OBJECTIVES: With this study, we explore communication about consistent and correct condom use among African American and Latino male adolescents ages 15 to 19 and their fathers.
METHODS: Twenty-five father-son dyads completed semistructured interviews designed to elicit specific preferences for teaching and learning about consistent and correct condom use and strategies for addressing common condom use errors and problems. For analysis, we used in vivo coding and vertical and horizontal analysis techniques.
RESULTS: Fathers and sons agreed that communication about condom use is feasible and acceptable. However, fathers tended to convey vague messages regarding protecting oneself from the negative consequences of sexual activity. Furthermore, both fathers and sons reported barriers hindering conversations. Secondly, the style and frequency of condom use conversations can help overcome barriers and support father-son relationship management. Talking frequently in 1-on-1 settings and using strategies to reduce discomfort made communication easier. Lastly, fathers and sons reported distinct preferences for teaching and learning about condom use. Sons wanted fathers to give specific guidance on the use and management of condoms. Fathers expressed interest in opportunities for improving their own condom knowledge and skills. Fathers identified gaps in their own condom use knowledge as a limitation to effective instruction of their sons.
CONCLUSIONS: A father-focused communication intervention about condom use is feasible and acceptable. Enhancing the intergenerational benefits of father-son communication by addressing specific father-son preferences and learning needs for condom use instruction, as well as communication barriers, represents a novel mechanism for reducing male sexual reproductive health disparities.
- CDC —
- Centers for Disease Control and Prevention
- SRH —
- sexual and reproductive health
- STI —
- sexually transmitted infection
What’s Known on This Subject:
Male adolescents experience negative sexual and reproductive health outcomes associated with inconsistent and incorrect condom use. Research suggests that fathers are influential in adolescent sexual behavior and decision-making. However, few studies explore how to support father-son communication about condom use.
What This Study Adds:
With this study, we explore the feasibility and acceptability of father-son communication about condom use and examine the potential for amplifying intergenerational benefits of father-son communication. Programmatic suggestions for father-focused interventions are presented to support father-son communication about condom use.
Male adolescents are at increased risk of negative sexual and reproductive health (SRH) outcomes and engage more frequently in sexual risk behaviors than their female counterparts.1–3 For example, according to the 2017 Centers for Disease Control and Prevention (CDC) Youth Risk Behavioral Survey, male high school students were more likely to have sex before age 13, report having had sex with 4 or more partners, and more frequently indicated alcohol or drug use before their last sexual intercourse.4 Furthermore, identified in the extant scientific literature are significant barriers facing male adolescents with regard to accessing SRH services, including lack of male-friendly prevention and treatment programming, lack of information on available male SRH services, inadequate health care provider SRH screening of males, lack of social support regarding SRH service use, and stigma associated with male use of SRH services.5–12
Despite documented sex differences in the health service needs of male adolescents,10 their SRH needs remain largely neglected.11–13 Male condoms remain a first-line recommendation for the prevention of unplanned pregnancy and transmission of sexually transmitted infections (STIs). In recent years, public health efforts regarding youth SRH have been used to implement biomedical approaches to prevent both unplanned pregnancies and STIs such as long-acting reversible contraception and HIV pre-exposure prophylaxis.14,15 Furthermore, several innovative biomedical approaches are currently under development, including multipurpose prevention technologies designed to prevent both unplanned pregnancies and STIs, including HIV, and a long-acting reversible contraception method designed specifically for men.16,17 Although these innovations represent important additions to the current cadre of contraceptive and reproductive health options available for youth, the male condom remains the most commonly used contraceptive method among adolescents ages 15 to 19. Of concern, CDC data reveal significant declines in the use of male condoms among adolescents in the past decade.18 Male condoms are also the only noninvasive male-specific contraceptive method currently available.17,19
Condoms, when used consistently and correctly, reduce the risk of pregnancy and many STIs, including HIV.20–22 However, couples vary greatly in their ability to use condoms properly with every act of intercourse.23–25 Too often, male adolescents report limited knowledge regarding condom use, which is correlated with greater likelihood of condom errors.26,27 Male adolescents oftentimes report inadequate preparation to address condom use problems before their occurrence.28,29 Highlighted in the lack of requisite knowledge and skills to successfully mitigate the impact of condom use problems and errors is the importance of targeted condom use programs.
