Effects of condom social marketing on condom use in developing countries: A systematic review and meta-analysis, 1990–2010

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DOI: 10.2471/BLT.11.094268 · Source: PubMed
Abstract
To examine the relationship between condom social marketing programmes and condom use. Standard systematic review and meta-analysis methods were followed. The review included studies of interventions in which condoms were sold, in which a local brand name(s) was developed for condoms, and in which condoms were marketed through a promotional campaign to increase sales. A definition of intervention was developed and standard inclusion criteria were followed in selecting studies. Data were extracted from each eligible study, and a meta-analysis of the results was carried out. Six studies with a combined sample size of 23,048 met the inclusion criteria. One was conducted in India and five in sub-Saharan Africa. All studies were cross-sectional or serial cross-sectional. Three studies had a comparison group, although all lacked equivalence in sociodemographic characteristics across study arms. All studies randomly selected participants for assessments, although none randomly assigned participants to intervention arms. The random-effects pooled odds ratio for condom use was 2.01 (95% confidence interval, CI: 1.42-2.84) for the most recent sexual encounter and 2.10 (95% CI: 1.51-2.91) for a composite of all condom use outcomes. Tests for heterogeneity yielded significant results for both meta-analyses. The evidence base for the effect of condom social marketing on condom use is small because few rigorous studies have been conducted. Meta-analyses showed a positive and statistically significant effect on increasing condom use, and all individual studies showed positive trends. The cumulative effect of condom social marketing over multiple years could be substantial. We strongly encourage more evaluations of these programmes with study designs of high rigour.
Bull World Health Organ 2012;90:613–622A | doi:10.2471/BLT.11.094268
Systematic reviews
613
Effects of condom social marketing on condom use in developing
countries: a systematic review and meta-analysis, 1990–2010
Michael D Sweat,
a
Julie Denison,
b
Caitlin Kennedy,
c
Virginia Tedrow
c
& Kevin O’Reilly
d
Introduction
e social marketing of condoms began in earnest in develop-
ing countries in tandem with global family planning eorts and
was dramatically expanded as an early response to the global
pandemic of acquired immunodeciency syndrome (AIDS).
is brought about a coordinated eort to ensure a steady sup-
ply of quality condoms at the local level in developing countries
as governments and donors injected considerable funds into
large-scale condom social marketing programmes globally.
1
A standardized theoretical and conceptual model of condom
social marketing emerged over time, as depicted in
Fig. 1.
Ongoing professional market research is used to inform three
main intervention components of condom social marketing:
condom branding, the development of a commodity logistics
system and a sustained marketing campaign.
15
For all three
components local adaptation and implementation are stressed.
Condom brands are designed to be appealing and to reect
local cultural values, and multiple brands are established as
needed to reach key segments of the market. e commodity
logistics system is tailored to the local economy, with eorts
made to ensure a steady supply of aordable quality condoms
at existing sales venues. e commodity logistics system is
also designed to track sales, warehouse supplies and ensure
timely delivery of products. e marketing campaign uses
professional marketing techniques based on market research
and is updated regularly as the market changes. A key prin-
ciple in such programmes is that condoms should be sold at
an aordable price, except for free distribution to the truly
destitute. On the supply side, condom branding and commod-
ity logistics systems are designed to increase the availability of
desirable and aordable quality condoms. On the demand side,
the sustained marketing campaigns are designed to increase
the desire for and use of condoms. e increased demand
for condoms, coupled with enhanced condom availability,
promotes condom sales and use, and this should ultimately
reduce the transmission of human immunodeciency virus
(HIV) infection, sexually transmitted infections and unwanted
pregnancies.
Ample evidence shows that condom social marketing
programmes increase condom sales,
6,7
which have oen been
cited as an indication that condom use is increasing, although
the evidence points to a weak relationship between condom
sales and use.
7
It is important to the eld of HIV prevention
to understand how condom social marketing programmes
inuence condom use. Hence, we systematically examined the
evidence on the relationship between condom social marketing
campaigns and increases in condom use.
Methods
Inclusion criteria
We began by dening condom social marketing as includ-
ing interventions in which condoms were sold, a local brand
name was developed for the condoms, and the condoms were
marketed through a promotional campaign to increase sales.
