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Even though many men say they do not like using condoms, condom use is increasing
sharply since it is a primary strategy for AIDS prevention among people at risk.
Condom sales through social marketing campaigns have risen
dramatically in some countries, with tens of millions of condoms sold annually where there
was hardly any condom use a decade ago. From 1991 to 1996, annual social marketing sales
increased about five-fold in the African country of Ethiopia (to 21 million) and by nine
times in the Latin American country of Brazil (to 27 million). A program that began in
1993 in Asia's Vietnam has typically doubled its sales each year, to 31 million by 1996.1
"Social marketing campaigns have made condoms accessible and for the most part
affordable, which were major barriers to use in the past," says Guy Stallworthy,
director of technical services for Population Services International (PSI), a U.S.-based
nonprofit organization that coordinates many of the world's largest condom social
marketing campaigns. "People also have a better sense of personal risk. Awareness of
AIDS is much higher now, and communication campaigns have shown that condoms are an
effective solution."
However, say Stallworthy and other experts, even more condoms need to be used in
high-risk sex. Many factors affect the limited acceptance of condoms. An individual's
knowledge, attitudes and awareness of risk are critical to condom use. The dynamics
between sexual partners play a crucial role, such as whether the couple talks freely to
each other about protection against disease and unwanted pregnancy, and whether sex is
voluntary for both parties. The attitudes and pronouncements of parents, church leaders,
peers, entertainment figures and political leaders shape community norms about condoms.
Men and women give many reasons for not using condoms, including fear that condoms will
fail, lack of sensation or interrupted sexual pleasure, and not perceiving the risk of
disease. Studies in 14 countries by the World Health Organization's Global Programme on
AIDS reported that the most important reason people reported for not using condoms was
that condoms reduced sexual pleasure.2 Women often mention
they fear men's reactions to suggesting condom use.
"It is clear that we have increased use, that we have met a demand that emerged
with AIDS," says Stallworthy. "But is there a plateau effect taking place? Are
we able to persuade more people to use condoms? To increase sales at this point, we have
to change societal norms."
Experts emphasize the importance of sustained behavior change,
not just persuading a person to try a condom once. "Condom use has increased because
people are protecting themselves and their families from disease," says Donna
Flanagan, an FHI behavior change specialist. "With AIDS prevention messages,
including condom use, we have to keep motivating and reminding people to change, because
most people would prefer not to use a condom. But we also have to move on to messages that
encourage men and women to sustain their use of condoms."
Outside marriage
Who uses condoms and under what circumstances? Recent surveys indicate that condoms are
used most often outside of marriage. In some areas where AIDS prevention campaigns include
highly visible condom promotion, use also is increasing among married couples.
Worldwide, only 5 percent of married women of reproductive age report using condoms,
when asked about choice of contraceptive method. Among developing countries, 3 percent
report using condoms, with only a handful of developing countries reporting more than 10
percent, including the Republic of Korea, Singapore, Costa Rica and Jamaica. (Condom use
in a few industrial countries is also high, above 10 percent in Scandinavian countries and
accounting for nearly half of all contraceptive use in Japan.)3
Measuring condom use is difficult because they may be used sporadically, often outside
of marriage. In the 1994 Zimbabwe Demographic and Health Survey (DHS), for example, five
times more married men reported using condoms during the preceding four weeks with a
non-spouse (60 percent) than with a wife (12 percent). Married women reported using
condoms 38 percent of the time with non-spouses and 7 percent with husbands. Despite such
high figures, only 2 percent of the married women reported using condoms for their primary
family planning method.4
In areas where social marketing campaigns have heavily promoted condoms, surveys
indicate an increase in condom use. For example, in the gold mining area of South Africa,
where men work and live for months away from home, about two of every three men used
condoms during sex outside of marriage. These men also used condoms more often with their
wives, with use during the last sex act jumping from 18 percent to 26 percent from 1995 to
1997. "This increase is important, given the concerns that have been expressed about
married women's risks of being infected by their partner and their difficulty in
negotiating condom use," a PSI survey report concluded.5
Young people are using more condoms where campaigns focus on youth. "But in many
areas, we're still in the stage of generating demand among youth," says Dr. Ann
McCauley, formerly of the U.S.-based FOCUS on Young Adults program. "The key problem
for youth is still access. Most adults do not approve of sex among unmarried youths and
hence do not approve of giving them easy access to condoms. Pharmacists won't sell to
youth in many countries. Also, many youth are too embarrassed to ask for condoms. And cost
remains an obstacle in many areas."
Since the AIDS epidemic, married men have indicated more interest in using condoms for
contraception. In Ghana and Kenya, where surveys were conducted in 1988 and 1989,
respectively, and again in 1993 for both countries, the portion of married men who said
they would like to use condoms as their contraceptive method jumped sharply. The portion
tripled in Ghana (from 5 percent to 16 percent) and doubled in Kenya (from 6 percent to 14
percent).6
Social marketing
International funding for AIDS prevention campaigns and, specifically, the expansion of
social marketing programs in all regions of the world, have made condoms widely available
and accessible. By 1996, social marketing campaigns were being conducted in 60 countries
worldwide.7 These campaigns use commercial marketing
techniques, including market research, message testing, advertising and consumer
education, as well as better access to products and affordable pricing. Generally, the
price is subsidized to encourage buyers while also assuring adequate profit incentives for
merchants who sell them.
Condom promotion campaigns have encountered obstacles. As recently as 1990, for
example, the word "condom" was prohibited in advertising in Kenya. Today, condom
advertising is permitted in many parts of the world where such advertising had once been
restricted or banned.