With the current study, we explored the feasibility and acceptability of father-son communication about consistent and correct condom use among African American and Latino male adolescents ages 15 to 19 and their fathers. Fathers (n = 25) and their adolescent sons (n = 25) were independently interviewed by using a semistructured interview protocol designed to elicit specific guidance regarding best approaches for fathers to support the instruction of consistent and correct condom use to their adolescent sons and strategies to reduce condom failure associated with common errors and problems. This research is used to address an important gap in that it is focused on the intergenerational role of men in reducing racial, ethnic, and sex SRH disparities and is used to elucidate how best to involve fathers in efforts to reduce adolescent unplanned pregnancies, STIs, and HIV with improved condom use.
Father-son dyads were recruited by using area sampling methods.30 Eligibility criteria included the following: (1) African American and Latino male adolescents between ages 15 and 19, (2) adolescents residing in the target geographic community, Mott Haven, South Bronx, (3) adolescents having a relationship with a “father” defined as a biological or nonbiological primary adult male caregiver, (4) adolescents who are not currently teenaged fathers, and (5) adolescents who are not married or cohabitating with a partner. Fathers provided written informed consent for themselves and adolescent minors. Adolescent minors provided written informed assent, and male adolescents ages 18 to 19 years provided written informed consent. The Institutional Review Board Committee at New York University approved the study. Interviews were audio recorded and transcribed. Fathers and adolescents received $30 and $20 incentives, respectively, for their participation in the study.
During recruitment, 45 male adolescents and their fathers were screened for eligibility. Thirty-two father-son dyads were eligible on the basis of inclusion criteria. Of these, 7 dyads (22%) declined to participate. Refusal bias data suggested that dyads declining participation were demographically similar to the study participants and the overall community. The remaining 25 father-son dyads gave informed and written consent or assent. CDC technical assistance on behalf of the US Department of Health and Human Services Office of Adolescent Health included consultations such as best practices in adolescent consent processes. However, the CDC and Office of Adolescent Health were not engaged in human subject research because there was no interaction with participants or receipt of data.
Data Collection and Analysis
The 1- to 1.5-hour semistructured interviews for fathers and sons were conducted and audio recorded in 2017 by bilingual (English and Spanish) interviewers in the participants’ homes or a location in the community that was mutually agreed on. Interviews were used to address best strategies for fathers to support their adolescent son’s condom use, father and son condom knowledge, and father-son communication about consistent and correct condom use. Fathers and adolescents were interviewed separately to encourage truthful responses, and names were replaced by identification numbers during transcription to ensure confidentiality.
Bilingual and bicultural researchers transcribed the interviews and then identified recurrent themes.31 Three coders performed the coding process, maintaining an intercoder reliability of >90%. The high coding consistency was achieved through open debate for all instances of controversy.32 For analysis, the research team used in vivo coding, in which data are categorized by using words, phrases, emerging themes, and short analytic summaries of the most important findings for each interview.33 We used vertical and horizontal analysis techniques33 and a codebook containing code definitions, inclusion and exclusion criteria, and code-specific narrative examples to analyze the participants’ responses in correspondence with our themes of interest. Vertical analysis allowed the research team to use in vivo–coded responses to evaluate recurring themes across the sample.33 Horizontal analysis was used to help us understand meaningful responses in the context of individual transcript narratives.33 Analysis continued until the recorded interview content reached thematic saturation.34
Demographics of the study sample are provided in Table 1. The median age of fathers was 44 years (range = 36–57), and the median age for adolescents was 17 years (range = 15–19). Seventy-two percent of the dyads identified as Latino (n = 18), and 28% identified as African American (n = 7). Spanish was the primary language spoken at home for 44% (n = 8) of Latino father-son dyads.
The interviews revealed the following 3 important themes: (1) Father-son communication about condom use is feasible and acceptable, but barriers frequently hinder conversations; (2) style and frequency of conversations help overcome barriers to communication regarding condom use; and (3) fathers and sons have specific preferences and needs for teaching and learning about consistent and correct condom use.
Feasibility, Acceptability, and Barriers
The majority of interviewed fathers and adolescents had previously talked about sex and expressed interest in talking about the use of male condoms. Fathers indicated their willingness to engage in conversations about condom use and acknowledged their role in promoting condom use among their sons: “I think condoms need to be talked about; I think condoms need to be practiced. If you don’t want your child to be a young dad or mom, explain to them how to use it.”
Likewise, adolescents expressed openness to talking about condoms with their fathers. Most adolescents were aware of the importance of condoms as protection against unplanned pregnancy and STIs and thought of paternal guidance on the subject as important: “I want him to say that he wants to talk about something important and it will benefit my future. And then he can take it from there.”
However, communication tended to be limited to general conversations about delaying sexual debut and the need for using “protection” to prevent the negative consequences of risky sex. Fathers expressed concern about the consequences of adolescents having unprotected sex, citing both unplanned pregnancies and STIs:
[We talk about] how to protect yourself from the diseases out here, what the diseases would do to you. The primary concern is to keep them safe, but also to let them know that, when they do engage when they’re a little older, to keep them safe from having unwanted pregnancies.
