Goodall et al. BMC Public Health 2012, 12:747 http://www.biomedcentral.com/1471-2458/12/747 between men testing HIV + ve and HIV-ve are small [5]. Clinic and community based behavior change interven- tions that reduce UAI and partner number in MSM are resource intensive [6] and the criteria for the selection of men who will benefit most from such interventions are to date unclear. Reducing onwards transmission by im- proving condom use amongst those who use them pre- sents an underexplored area of sexual health research. Moreover, increasing condom skills may well reduce negative condom experiences and lead to an overall in- crease in condom use. The effectiveness of condoms in preventing sexually transmitted infections (STI) including HIV depends on consistent and correct use [7]. The frequency and corre- lates of condom use problems and errors have been reported in a range of populations [8] and in men en- gaging in vaginal sex and anal sex with female partners [9] and anal sex with male partners [10]. Recent research also indicates that condom use problems are common among Scotland’s MSM. A 2008 cross-sectional study of MSM recruited from the gay bars of Glasgow and Aber- deen, or men receiving condoms through a Scottish pos- tal distribution scheme, found that 27% of men reported condom breakage and 40% condom slippage in the last year [11]. To date condom errors have been associated with the likelihood of sexually transmitted infections in heterosexual STI clinic attendees [12] but not in MSM [13] and direct evidence of a link between condom pro- blems and STI acquisition in MSM has so far been lacking. This exploratory study addresses this lacuna. It investi- gates the associations between demographics, STI risk, condom proficiency and condom errors in MSM and the likelihood of STI acquisition among MSM. It has been designed to inform both the selection of candidates for brief behavior change interventions in clinic and community settings, and to guide the design and content of such interventions. Methods A cross-sectional questionnaire study of MSM attending STI clinics and community settings; including gay- identified bars, clubs and saunas was performed over a 16- week period ending 27 August 2010. The self-completed, pen-and-paper, anonymous questionnaire was based on a framework that had previously been successfully used in the triennial MRC bar-based Gay Men’s Sexual Health Surveys to assess HIV prevalence and sexual attitudes and behaviors in Scottish MSM [2-4]. The questionnaire was further developed in consultation with sexual health clinicians and MSM representatives who advised on question style and content. Pilot questionnaires were trialed on 15 clinic attendees to assess suitability of questionnaire length and to identify Page 2 of 8 potential difficulties with comprehension or presentation of questions within this particular population. The pilot study indicated clinic attendees were happy to participate and most were able to fully complete the questionnaire within 10 minutes. Following the pilot, minimal adjust- ments were made to the wording of some questions in order to increase clarity. The questionnaire recorded data on demographics, sexual activity, condom use for anal sex and condom problems and assessed condom knowledge and proficiency. Self-reported data on STIs diagnosed in the last 12 months were also collected. For the purpose of this study ‘STIs’ included gonorrhea, syphilis, chlamydia, HIV, Hepatitis B and Hepatitis C only; diagnoses of genital warts and herpes simplex virus were excluded due to difficulty distinguishing between incident and recurrent infections. In clinic attendees additional consent was requested to allow the questionnaire to be linked anonymously to la- boratory STI results by attaching a unique patient iden- tifier to each questionnaire and to laboratory request forms. The unique identifier was used to obtain results of STI tests from each participant at that clinic visit. This enabled the matching of self-report data with clin- ical data for a subset of the sample (n = 333), while avoiding the exclusion of men who were not happy for their clinical records to be linked to the questionnaire. Information leaflets describing the study were available in both clinic and community settings. In clinics, ques- tionnaires were distributed by receptionists, nurses, health advisors and doctors to all men identified as MSM attending the clinic during the study period. In community settings an established time and location sampling methodology [14] was used to recruit a repre- sentative sample of men visiting the gay bars and saunas of Edinburgh (6 different settings). Trained volunteers distributed all questionnaires in community settings, offering questionnaires to all men attending each venue during the sampling period. Response rates were recorded for both clinic and community arms of the study. Study participants All MSM aged over 16 years attending STI clinics or community venues were eligible to take part in the study. The survey was only available in English language. However, interpreters were offered when required to en- able men whose first language was not English to par- ticipate. An interpreter was needed by only one Polish male who participated in the clinic arm of the study. Ethical approval Ethical approval for this study was granted by the Lo- thian Research Ethics Committee.