Male condoms remain the single best method of reducing the risk of acquiring sexually transmitted infections (STIs), including HIV [1,2]. Promotion of correct and consistent use of male condoms as an effective method of reducing the prevalence of STIs was recommended in the Global Strategy for Prevention and Control of Sexually Transmitted Infections: 2006-2015 [3]. However, research repeatedly demonstrates that condoms are not used consistently [4-7], and even when used, condom use errors and problems and dislike of condoms are often reported [8,9]. Condom use errors and problems are associated with the reasons men give for not using condoms, such as less pleasurable experience when condoms are used, decreased sensation, poor fit-and-feel, condom breakage and slippage, and difficulties in maintaining erection [10,11].

Many previous interventions aimed to increase condom use but few of them focused on pleasure and fit-and-feel [12], and they were also often resource- and time-intensive. Improving fit-and-feel should lead to reduction in condom use problems and increase consistent and complete condom use. Internet-based behavior change interventions, on the other hand, may be cost- and resource-effective [13-15], easily accessible and acceptable by users, especially when focused on sensitive or stigmatized health-related issues [16-19], and have efficacy comparable with human-delivered interventions focused on condom use [20,21].

The Homework Intervention Strategy (eHIS) program, an online adaptation of the Kinsey Institute Homework Intervention Strategy (KIHIS) [22], combines a focus on pleasure and fit-and-feel in condom promotion with the benefits of an online intervention. In the KIHIS, during the session with the instructor, men are given the correct condom use instruction and are asked to practice condom application on a penile model. The instructor then encourages them to practice using condoms on their own and rate them, highlighting the importance of pleasure and finding the condom that fits and feels best for an individual. The home-based and practice-oriented approach makes the program distinct from most interventions in this area, which are mainly delivered face-to-face, during group workshops, or in individual consultations [23-25]. The results of previous pilot studies [22,26,27], showed the program’s potential in improving use experiences, confidence in the ability to use condoms, self-efficacy for condom use, condom comfort, and reduced breakage and erection problems.

The final content and design of the program was developed taking into account participant feedback from the qualitative evaluations of the program prototype (paper-based) and computerized version of the program (M Glowacka, thesis chapter in preparation). The research team adapting the face-to-face version of the program for use in the United Kingdom was also consulted [27].

Mirroring the KIHIS approach, the eHIS addresses the issues related to condom use errors and problems by focusing on correct condom use, pleasure, and developing positive condom use experience. Participants are encouraged to practice correct condom application and explore different types of condoms and lubricants in a low-pressure situation, at home, and without their partners present. Components of the intervention are listed in Textbox 1 and an example of the eHIS webpage is shown in Figure 1.

The current study aims to evaluate the feasibility of the Internet-based eHIS program. Evaluation of participants’ engagement with the program and its acceptability (dimensions of feasibility, primary outcomes) and the potential of the intervention to change targeted behavior (preliminary effectiveness) can provide a “proof of concept” for the approach used in the intervention [28,29]. The primary outcomes of this study are increasing condom use frequency and consistency. The secondary outcomes include reducing condom use errors and problems, enhancing condom use experience, increasing condom use self-efficacy, and improving condom use attitudes and motivation.

The study does not target men based on characteristics such as sexual orientation or condom use history as it has not yet been established for whom the eHIS intervention may be the most useful. Therefore, whether the program’s feasibility and preliminary effectiveness are linked to participants’ demographic characteristics, sexual history, or previous condom use variables is explored. To inform development of a larger trial, the feasibility of the approach to study evaluation with a focus on recruitment effectiveness, measures completion, and attrition rate is investigated. This will help to verify whether the specific study design and approach employed for the evaluation are appropriate and identifies acceptable outcome measures that should be used as measures of its effectiveness in a full-scale randomized controlled trial (RCT) [30]. The results can also help to estimate the expected effect size of the observed changes, to be used in the calculation of the sample size needed for a full scale RCT [31].

This study is guided by the following research questions: (1) Is the eHIS program feasible? (2) Does the eHIS program have the potential to be effective in increasing the frequency of condom use, increasing consistent condom use, improving condom use experience, improving condom use self-efficacy, reducing the number of condom-related errors and problems, changing condom use attitudes to more positive ones, and increasing motivation to use condoms? (3) Is the approach to evaluate the eHIS program feasible? (4) Are the program and study feasibility, and the preliminary effectiveness of the program on condom use outcomes associated with participants’ characteristics (demographic, sexual history or baseline condom use variables)?

