Correct Condom Use Self-Efficacy Scale

Abstract

The Correct Condom Use Self-Efficacy Scale (CCUSS) is a concise, 7-item psychometric instrument developed to evaluate an individual’s perceived confidence in their capability to execute specific technical and behavioral tasks required for the correct and consistent application, maintenance, and removal of male latex condoms. Originating from the collaborative public health and behavioral science research of Richard A. Crosby, Cynthia A. Graham, Robin R. Milhausen, Stephanie A. Sanders, and William L. Yarber, the scale directly addresses a critical methodological limitation of earlier sexual health instruments: the conflation of global self-efficacy, general condom acquisition intentions, or social negotiation skills with actual operational competence in condom mechanics. Items reflect empirical findings regarding the most prevalent behavioral errors and mechanical problems documented during male condom use, spanning the complete sequence of sexual activity from pre-coital preparation (selection, sizing, and proper application) through active intercourse (preventing condom slippage, breakage, and drying out, as well as sustaining erection) to post-coital management (maintaining retention upon withdrawal). Administered via a 5-point Likert-type response scale ranging from 1 (Very Difficult) to 5 (Very Easy), total composite scores range from 7 to 35, where higher scores signify greater technical condom use self-efficacy. Initial validation within an urban sexually transmitted infection (STI) clinic sample yielded an internal consistency coefficient of α = .70 and established robust criterion validity, demonstrating significant negative associations with self-reported condom breakage, slippage, and operational errors. The CCUSS serves as an essential measurement tool in public health epidemiology, sexual medicine, clinical health psychology, and translational HIV/STI prevention intervention trials.

Keywords

Correct Condom Use Self-Efficacy Scale, CCUSS, condom self-efficacy, condom errors, condom slippage, condom breakage, HIV prevention, STI prevention, psychometrics, social cognitive theory, sexual health behavior, male condoms

Authors

The Correct Condom Use Self-Efficacy Scale was developed by an interdisciplinary consortium of prominent sexual health, behavioral oncology, and applied health science researchers:

• Richard A. Crosby, Ph.D. — Department of Health Behavior, College of Public Health, University of Kentucky, Lexington, Kentucky, United States.
• Cynthia A. Graham, Ph.D. — Department of Physiology, Anatomy and Genetics, University of Oxford, Oxford, United Kingdom; and The Kinsey Institute for Research in Sex, Gender, and Reproduction, Indiana University, Bloomington, Indiana, United States.
• Robin R. Milhausen, Ph.D. — Department of Family Relations and Applied Nutrition, University of Guelph, Guelph, Ontario, Canada.
• Stephanie A. Sanders, Ph.D. — The Kinsey Institute for Research in Sex, Gender, and Reproduction, and Department of Gender Studies, Indiana University, Bloomington, Indiana, United States.
• William L. Yarber, H.S.D. — Rural Center for AIDS/STD Prevention, Department of Applied Health Science, Indiana University, Bloomington, Indiana 47405, United States. (Address correspondence to: [email protected])

Purpose

Male latex condoms are one of the most cost-effective and accessible public health technologies available for preventing the sexual transmission of the Human Immunodeficiency Virus (HIV), reducing the incidence of other sexually transmitted infections (STIs) such as Chlamydia trachomatis, Neisseria gonorrhoeae, and human papillomavirus (HPV), and mitigating unintended pregnancies. Nevertheless, epidemiologic surveillance consistently reveals an alarming divergence between condom promotion initiatives and actual clinical efficacy. While laboratory testing demonstrates near-perfect barrier efficacy of intact latex against virion penetration, clinical trials and field evaluations persistently reveal real-world condom failure rates. Historically, public health surveillance attributed failure primarily to non-use or inconsistent use; however, empirical investigations over the last two decades have documented that correct usage is equally critical. Condoms frequently fail because users commit procedural errors before, during, or after sexual intercourse, resulting in mechanical breakage, complete or partial slippage, leakage, or early removal.

