Systematic Review of Peer-Reviewed Literature on Global Condom Promotion Programs

"Sustained demand generation that results in repeat, intensive exposure to behavior change messages tailored to diverse user needs remains a critical need in many countries."

Evidence suggests that intensified efforts are needed to increase condom use, especially in high HIV/sexually transmitted infection (STI) prevalence countries. This study synthesises peer-reviewed literature on condom promotion programmes, with a focus on low- and middle-income (LMIC) countries and adolescent and young adult (AYA) users. The goal is to document the effectiveness of interventions to promote condom use through communication and social marketing, which have been the primary demand creation strategies used to date.

Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methods, the researchers identified 99 peer-reviewed articles published between 2000 and 2019 relating to social marketing and promotion of condom brands, HIV/STI prevention programmes based on increasing condom use, and family planning programmes that promoted condoms. Most of the articles reviewed described studies with an observational design; the remaining studies were equally split between experimental and quasi-experimental designs. (Table S1 in the paper provides a summary of the 99 articles that underwent full text review (references provided at the end of this manuscript). The appendix table lists the study, the population reached, the location, the product promoted, the marketing and intervention components applied, and the research design and significant effects observed.)

The interventions used a wide range of health communication and social marketing strategies, including mass media, interpersonal communication (IPC) through community outreach, and visits to households by health workers. (Relatively few studies used social media or other digital media to promote condoms, likely because they were often conducted in LMICs.) High levels of awareness of the promoted health messages were reported. Psychological theories were the most commonly used theories, found in 29% of the studies reviewed, followed by marketing theory with 19%. Examination of the studies in terms of the use of the four Ps of marketing (place, price, product, and promotion) revealed that 45% used all four marketing techniques.

Table 5 in the paper summarises the significant findings reported by the articles reviewed, both overall and by the marketing approaches used. Almost all articles (96%) that assessed sales or distribution of condoms reported significant increase in this measure. Most articles assessed condom use pre-behavioural (attitudes, social norms, and beliefs about condom use) and condom use behavioural outcomes (use overall, frequency, and with specific partner types), and 85% reported significant increases in each outcome. A higher percentage of the overall sample reported significant effects on condom awareness or positive reactions to promotions and sales/distribution (37% and 23%, respectively) compared to efforts meant to reach AYA specifically (26% and 14%, respectively). However, a higher percentage of efforts geared toward AYA reported achieving condom use pre-behavioural outcomes (71%) compared to the overall sample (58%).

In terms of intervention characteristics, one notable finding was that 90% of interventions using mass media (51 in total) reported significant effects on attitudes, beliefs, and intentions to use condoms, and the same percentage was displayed among programs for AYA (23 in total). Across the marketing Ps, all AYA-focused programmes showed significant effects and were consistently higher than the overall sample and other populations, suggesting that marketing strategies are especially effective in encouraging condom purchases among AYA.

This study has demonstrated that condoms continue to be widely promoted worldwide and, given the epidemiology of HIV/STIs, they remain a crucial technology for preventing transmission. However, as noted here, the percentage of studies showing a significant effect on condom use dropped from 87% in 2000-2009 to 78% in 2010-2019. "Significantly more investment in demand generation activities ranging from branded and generic mass media to highly targeted interpersonal communication (IPC) is needed to ensure that people - especially youth - have the knowledge, the skills, and the power to use condoms correctly and consistently."

The researchers suggest avenues for future study, including on how to encourage condom use using digital media marketing strategies, which can increasingly reach the young adult audience in LMICs.