Despite the feasibility and acceptability of communication about consistent and correct condom use, the data suggest that barriers hinder conversations about condoms. Both fathers and adolescents reported feeling uncomfortable during communication about condom use, as well as hesitation to initiate conversations: “It is uncomfortable for both; I can’t just approach him all the time with that because you have to be comfortable, you have to be comfortable [to talk about condoms].”
Additionally, fathers disclosed concerns about being perceived as intrusive, fears of their sons losing respect for them, or damaging the father-son relationship. Not wanting to pressure the adolescent, fears of offending them, and respect for the adolescent’s privacy were among the most common explanations given by fathers for not initiating conversations about condoms.
Furthermore, fathers and adolescents reported having asymmetric perceptions of responsibility to initiate communication about condoms. In an apparent disconnect, fathers and teenagers made it clear that they expected the other to start conversations about condom use. Many adolescents expressed reluctance to approach their father with questions: “I am not much of an asking person. I do not ask for information. I rather wait for it to come to me or search it out [myself].”
Similarly, fathers often reported that their son should initiate communication about condom use:
You have to ask me questions, the questions that he wants to ask. I mean, I just want him to know the initial stuff […]. How to do it, how to put it on and stuff like that. Anything else you want to know, you have to ask me. That’ll make him more comfortable […]. Anything else it’s like I’m forcing it on them.
Whereas most participants reported experiencing barriers to father-son communication about condom use, some reported overcoming barriers by adopting communication styles that reduced discomfort. Fathers repeatedly cited alone time with their sons as helpful to initiate communication about condom use and expressed a greater willingness to start conversations in a 1-on-1 setting. Fathers and adolescents recognized the value of sex-symmetric communication about condoms and indicated that talking without disturbances helped them to be at ease during the conversation. One father stated the following: “[We talk about condoms] just me and him, […] in his room. […] We could really talk if it could be in his room, unless I’m in my room and we are by ourselves and we’re talking.”
In addition, fathers and sons reported favoring humor to overcome discomfort in communication about condom use: “The best is to start off with a joke. […] Laughter I find the best way to make the awkwardness go away,” explained a father, and his son agreed, “It makes it more fun to talk about when he jokes about it.”
Participants reported that frequent and ongoing communication about condom use gradually lowered perceived communication barriers. Frequent communication reduced the discomfort associated with the subject matter and made it easier to bring up details about the consistent and correct use of condoms. One adolescent explained, “Well, at first it was kind of weird but now it’s kind of regular because it happened already a couple of times […]. It’s kind of regular now, it’s not like it’s weird. I’m kind of used to it.”
Preferences and Needs
Fathers and sons reported specific preferences for teaching and learning about consistent and correct condom use. Adolescents conveyed wanting specific applied guidance on the prevention and management of condom use errors and problems. Teenagers described experiences with condom breakage and slippage, as well as incomplete and incorrect condom use but reported being unsure about how to react appropriately. Adolescents indicated that sharing personal experiences is a welcome way for fathers to help their sons with the correct use of condoms: “I guess I kind of prefer my father telling me because he’s been through the experience.”
Along these lines, adolescents expressed interest in receiving experiential instruction from their fathers.
You could get a pencil or something, or a marker and anything. Use the materials to show how to put a condom on. I’d rather him show me. […] The most important thing is using a condom and how to put it on […] the right way and be aware of what you’re doing when you’re using a condom.
Fathers disclosed the need to expand their own knowledge about the consistent and correct use of condoms. Many fathers reported feeling incapable of adequately instructing their sons because of their own knowledge gaps. As a result, fathers expressed interest in receiving educational instruction before talking to their sons to provide more specific guidance and experiential instruction. Furthermore, fathers highlighted the potential value of teaching their sons about consistent and correct condom use as a strategy for improving their own condom use. One father highlighted the intergenerational impact of father-son communication about condom use: “I’m willing to teach him as much as possible, […] as much as he needs to know, [but] if I’m teaching him, I’m actually teaching myself.”