Prior to the formulation of the CCUSS, behavioral interventions and survey research relied heavily on self-efficacy inventories that exhibited notable conceptual ambiguities. Many scales evaluated condom self-efficacy as a generalized social assertiveness construct—evaluating whether an individual felt confident asking a partner to use a condom, purchasing condoms in a pharmacy, or refusing sexual intercourse if a condom was unavailable. Other instruments captured sexual risk knowledge, abstract behavioral intentions, or broad attitudes toward safer sex practices. While interpersonal negotiation self-efficacy is vital, it fails to evaluate whether an individual possesses the perceived capability to physically operate the barrier device properly under the physiological, mechanical, and emotional conditions of sexual arousal.

The primary purpose of the Correct Condom Use Self-Efficacy Scale (CCUSS) is to resolve this assessment gap by offering a psychometrically validated, domain-specific instrument that measures an individual’s subjective confidence in executing the precise technical behaviors essential for flawless condom application and retention. By isolating technical-mechanical efficacy from interpersonal negotiation, the CCUSS allows researchers and clinicians to:

• Identify individuals and subpopulations that possess the communicative assertiveness to negotiate condom use but lack the behavioral self-confidence or psychomotor competence to prevent mechanical failure.
• Diagnose specific behavioral vulnerabilities (e.g., fit concerns, loss of erection, lack of lubrication, post-ejaculatory withdrawal issues) that drive condom abandonment during sexual episodes.
• Serve as an evaluation tool in structural, educational, and clinical sexual health interventions (such as condom distribution and technical demonstration programs) to measure targeted self-efficacy gains.
• Advance theoretical research regarding the functional mechanisms through which psychological confidence translates into physical risk reduction.

Psychological Construct

The underlying construct operationalized by the CCUSS is domain-specific technical condom use self-efficacy. Rather than treating self-efficacy as a generalized trait or a macro-level interpersonal capability, the CCUSS conceptualizes it as a micro-level, situational perception of behavioral competence directed toward the mechanical sequence of male condom use. Grounded in the extensive observational research conducted by Crosby, Yarber, Graham, Sanders, and Milhausen, this construct encompasses behavioral domains spanning pre-coital preparation, mid-coital maintenance, and post-coital management.

Pre-Coital Technical Precision: Sizing, Fit, and Application

A primary dimension of correct condom use self-efficacy involves perceived confidence in selecting and applying the barrier device. Anatomical variation in penile dimensions requires users to identify condoms of proper width and length; ill-fitting condoms represent a primary antecedent to both slippage (when too loose) and breakage or discomfort (when too tight). Item 1 (“How easy or difficult would it be for you to find condoms that fit you properly?”) taps into this critical self-regulatory assessment. Furthermore, correct application demands fine motor control: unrolling the sheath in the proper orientation, expelling air from the reservoir tip to avoid pressure-induced bursting, and unrolling the condom smoothly to the base of the erect penis before any genital contact. Item 2 (“How easy or difficult would it be for you to apply condoms correctly?”) directly measures global confidence in performing this delicate initial sequence without tearing the latex with fingernails or contaminating the outer surface with pre-ejaculatory fluid.

Mid-Coital Mechanical Integrity: Lubrication, Tension, and Duration

During active vaginal or anal penetration, mechanical shear stress presents a threat to barrier integrity. Friction can cause latex degradation, micro-tears, or catastrophic rupture. Items 3 and 4 directly assess self-efficacy related to physical maintenance: “How easy or difficult would it be for you to keep a condom from drying out during sex?” and “How easy or difficult would it be for you to keep a condom from breaking during sex?” Perceived capability in these areas implies behavioral knowledge of compatible (water- or silicone-based) lubricants, the vigilance to reapply lubrication as duration increases, and the self-regulation required to adjust coital vigor or friction dynamics before tensile failure occurs. Additionally, Item 7 (“How difficult would it be for you to wear a condom from start to finish of sex with your partner?”) assesses temporal fidelity—the confidence to resist premature removal during extended intercourse or delaying application until immediately prior to ejaculation.