Studies were included if they: (i) were conducted in a develop-
Objective To examine the relationship between condom social marketing programmes and condom use.
Methods Standard systematic review and meta-analysis methods were followed. The review included studies of interventions in which
condoms were sold, in which a local brand name(s) was developed for condoms, and in which condoms were marketed through a promotional
campaign to increase sales. A definition of intervention was developed and standard inclusion criteria were followed in selecting studies.
Data were extracted from each eligible study, and a meta-analysis of the results was carried out.
Findings
Six studies with a combined sample size of 23 048 met the inclusion criteria. One was conducted in India and five in sub-Saharan
Africa. All studies were cross-sectional or serial cross-sectional. Three studies had a comparison group, although all lacked equivalence in
sociodemographic characteristics across study arms. All studies randomly selected participants for assessments, although none randomly
assigned participants to intervention arms. The random-effects pooled odds ratio for condom use was 2.01 (95% confidence interval,
CI: 1.42–2.84) for the most recent sexual encounter and 2.10 (95% CI: 1.51–2.91) for a composite of all condom use outcomes. Tests for
heterogeneity yielded significant results for both meta-analyses.
Conclusion The evidence base for the effect of condom social marketing on condom use is small because few rigorous studies have been
conducted. Meta-analyses showed a positive and statistically significant effect on increasing condom use, and all individual studies showed
positive trends. The cumulative effect of condom social marketing over multiple years could be substantial. We strongly encourage more
evaluations of these programmes with study designs of high rigour.
a
The Medical University of South Carolina, Department of Psychiatry and Behavioral Sciences, 67 President St Suite MC 406, Charleston, South Carolina 29425, United
States of America (USA).
b
Family Health International, Durham, USA.
c
The Johns Hopkins Bloomberg School of Public Health, Baltimore, USA.
d
World Health Organization, Geneva, Switzerland.
Correspondence to Michael D Sweat (e-mail: sweatm@musc.edu).
(
Submitted: 3 August 2011 – Revised version received: 8 March 2012 – Accepted: 10 March 2012 – Published online: 29 May 2012 )
Bull World Health Organ 2012;90:613–622A | doi:10.2471/BLT.11.094268
614
Systematic reviews
Condom social marketing in developing countries
Michael D Sweat et al.
ing country or emerging economy as de-
ned by the World Bank
8
; (ii) evaluated
a condom social marketing intervention
as dened above; (iii) were a pre–post
assessment or a controlled trial compar-
ing a group exposed to an intervention
with a control group exposed to none, to
a less intensive form of the intervention,
or to another intervention altogether;
(iv) measured condom use behaviour;
(v) were published between January
1990 and March 2010, and (vi) speci-
cally sought to prevent HIV infection.
Studies that compared more intensive
with less intensive versions of the same
intervention and those that measured
outcomes across dierent levels of expo-
sure to an intervention were included if
they met all other criteria. Unpublished
materials and conference abstracts were
excluded from the review. In a separate
process we also identied and coded
background citations, studies with data
on intervention costs, previous reviews
and meta-analyses, and seminal reports
addressing the theoretical or policy is-
sues surrounding condom social mar-
keting, regardless of their geographical
focus. No materials published before
1990 were included, since earlier data
would not have reected the important
developments that have occurred since
then in HIV prevention.
Search and acquisition
Trained sta broadly searched the fol-
lowing databases: the National Library
of Medicines Gateway (which includes
Medline and AIDSline), PsycINFO,
Sociological Abstracts, the Cumulative
Index to Nursing and Allied Health
Literature (CINAHL) and EMBASE.
Sta then hand searched ve HIV-
related journals – AIDS Care, AIDS,
AIDS and Behaviour, AIDS Education
and Prevention and the Journal of AIDS
– for any citation appearing to meet the
inclusion criteria based on the title and
abstract. Sta were given a preliminary
list of search terms but were also free
to explore search terms of their choice
to increase the yield of relevant studies.
e Boolean logic used for the database
searches was as follows: (marketing
OR sale OR sold); AND (condom* OR
contraceptive*) AND (HIV or AIDS).