The vast majority of US public health and health care provider efforts designed to reduce adverse male adolescent SRH outcomes tend to be focused directly on adolescents’ individual behavioral decision-making.35 Significantly, less attention has been focused on prioritizing the contexts in which male adolescents’ sexual and reproductive decision-making is shaped.5 One such context is the family.36 In a large corpus of research, it is suggested that parents are influential in the prevention of negative SRH outcomes and the adoption of prevention methods.35–37 In response, the American Academy of Pediatrics has in recent years urged health care providers to support parents in promoting adolescent sexual health, specifically with regard to condom use and male SRH care.12,22,38 Interestingly, the majority of the extant literature related to parental influences on adolescent sexual behavior has been concentrated on maternal influence, with scant attention to the potential of father-focused adolescent SRH interventions.37,39,40 The nascent literature related to paternal influences on adolescent sexual behavior and decision-making supports the development of father-focused interventions designed to support the prevention of adolescent unplanned pregnancies, STIs, and HIV. However, these studies have seldom been focused on the specific mechanisms by which male adolescents uniquely benefit from their fathers’ involvement in their SRH.40 Furthermore, there is a dearth of research that specifically elicits perspectives from both male adolescents and their fathers regarding the feasibility and acceptability of father-son communication about consistent and correct condom use. Greatly needed is applied research used to identify paternal and male adolescent preferences regarding how best to increase the use of male condoms and to leverage the potential intergenerational benefits of father-son communication about condom use.
Our findings reveal the feasibility and acceptability of a father-focused SRH intervention designed to improve father-son communication and to provide fathers with guidance for conversations about condom use. Although fathers and their sons generally expressed willingness and interest in talking about condom use, it was noted in our findings that fathers may benefit from support to overcome common communication barriers. Common barriers include lack of knowledge, discomfort, and hesitation to initiate condom use conversations.
It is suggested in our results a number of viable approaches for helping fathers and adolescents overcome common communication barriers in conversations about condom use. We identified communication styles that reduce the awkwardness associated with conversations about condom use and make it easier for fathers to initiate such conversations. Successful communication styles include initiating conversations about condoms in 1-on-1 settings and diffusing discomfort with humor. Furthermore, participants indicated that frequent and ongoing communication about condoms gradually lowered perceived barriers.
Adolescents expressed interest in hearing about their father’s experiences with condoms, in particular with regard to specific paternal guidance on the prevention and management of condom use errors and problems, and in fathers showing demonstrations of correct condom use. Fathers reported wanting to expand their knowledge about consistent and correct condom use to become a more valuable resource for advice and instruction. Often, fathers were aware of their own knowledge gaps preventing them from educating their sons about consistent and correct condom use as well as how to best manage condom problems and errors.
Our findings have important implications for health care providers and SRH programming targeted at contraceptive use among male adolescents. With Table 2, we summarize our findings about barriers, preferences, and needs in father-son communication and offer programmatic suggestions to adequately address them. With this study, a father-focused approach to improve condom use among young men is validated, and novel insights into the perspectives of fathers and adolescents on teaching and learning about condom use are provided. The current study has certain limitations. In our study, we relied on a minority urban sample recruited from a single geographic area. Authors of future research should consider if diverse fathers and sons in distinct contexts share similar views. All adolescents in our study identified as heterosexual.
Caution is warranted when generalizing the findings to adolescents with nonheteronormative sexual orientations. Furthermore, our inclusion criteria limited the study population to adolescents with a father or primary adult male caregiver. Condom use views, preferences, and needs might differ in young men lacking the influence of a father figure. Lastly, it is possible the sample includes families favorably predisposed to the study’s focus and that social desirability played a role in shaping the study results. However, both fathers and adolescents highlighted areas of need, additional assistance, and barriers to communication, which suggest authenticity of responses versus solely reflecting a tendency toward social desirability bias. Given declines in adolescent condom use, the only multipurpose prevention technology available to men, our research took a narrow focus on father-son communication about consistent and correct condom use specifically. Future research should be used to explore the role of fathers in regard to male adolescent SRH more broadly.
Important applied public health and health care provider implications are suggested in the results of this study. Helping fathers teach their sons about the consistent and correct use of condoms by addressing common communication barriers and focusing specifically on strategies to avoid condom use errors and problems is a promising and novel mechanism to increase the use of male condoms and to reduce unplanned pregnancies, STIs, and SRH disparities among male adolescents.
- Accepted October 22, 2018.
- Address correspondence to Vincent Guilamo-Ramos, PhD, MPH, LCSW, RN, ANP-BC, AAHIVS, Center for Latino Adolescent and Family Health, New York University, 15 Washington Place, New York, NY 10003. E-mail:
The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
FUNDING: This publication is made possible by cooperative agreement 5UO1DP006106 from the Centers for Disease Control and Prevention through a partnership with the US Department of Health and Human Services Office of Adolescent Health.
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
COMPANION PAPER: A companion to this article can be found online at www.pediatrics.org/cgi/doi/10.1542/peds.2018-2595.
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- Copyright © 2019 by the American Academy of Pediatrics