Psychophysiological Regulation: Erection Maintenance

A frequent reason for condom discontinuation or improper usage is condom-associated erection problems (CAEP). Many men experience partial or complete loss of tumescence during condom application or throughout sex, frequently attributing it to reduced tactile sensitivity, performance anxiety, or disruptive interruption of foreplay. Erection loss dramatically elevates the risk of condom slippage and fluid leakage, or prompts the user to remove the condom entirely. Item 5 (“How easy or difficult would it be for you to keep an erection while using a condom?”) captures perceived psychophysiological control, measuring confidence in maintaining sexual arousal and erectile rigidity in the presence of the physical barrier.

Post-Coital Barrier Containment: Safe Withdrawal

The protective sequence is incomplete if containment fails during the resolution phase. Following ejaculation, rapid detumescence can cause the condom to slip off into the partner’s vagina or rectum, resulting in semen spillage. Standard public health guidelines mandate withdrawing the penis immediately after ejaculation while holding the base of the condom firmly against the penile shaft. Item 6 (“How easy or difficult would it be for you to keep a condom on when withdrawing after sex?”) measures the user’s perceived competence in executing this post-ejaculatory protocol.

Theoretical Framework

The CCUSS is rooted in Social Cognitive Theory, formulated by Albert Bandura (1986, 1994, 1997). Central to this theoretical architecture is the construct of perceived self-efficacy: an individual’s subjective conviction in their capability to organize and execute the courses of action required to manage prospective situations. Bandura argued that self-efficacy beliefs govern human functioning through four major psychological processes: cognitive (goal selection and visualization), motivational (persistence against obstacles and failure attribution), affective (coping with stress and anxiety), and selection processes (choosing environments that fit capabilities).

Domain Specificity vs. Generalized Traits

A fundamental tenet of Bandurian theory is that self-efficacy is not a global, omnibus trait akin to general self-esteem, locus of control, or broad ego-resiliency. Instead, efficacy beliefs vary across distinct domains of functioning, situational contexts, and specific task complexities. An individual may exhibit exceptional self-efficacy in negotiating relationship agreements or communicating safer-sex requirements, yet feel completely helpless when faced with the physical mechanics of rolling a latex sheath onto an erect penis under acute sexual arousal. Bandura (1994, 1997) emphasized that measurement tools must be micro-analytic and correspond directly to the targeted behavioral criteria. Forsyth and Carey (1998) reaffirmed this principle within HIV prevention research, documenting that generic sexual self-efficacy measures frequently fail to predict clinical outcomes because they decouple psychological assessment from behavioral execution. The CCUSS operationalizes this domain specificity, tailoring every item to the practical challenges of male condom deployment.

The Triadic Reciprocal Causation Model

The operational framework of the CCUSS reflects Bandura’s model of triadic reciprocal causation, in which behavior, internal cognitive/biological events, and external environmental influences continuously interact. When applied to correct condom use:

• Cognitive/Biological Influences: Knowledge of correct procedures, anxiety over performance failure, physiological tumescence/detumescence patterns, and sensory tactile feedback.
• Behavioral Executions: The physical acts of sizing, lubricating, rolling the condom, checking the reservoir tip, and gripping the rim during withdrawal.
• Environmental/Interpersonal Dynamics: Partner reactions, lubricant availability, situational ambient pressures, and physical intimacy settings.

Under this reciprocal framework, an individual who doubts their operational efficacy (e.g., fearing erection loss or breakage) experiences heightened performance anxiety. This autonomic arousal can physiologically induce erection loss or cause the individual to rush application, increasing the likelihood of tears or improper fit. The resulting failure reinforces low self-efficacy beliefs, establishing a self-defeating behavioral loop. By quantifying efficacy expectations across these exact functional points, the CCUSS maps directly onto Bandura’s socio-cognitive architecture.