Searchers were instructed to err on
the side of including papers in the pre-
liminary search, as references were later
subjected to a more in-depth review. We
also iteratively searched the references of
those papers selected for inclusion until
no new papers were identied. Finally,
we carefully reviewed the references
from previous review papers and meta-
analyses for possible citations. Referenc-
es identied as potentially eligible were
imported into a database for additional,
separate screening of titles and abstracts
by two senior sta members who then
classied each citation as either: (i) ac-
cepted, in which case the paper was
included in the meta-analysis; (ii) suit-
able as background material (included
review papers and cost-eectiveness
studies), used only to write the intro-
duction and discussion (“qualitative”)
sections of this paper but not included
in the meta-analysis; or (iii) excluded.
e citations screened by the two senior
sta were then merged for comparison
and dierences were resolved through
additional review and discussion. A
list of citations for acquisition was thus
generated, the citations were obtained,
two independent coders screened the
full citations and discordant results were
resolved by a senior member of the team.
Coding
To extract data from each eligible cita-
tion the two independent coders used
a highly detailed coding form covering
15 content areas: citation information;
study inclusion criteria; study methods;
study population characteristics; setting;
sampling; study design; unit of analysis;
rates of loss to follow-up; characteristics
of the study arms or comparison groups;
(11) characteristics of the intervention;
questions specic to condom social
marketing interventions, such as funder,
charge for condom, condom sale ven-
ues, etc.; outcome measures; eligible
outcomes, and additional information
(e.g. costs, limitations, potential harms
and community acceptance). We coded
citations used as background (“quali-
tative” citations) less intensively; for
these we only extracted data on study
participants, setting, study design and
key ndings (as described in the original
citation).
All outcome variables reported in
a study were noted, but outcomes were
only recorded in detail for studies with
a pre–post or group comparison design.
Such eligible outcomes were coded
in a structured format that included:
(i) the type of statistical analysis used;
(ii) the eect size and base rate; (iii) the
independent variable; (iv) catchments
and/or follow-up times, (v) the con-
dence interval (CI) and/or P-value;
(vi) the page number and table where
the results were located, and (vii) any
Fig. 1. Theoretical/conceptual model for condom social marketing
Develop
commodity
logistics system
Increased availability of
desirable, affordable &
quality condoms
Sustained
marketing
campaign
Condom brand
development
Increased demand
for condoms
Enhanced risk perception & norms
towards condom use and effectiveness
Reduced HIV/STI
transmission
Intervention
component
Intermediate outcomes
Health outcomes
Reduced fertility
Condom sales
Condom use
Market research
HIV, human immunodeficiency virus; STI, sexually-transmitted infection.
Bull World Health Organ 2012;90:613–622A | doi:10.2471/BLT.11.094268
615
Systematic reviews
Condom social marketing in developing countries
Michael D Sweat et al.
additional brief information felt to
be important (e.g. unusual statistical
analyses or inconsistencies found in the
published paper). All eligible outcomes,
whether presented in the aggregate or
by subgroups, were coded. Project sta
resolved discrepancies between coders,
corrected data entry errors and identi-
ed dierences between coders in the
interpretation of study results. Senior
sta resolved any remaining discrepan-
cies in consultation with the principal
investigator of this systematic review
project (MDS) and other senior col-
laborators. We tried contacting authors
when necessary to resolve dierences.
Data from all coding forms were double
entered into EpiData version 3.1 (Epi-
Data Association, Odense, Denmark)
and later transferred to a statistical
database using SPSS version 19 (SPSS
Inc., Chicago, United States of America).
Study rigour
We applied various criteria to control
for methodological rigour: (i) for pro-
spective cohort studies, we checked for
pre- and post-intervention analyses or
for a control or comparison group; se-
rial cross-sectional studies and “post”
only analyses were not held to these
requirements; (ii) for studies compar-
ing an intervention group with a con-
trol group receiving no intervention
or a less intensive one, we checked for
stratication in cross-sectional analyses
and pre–post analyses; (iii) we checked
whether pre- and post-intervention-
outcomes were compared or whether
only post-intervention outcomes were
presented; (iv) in multi-arm studies,
we checked for random assignment to
intervention groups; (v) in all studies
we checked for random selection of
subjects for assessment as a measure to
reduce enrolment bias; (vi) we veried
assessment of attrition and checked
for a minimum follow-up of 80% at
each analysis point in cohort studies;
(vii) in multi-arm studies, we checked
for sociodemographic matching of in-
tervention and control subjects to rule
out signicant baseline dierences; and
(viii) we checked for outcome matching
of intervention and comparison groups,
also to rule out signicant baseline dif-
ferences in outcome measures.