Other promotional efforts have also been successful. In Nepal, a sales force
concentrated on the highways into the country from India, where truckers and commercial
sex workers made this an area with high rates of HIV transmission. Increasing from only
three outlets in 1994, dozens of pharmacies, tea shops, liquor shops and others businesses
currently offer condoms along these highways.8 In Thailand,
the government developed a nationwide "100 percent condom" program at commercial
sex establishments, requiring that sex workers always use a condom. Condom use at
commercial sex establishments increased from about 14 percent when the program began in
1989 to 90 percent in 1994 and is credited with a sharp decrease in STD rates.9
While AIDS prevention campaigns focus on those having multiple sexual partners, social
marketing can also have an impact on condom use among married couples. In Vietnam, a
campaign begun in 1993 by DKT International advertising the Trust condom resulted in a
sharp increase in sales among married couples in cities.10
Family planning programs
Until AIDS, condoms were not generally well promoted by family planning clinics.
Providers assumed they were for disease protection and that they were not very effective
at pregnancy prevention. To varying degrees, family planning programs have begun to
incorporate disease prevention and the importance of condoms into their primary mission of
providing contraception.
"We have made condom use part of our regular community presentations on family
planning methods," says María Isabel Plata, executive director of Asociación
Probienestar de la Familia Colombiana (PROFAMILIA), the largest nongovernmental family
planning provider in Colombia. Use has increased due to the AIDS epidemic, she says.
Another example comes from International Planned Parenthood Federation (IPPF)
affiliates in Brazil, Honduras and Jamaica. Initially, the three programs resisted condom
promotion. Most staff had never opened a condom package to let a client touch the condom,
nor had they demonstrated how to use one correctly.
Staff training used penis models for practicing correct use and provided other
information, including details about storage, use of lubricants and promotional
techniques. The training helped overcome staff resistance, says Dr. Ney Costa, director of
Sociedade Civil Bem estar Familiar no Brasil (BEMFAM/Brazil). "Before, staff members
might say, 'here it is.' Now they have clients put them on a model and explain how to
store them."
The project promoted condoms in the broader context of introducing sexuality into
family planning. To increase the use of condoms, people need knowledge about HIV
transmission, what types of sexual behaviors can put a person at increased risk of
infection, and how to change those behaviors. Discussing such issues requires counselors
with an ability to talk about sensitive and private issues. People have to change
attitudes towards condoms, such as acknowledging their risk of infection. And, they need
skills, such as how to communicate with a partner about the importance of using a condom.
Also, clients have to believe that condoms work.
While many family planning providers and potential condom users believe that condoms
are not reliable, FHI research has found most condom breakage and slippage happens to a
small minority of users. Counseling can identify persons at increased risk of condom
failure (breakage or slippage), who may need more intensive information and attention
regarding consistent and correct use. "A history of condom failure and less
experience in using condoms are the most important risk factors for future failure,"
says Alan Spruyt, FHI senior research analyst.
Spruyt and his colleagues conducted a prospective study among 386 men using 1,810
condoms in Mexico, Philippines and the Dominican Republic. The men who reported condom
failure during the year prior to the study were more likely to experience failures during
the study, compared with those who did not experience failure during the year prior to the
study.11 Most behaviors that could lead to condom failure can
be addressed by instructing clients on correct use, such as not using oil-based lubricants
(which weaken the integrity of latex), not opening the package with teeth or sharp
objects, and not re-using the condom.
-- William R. Finger
References
- The World Bank, European Commission, Joint United
Nations Programme on AIDS. Confronting AIDS - A World Bank Policy Research Report. (New
York: Oxford University Press, 1997) 112.
- Mehryar A. Condoms: awareness, attitudes and use. In
Cleland J, Ferris B, eds. Sexual Behaviour and AIDS in the Developing World.
(London: Taylor and Francis, 1995) 124-56.
- United Nations, Department of Economic and Social
Resources. World Contraceptive Use, 1994, poster. New York: United Nations, 1995.
- Central Statistical Office (Zimbabwe) and Macro
International, Inc. Zimbabwe Demographic and Health Survey 1994, Summary Report.
Calverton, MD: Central Statistical Office and Macro International, Inc., 1995.
- Meekers D. Going Underground and Going After Women:
Combating Sexual Risk Behavior among Gold Miners in South Africa. PSI Research
Division Working Paper No. 13. (Washington: Population Services International, 1997)
15.
- Ezeh AC, Seroussi M, Raggers H. Men's Fertility,
Contraceptive Use, and Reproductive Preferences - DHS, Comparative Studies No. 18.
(Calverton, MD: Macro International, Inc., 1996) 26.
- The World Bank, 164.
- Making prevention work - global lessons from the AIDS
control and prevention (AIDSCAP) project, 1991-1997. Unpublished paper. Family Health
International, 1997.
- Nelson KE, Celentano DD, Eiumtrakol S, et al. Changes in
sexual behavior and a decline in HIV infection among young men in Thailand. N Engl J
Med 1996;335:297-303; Rojanapithayakorn W, Hanenberg R. The 100 percent condom program
in Thailand. AIDS 1996;10(1):1-7.
- Goodkind D, Anh PT. Reasons for rising condom use in
Vietnam. Int Fam Plann Perspect 1997;23(4):173-78.
- Spruyt A, Steiner MJ, Joanis C, et al. Identifying
condom users at risk for breakage and slippage: findings from three international sites.
Am J Public Health 1998;88(2):239-44.
For more information, visit Family Health International's Website at www.fhi.org
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