Validity

The psychometric validity of the CCUSS was established through a series of empirical investigations led by Richard Crosby, William Yarber, and colleagues, examining diverse cohorts including urban STI clinic patients, rural populations, and university student samples.

Criterion and Predictive Validity

Criterion-related validity was established by evaluating the degree to which CCUSS scores correlate with and predict documented, real-world condom use errors and technical failures. In a pivotal validation study involving 278 adult male patients attending an urban STI clinic (Crosby, Salazar, et al., 2008), the scale demonstrated strong criterion validity. Higher total CCUSS scores were significantly associated with fewer self-reported condom use errors and problems during the preceding three months. Specifically, multivariable logistic regression models revealed that individuals with lower self-efficacy were substantially more likely to report:

• Condom breakage during intercourse or withdrawal.
• Complete or partial slippage of the condom off the penis during penetration.
• Condom-associated erection loss leading to complete abandonment of the barrier.
• Experiencing dry friction and discomfort due to inadequate lubrication.

These findings established that the CCUSS does not simply measure theoretical optimism; it functions as an accurate behavioral predictor of clinical failure modes.

Construct and Content Validity

Content validity was established through empirical derivation. The 7 items of the CCUSS were not fabricated through arbitrary clinical intuition; they were systematically extracted from an extensive program of earlier research investigating the exact phenomenology, prevalence, and correlates of male condom failure (e.g., Crosby et al., 2002; Graham et al., 2006; Sanders et al., 2003; Yarber et al., 2004, 2005). These foundational epidemiological studies surveyed thousands of men and women, establishing an empirical taxonomy of the most prevalent mechanical and behavioral errors. Content experts confirmed that the final 7 items fully represent the clinical sequence required for barrier integrity.

Construct validity was further evidenced through convergent associations with related psychosocial and behavioral health constructs. CCUSS scores correlate positively with prior formal condom education, frequent lifetime condom usage, and broader measures of health protective motivation, while showing discriminant divergence from unrelated personality traits, demonstrating that the scale assesses a specific behavioral capability.

Reliability

The reliability of the Correct Condom Use Self-Efficacy Scale has been evaluated primarily through internal consistency metrics across clinical and community samples.

Internal Consistency

In the primary psychometric validation study conducted by Crosby, Salazar, et al. (2008), the CCUSS demonstrated acceptable internal consistency reliability:

• Cronbach’s Alpha (α): .70 among an urban sample of 278 heterosexually active adult males attending a public STI clinic.

While an alpha coefficient of .70 represents the standard psychometric threshold for clinical and field research instruments, this magnitude is particularly notable given the brevity of the scale (only 7 items) and the functional diversity of the tasks assessed. In psychometrics, Cronbach’s alpha is inherently constrained by test length (the Spearman-Brown prophecy formula demonstrates that shorter scales artificially depress alpha values). Furthermore, the 7 items capture distinct behavioral moments across time—such as finding the right size (purchasing), maintaining an erection (psychophysiology), and holding the rim upon withdrawal (motor execution). Because these behavioral events do not necessarily covary perfectly within every user, an alpha of .70 indicates strong internal coherence without excessive item redundancy.

Measurement Precision and Sample Distributions

Within the STI clinic validation sample (N = 278), the observed mean total score was 27.61 (SD = 4.37), with an observed range spanning from 8 to 35 (theoretical range: 7 to 35). The absence of extreme ceiling effects in high-risk populations indicates that the scale successfully differentiates between moderately confident users and those who possess absolute technical self-assurance across all stages of sexual activity.

Factor Analysis

The structural dimensionality of the Correct Condom Use Self-Efficacy Scale has been evaluated using both exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) within behavioral health samples.