9
Meta-analysis
We standardized the eect size estimates
from study reports to the common met-
ric of an OR, since all studies compared
two groups and reported dichotomous
outcomes. We used standard meta-
analytic methods to derive standardized
eect size estimates.
10
We used the Com-
prehensive Meta-Analysis v.2.2 soware
package (Biostat, Englewood, USA)
to conduct statistical analyses, and we
sometimes hand-calculated eect sizes.
All studies identied for this analysis
reported eect sizes as the proportion
of sexually active subjects who used,
or did not use, a condom with various
sexual partners. To test for the presence
of heterogeneity across the studies in-
cluded in the meta-analyses we used the
Q statistic, a weighted sum of squared
dierences between individual eects
and the pooled eect across studies.
11
To assess the degree of heterogeneity
between studies, we used the I
2
statistic.
Selection of study endpoints
Most studies report multiple endpoint
measures, and for this analysis we spe-
cically sought to examine the impact
of HIV-related condom social market-
ing programmes on condom use rates.
us, we focused our analysis only on
behaviours linked to condom use rather
than on factors such as the intention
to use a condom or attitudes towards
condoms. Condom use behaviour was
measured slightly dierently both within
and across studies, and several studies
reported results with multiple measures
of condom use that met our inclusion
criteria. We thus established guidelines
for prioritizing the measures to include
in primary meta-analysis. We chose:
(i) the measure of condom use during
the most recent sexual act when other
measures of condom use over a longer
term were also reported in the citation;
(ii) the measure of condom use with
the last partner rather than all partners;
(iii) measures of condom use among
casual partners rather than regular part-
ners; and nally, (iv) measures of con-
dom use whose denominator included
only sexually active participants were
selected. Based on this selection process
we dened our primary outcome for
analysis as condom use during the most
recent sexual encounter. e outcomes
that satised these criteria and that were
selected for the primary meta-analysis
are described in
Table 1.
We conducted an additional meta-
analysis based on an average eect size
for all condom use outcomes within a
study meeting our inclusion criteria.
Table 1. Outcomes of studies on condom use included in meta-analyses
Study Condom use behavioural outcomes reported in primary studies
Agha et al., 2001
12
Percentage of participants who reported using a condom in last sex
with a non-regular partner
a
Lipovsek et al., 2010
13
Used condom during last sexual encounter with an FSW
a
Always used a condom with FSWs over the past 12 months
Confirmed having never failed to use a condom with a FSW in past
12 months
Meekers, 2000
14
Used condom during last sexual encounter, any type of partner
a
Used condom with wife
Used condom with long-term partners
Used condom with other partners
Plautz & Meekers,
2007
15
Ever used condom
Used condom during last sexual encounter with a regular partner
Always used condoms with regular partners
Used condom during last sexual encounter with a casual partner
a
Used condom with casual partner
Van Rossem &
Meekers, 2000
16
Used condom during last sexual encounter
a
Used condom during last sexual encounter with an occasional
partner
Ever used condoms
Used condoms for family planning
Van Rossem &
Meekers, 2007
17
Ever used condoms
Used condom during last sexual encounter
a
FSW, female sex worker.
a
Measure used in meta-analysis of condom use during most recent sexual encounter.
Bull World Health Organ 2012;90:613–622A | doi:10.2471/BLT.11.094268
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Systematic reviews
Condom social marketing in developing countries
Michael D Sweat et al.
Average within-study eect sizes were
estimated by converting ORs to a stan-
dard Hedges’ g statistic, with associ-
ated standard errors (SEs) and sample
sizes. Hedgesg, standard errors and
sample sizes were then averaged across
measures within each study, and this
composite eect size was used in our
secondary meta-analysis. When avail-
able, adjusted eect sizes were used in
the meta-analysis rather than unad-
justed values. Given the limited number
of studies and the large heterogeneity
between intervention model, moderator
analyses and multivariate meta-analysis
could not be conducted. us, we are
unable to examine how factors such as
variations in programme implementa-
tion or type of target population aected
intervention outcomes.