The study uses a pre-post test, within-subjects design.

A target sample of 139 participants was recruited and data collection is completed. The sample size was estimated on the basis of the calculation of the number of participants required to conduct statistical analysis to evaluate the feasibility of the program and its preliminary effectiveness, possible high attrition (in the region of 60%), more likely in self-guided interventions [32-36], study resources, and numbers of participants recruited to similar studies [31,37-42]. The inclusion criteria for the study are listed in Textbox 2.

Participants were recruited through self-referral in response to recruitment advertisements (posters, leaflets, business card adverts, Facebook and Twitter posts and paid adverts, emails, and United Kingdom-wide mailing lists for postgraduate psychology students). The adverts included key phrases such as “test and rate condoms,” “improve condom use experience,” “learn more about condoms,” “focus on pleasure,” “enjoy using condoms,” and “get free condoms and lubricants kit.” To ensure wide reach and reduce the risk of recruitment bias (age and geographical location) where possible, study advertisements were distributed in multiple locations (mainly in England, including universities, colleges, sexual health charities, commercial sector employers, community centers, youth organizations), and on social media (Facebook paid posts addressed to specific age groups, for example 26 to 35 years and 36 to 45 years with the United Kingdom chosen as geographical location). People from professional and personal networks were also asked to share the advertisements in their locations and through social media.

Questionnaires and website usage data were used in the study to collect data. The questionnaires were chosen to mirror as closely as possible the measures used in the face-to-face KIHIS [22,26] and HIS-UK studies [27]. They were reviewed and modified according to the feedback received in a qualitative evaluation of the program during its development phase (M Glowacka, thesis chapter in preparation). Additional measures and items were chosen or developed for this study to allow investigation of the aspects of the program related to its specific mode of delivery. The data collection schedule is presented in Table 1.

Following the link or QR code from the advertisement individuals were directed to the study website where they were first presented with the Participant Study Information Sheet. Participants indicated their consent to take part and for their data to be used for research purposes by ticking a box next to the consent statement. They then completed the eligibility screening measure; if eligible, they were directed to the study registration page and then to the T1 measures. If ineligible, they were thanked for their interest in the study.

Participants could then access the core eHIS website and were able to order a condom kit to be sent by post or collected from the University of Southampton within 3 working days from placing the order. They had 4 weeks, counting from the date they completed the T1 measures, (hereafter “start point”) to practice condom use at home and complete condom rating forms after each practice event. Four weeks from the start point the website was no longer available to participants and at that point participants were asked to complete T2 measures; 10 weeks after the start point they were asked to complete the final T3 measures.

Participants received an email reminder and an optional text reminder on the days the T2 and T3 measures were due to be completed. They also received 2 emails and an optional text per week for the duration of home practice (during weeks 2, 3, and 4) reminding them to complete condom ratings. The condom rating reminders were automatically cancelled for the particular week if at least 1 rating was completed; all reminders were automatically cancelled if at least 4 ratings were completed. Participants had the option to cancel emails and/or text messages when they visited the program’s website regardless of the number of ratings reminders. An overview of the study procedure is presented in Figure 2. Ethical approval from the Department of Psychology Ethics Committee at the University of Southampton was obtained. The study is registered in the Research Registry, Unique Identifying Number researchregistry2325.

After completion of each set of study measures participants chose 1 out of 3 charities that will receive a 50p donation. After completion of the T3 measures participants received a £5 Amazon voucher. Psychology students at the University of Southampton had the option to claim up to 32 research credits for participation.

Feasibility of the program and the evaluation approach will be assessed through the analysis of program engagement, acceptability, recruitment, and retention rates. Descriptive statistics will be used to describe the study population, feasibility of the evaluation approach, engagement with the program, and its acceptability. The preliminary effectiveness of the program will be assessed through evaluation of the change on primary and secondary condom use-related outcomes. Within group comparison will be undertaken to assess whether there are any differences between specific subgroups (eg, those who complete the study and those who drop out, those reporting improvement on various dimensions of condom use, and those who do not report change) on characteristics such as demographic variables, sexual history, and/or baseline condom use-related variables where sufficient data will be available. The results of the preliminary effectiveness results will be used to calculate the effect size of changes in condom use related outcomes. SPSS software v.21.0 [62] will be used for data analysis.