Dimensionality and Exploratory Modeling

Initial principal components and exploratory factor analyses conducted on the 7 items support a robust unidimensional construct representing generalized technical self-efficacy, while also indicating the presence of meaningful, correlated sub-dimensions. When extracted as a single general factor, all 7 items demonstrate positive, salient factor loadings typically exceeding .40:

• Item 2 (Apply condoms correctly): Displays the highest primary loading onto the general factor (loadings often ranging between .65 and .75), reflecting its role as the core indicator of technical competence.
• Item 4 (Keep condom from breaking): Demonstrates strong communality and high loading (.60 to .70), anchoring the mid-coital physical integrity component.
• Item 3 (Keep from drying out) & Item 7 (Wear from start to finish): Consistently load between .50 and .65, reflecting self-regulatory maintenance across the duration of sex.
• Item 1 (Proper fit), Item 5 (Keep erection), & Item 6 (Keep on during withdrawal): Exhibit moderate-to-strong loadings (.42 to .58), capturing somatic and procedural variations.

Confirmatory Factor Analysis and Fit Indices

In structural modeling, the single-factor model yields satisfactory to good goodness-of-fit indices when error covariances between functionally adjacent items (such as Item 3 [drying out] and Item 4 [breaking]) are accounted for. Typical fit statistics for the unidimensional structure demonstrate:

• Comparative Fit Index (CFI): ≥ .92 to .96
• Tucker-Lewis Index (TLI): ≥ .90 to .94
• Root Mean Square Error of Approximation (RMSEA): ≤ .05 to .07 (90% CI: .03–.09)
• Standardized Root Mean Square Residual (SRMR): ≤ .04 to .06

These empirical indices confirm that summing the 7 items into a single composite score is psychometrically justified and structurally sound for research and diagnostic applications.

Instrument / Measurement Tool

• Instrument Name: Correct Condom Use Self-Efficacy Scale
• Acronym: CCUSS
• Construct Measured: Perceived self-efficacy regarding the correct technical and behavioral application, maintenance, and post-coital management of male latex condoms.
• Target Population: Sexually active adolescents and adults (specifically evaluated among males; adaptable for female partners who apply condoms to male partners).
• Administration Format: Self-administered paper-and-pencil questionnaire, computer-assisted personal interview (CAPI), or secure web-based online survey.
• Item Count: 7 items.
• Estimated Completion Time: 1 to 3 minutes.
• Response Format: 5-point Likert-type scale:
  • 1 = Very Difficult
  • 2 = Somewhat Difficult
  • 3 = Neither Easy nor Difficult (Neutral)
  • 4 = Somewhat Easy
  • 5 = Very Easy
• Scoring Protocol:
  • All 7 items are framed positively (assessing ease vs. difficulty) and scored directly from 1 to 5.
  • There are no reverse-scored items.
  • The overall score is calculated by taking the direct arithmetic sum of all 7 responses.
  • Total Score Range: 7 to 35.
  • Interpretation: Higher aggregate scores indicate greater perceived self-efficacy and technical confidence in executing correct condom use. Lower scores indicate specific psychomotor, somatic, or behavioral self-doubts that correlate with elevated rates of condom failure (breakage, slippage, CAEP, or premature discontinuation).

Permissions & Fee and Test Year

The Correct Condom Use Self-Efficacy Scale (CCUSS) was developed in the mid-2000s and formally published in peer-reviewed scientific literature in 2008 (Crosby, Salazar, et al., 2008). The instrument was developed with public and institutional academic research support and is considered to be in the public domain for non-commercial educational, scientific, and public health intervention purposes.

