if partner annoyed (%) |
Even if sexually excited (%) |
Even if
depressed (%) |
Even if risk
seemed low (%) |
| Age (years) |
| <25 |
13 |
7 |
7 |
5 |
4 |
| 25–34 |
14 |
7 |
9 |
9 |
13 |
| >35 |
11 |
7 |
9 |
4 |
13 |
| Highest level of education |
| University |
13 |
6 |
8 |
8 |
10 |
| Certificate/diploma |
14 |
5 |
18 |
0 |
18 |
| Year 12 or below |
13 |
9 |
6 |
6 |
5 |
| Country of birth |
| Australia |
13 |
7 |
8 |
5 |
8 |
| Other |
13 |
4 |
9 |
13 |
15 |
| Marital status |
| Married/de facto* |
14 |
8 |
9 |
9 |
15 |
| Not married/de facto |
13 |
7 |
8 |
6 |
7 |
| Socioeconomic status |
| Low† |
13 |
6 |
8 |
5 |
9 |
| Not low |
13 |
7 |
8 |
7 |
10 |
*De facto: living with partner
†Low socioeconomic status: difficulty paying for housing/food/transport/healthcare card holder |
Discussion
To the authors’ knowledge, this is the first study reporting the use of condoms for contraception by women attending general practice. Condom use was reported by 47% (325/698) of women. Previous studies have estimated that condoms are used in Australia by approximately 30% of couples for both contraception and the prevention of STI.12 The higher proportion of condom users in the ACCORd study reflects the fact that 75% of women in the sample were aged under 35 years, which correlates with lower patterns of condom use reported in other studies of older women.6,12 Women in a long-term relationship often perceive themselves to be at low risk for STI, and therefore, are less likely to use condoms.6,12,18
Women’s perceived ability to negotiate condom use in challenging situations was significantly lower when alcohol or substance use was involved. Previous studies have confirmed an association between unintended pregnancy and alcohol/substance use and increased risk of STI.19 Other authors have indicated that, especially in younger age groups, both sexual negotiation and intention are affected by substance use.20 In the Contraceptive CHOICE project, women who were more uncertain about their use of condoms in hypothetical situations were twice as likely to report episodes of unprotected sexual intercourse as those with a higher level of certainty.8
Condoms were used as the sole method of contraception by 42% (137/325) of women in the present study. Similar to a large study of female students in the USA,15 fewer than 20% of women used condoms together with LARC, compared with 36% who used condoms with oral contraceptive pills. A recent systematic review and meta-analysis confirmed that the odds of using condoms with LARC was 60% lower than the use of condoms, as well as oral contraceptives.15 This may reflect the reduced need to have back-up contraception with LARC methods than for other less effective forms of contraceptives.21 Lower use of condoms with LARC has implications for STI prevention, but a woman’s individual level of risk should be assessed considering her relationship status and number of sexual partners.22
Most women reported high levels of satisfaction with condoms. One of the main reasons for a lack of satisfaction cited by women in the present study was partner dislike of condoms. Whether a male partner is willing to use condoms affects their use in a relationship, with women less likely to use condoms if their partners were not willing to use them.14,23 In the US CHOICE study, a lack of willingness to use condoms by a male partner correlated with a higher number of unprotected sexual encounters.7 In the present study, most women (those with and without a regular male partner) reported that their partners demonstrated some degree of willingness to use condoms, but only half reported that the men were extremely willing. This reported low level of enthusiasm for condom use is associated with inconsistent use.11 In 2009, a secondary analysis of the US CHOICE study data found that 59% of the cohort reported consistent condom use.7 More than 10 years later, little has changed. In the present study, even with women with extremely willing partners who only used condoms for contraception and had sex in the previous 30 days, 20% reported not using condoms, putting them at increased risk of STI and unintended pregnancies.
Although most women in the present study reported that the decision to use condoms was equally shared between themselves and their partners, fewer women reported having more say in the decision to use a condom if they were with a regular partner compared with those in a casual relationship. A higher number of women with casual partners reported condom use, a finding that aligns with other studies reporting higher use of condoms with non-regular partners, usually for STI prevention.24,25 Potentially, GPs could have a role in empowering women with decision making regarding the use of condoms by normalising the purchase and initiation of condoms and encouraging them to keep a supply of condoms on hand.
GPs are at the forefront of contraceptive care. This study is one of the first to examine condom use by patients attending general practice and demonstrates the near universality of inconsistent condom use. A strength of this study is that the interviews were conducted using study tools from the successful Contraceptive CHOICE study,8 which were then adapted for the Australian context.
Strengths and limitations
One limitation of this study is that a very small number of women used only condoms for contraception, and a low number of women reported having casual partners. Consequently, the study may not have been adequately powered to detect a difference between these women and those who used condoms together with other contraceptive methods. However, the overall results provide a picture of the complexity around women’s decision making regarding condom use, highlighting the influence of situations and sexual partner on the use of condoms. As this population was drawn from a subgroup of a randomised controlled trial, the benefits of randomisation are no longer present, and the potential for confounding exists. Additionally, eligible women were participants in a trial in general practice who were interested in discussing contraception, and this may limit generalisability of these findings to the wider population. It is likely that, even amongst GPs with a keen interest in women’s health, condoms are not commonly discussed. Another limitation is that the study sample was well educated, mostly from high socioeconomic status and from metropolitan Melbourne, and these results may not be generalisable to the wider population.
Conclusion
Women’s intentions to use condoms to prevent pregnancy and STI, and their confidence in their ability to negotiate condom use, can be thwarted by lack of partner compliance, as well as various situational factors. Women may need encouragement to purchase, initiate and use condoms in order to avoid the consequences of STI and unintended or unwanted pregnancies, particularly if condoms are the sole form of contraception being used. GPs should use opportunities in primary care to encourage individuals to discuss contraceptive preferences before sexual encounters. For women using condoms as the sole method of contraception, discussions about partner willingness and alcohol use may alert the GP to those at risk for unintended pregnancies and STI, and to the importance of discussing the most effective methods of contraception. Future research could focus on GP interventions to increase condom use to prevent STI, particularly among women using LARC methods.