Researchers, public health practitioners, and clinical psychologists may utilize the CCUSS without paying licensing or royalty fees. However, professional academic ethics require proper formal attribution of the original authors and validation studies in all scientific publications, dissertations, and conference presentations. For institutional inquiries, formal permissions regarding large-scale commercial adaptations, or clinical trial documentation, correspondence should be directed to the corresponding author:

• William L. Yarber, H.S.D.
  Department of Applied Health Science, Indiana University
  1025 E. 7th Street, SPH 116, Bloomington, IN 47405, USA
  Email: [email protected]

References

• Bandura, A. (1986). Social foundations of thought and action: A social cognitive theory. Prentice-Hall.
• Bandura, A. (1994). Social cognitive theory and exercise of control over HIV infection. In R. J. DiClemente & J. L. Peterson (Eds.), Preventing AIDS: Theories and methods of behavioral interventions (pp. 25–59). Plenum Press. https://doi.org/10.1007/978-1-4899-1193-3_3
• Bandura, A. (1997). Self-efficacy: The exercise of control. W. H. Freeman.
• Centers for Disease Control and Prevention. (2009). Condoms and STDs: Fact sheet for public health personnel. U.S. Department of Health and Human Services.
• Crosby, R. A., Milhausen, R. R., Sanders, S. A., Graham, C. A., & Yarber, W. L. (2008). Two heads are better than one: The association between condom decision-making and condom use errors and problems. Sexually Transmitted Infections, 84(3), 196–201. https://doi.org/10.1136/sti.2007.028779
• Crosby, R. A., Salazar, L. F., Yarber, W. L., Sanders, S. A., Graham, C. A., Head, S., & Milhausen, R. R. (2008). A theory-based approach to understanding condom errors and problems reported by men attending an STI clinic. AIDS and Behavior, 12(3), 412–418. https://doi.org/10.1007/s10461-007-9318-z
• 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(10), 552–557. https://doi.org/10.1097/00007435-200210000-00002
• Forsyth, A. D., & Carey, M. P. (1998). Measuring self-efficacy in the context of HIV risk reduction: Research challenges and recommendations. Health Psychology, 17(6), 559–568. https://doi.org/10.1037/0278-6133.17.6.559
• Goldman, J. A., & Harlow, L. L. (1993). Self-perception variables that mediate AIDS-preventive behavior in college students. Health Psychology, 12(6), 489–498. https://doi.org/10.1037/0278-6133.12.6.489
• Graham, C. A., Crosby, R. A., Yarber, W. L., Sanders, S. A., McBride, K., Milhausen, R. R., & Arno, J. N. (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(4), 255–260. https://doi.org/10.1071/sh06031
• Lux, K. M., & Petosa, R. (1994). Using the health belief model to predict safer sex intentions of incarcerated youth. Health Education Quarterly, 21(4), 487–497. https://doi.org/10.1177/109019819402100408
• Milhausen, R. R., Wood, J., Crosby, R. A., Graham, C. A., Sanders, S. A., & Yarber, W. L. (2009). A novel home-based intervention to promote condom use among young heterosexual males: A pilot study. Bulletin of the Transilvania University of Braşov, 2(51), 77–86.
• 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(2), 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? The Journal of Sexual Medicine, 6(5), 1451–1456. https://doi.org/10.1111/j.1743-6109.2009.01217.x
• Schaalma, H., Kok, G., & Peters, L. (1993). Determinants of consistent condom use by adolescents: The impact of experience of sexual intercourse. Health Education Research, 8(2), 255–269. https://doi.org/10.1093/her/8.2.255
• St. Lawrence, J. S., Brasfield, T. L., Jefferson, K. W., Alleyne, E., & Shirley, A. (1994). Social support as a factor in African American adolescents’ sexual risk behavior. Journal of Adolescent Health, 15(4), 292–310. https://doi.org/10.1016/1054-139x(94)90604-x
• Wulfert, E., & Wan, C. K. (1993). Condom use: A self-efficacy model. Health Psychology, 12(5), 346–353. https://doi.org/10.1037/0278-6133.12.5.346
• 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 & AIDS, 15(7), 467–472. https://doi.org/10.1258/0956462041211153
• Yarber, W. L., Kennedy, J., Sanders, S. A., Crosby, R. A., Graham, C. A., Heckman, T. G., & Dodge, B. (2005). Prevalence of condom use errors and problems among Indiana rural men: An exploratory telephone survey. The Health Education Monograph, 22(3), 36–38.

Items of the Scale