Results
Fig. 2 is a ow diagram showing the
study selection process and the reasons
for excluding studies at various stages.
Of an initial 656 citations, successive
rounds of review yielded 11nal cita-
tions
4,1221
and 6 studies
1217
for inclusion
in the qualitative and the quantitative
syntheses, respectively. Of the 11 stud-
ies in the qualitative synthesis, 5 were
excluded from meta-analysis for the
reasons shown in
Fig. 2.
4,1821
In three
studies ultimately included in the quan-
titative synthesis and meta-analysis,
1517
the authors analysed and reported
the results separately by gender, and
we treated each gender separately in
meta-analysis with no double counting
of results.
Studies, participants and
interventions
Table 2 (available at: http://www.who.
int/bulletin/volumes/90/8/11-094268)
describes the characteristics of the six
studies in the quantitative synthesis
and their participants. All interventions
were highly similar, perhaps because
they were funded and operated by the
same donor organization (Population
Services International). All studies
evaluated interventions that followed
standard condom social marketing con-
ventions, as depicted in
Fig. 1, including
condom branding based on pilot studies
of acceptability, a commodity logistics
system, and a sustained professional,
media-based marketing campaign.
One study was conducted in India
among clients of female sex workers.
13
e remaining ve were conducted in
sub-Saharan Africa. ree programmes
targeted broad population groups
12,16,17
;
the other two targeted urban youth
15
and male miners.
14
Of the four mixed
gender studies, two had approximately
equal numbers of males and females,
12,15
another was approximately 75% female
17
and the other did not report the sex dis-
tribution.
16
Only three studies reported
the age range of study subjects.
13,15,17
Four used a serial cross-sectional design
to compare outcomes before and aer
the intervention, with random selection
of study participants.
1316
One study
12
used a single cross-sectional design to
compare provinces where condom social
marketing programmes had operated for
18 months versus less than 6 months.
One cross-sectional study examined
condom use by measuring interven-
tion exposure.
17
In the South African
study among male miners,
14
baseline
assessment sites diered from follow-up
assessment sites, although the authors
reported them as “similar”. Two studies
were described as national in scope.
12,14
e mass media were used extensively
in all interventions, supplemented by
community-based outreach eorts.
All studies randomly selected study
participants for all assessments. Among
serial cross-sectional studies, the aver-
age baseline sample size was 1723 (range:
928–2401) and the average follow-up as-
sessment sample size was 1896 (range:
200–3370). e two cross-sectional
studies had sample sizes of 5412
12
and
9803.
17
In the four serial cross-sectional
studies, follow-up ranged from 12 to 36
months, and the six studies were con-
ducted between 1995 and 2008.
Detailed descriptions of the in-
terventions evaluated were limited
in the source citations. However, the
general social marketing strategy was
very similar across studies, as men-
tioned before, with some differences
only in the communication channels
used. Peer education was reported in
Fig. 2. Flow diagram of study selection for systematic review of the literature on
condom social marketing and condom use
Full-text articles excluded (n = 50) because:
intervention does not meet definition of condom
social marketing (n = 5)
not a pre/post or multi-arm study design (n = 2)
articles coded as background (n =43)
Articles excluded from meta-analysis (n = 5)
because:
large difference in baseline outcome variable
between study groups (n = 1)
no behavioural outcome measured (n = 1)
study outcome (use of female condom) not
comparable to other included studies (n = 1)
use of retrospective data (behaviours reported in
previous 4 years) (n = 1)
repeated results from an included study reporting
on the same intervention (n = 1)
Records identified through
database searching (n = 857)
Abstracts screened at first level
(one person) (n = 656)
Abstract screened at second
level (two people) (n = 100)
Full-text articles assessed for
eligibility (n = 61)
Studies included in qualitative
synthesis (n = 11)
Studies included in quantitative
synthesis (meta-analysis) (n = 6)
Additional records identified
through other sources (n = 82)
Records after duplicates removed (n = 656)
Records excluded (n = 556)
Records excluded (n = 39)
Bull World Health Organ 2012;90:613–622A | doi:10.2471/BLT.11.094268
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Michael D Sweat et al.
five study interventions
12,1417
; inter-
personal communication supporting
condom use was reported in the sixth.
14
Radio advertisements were used in five
interventions
12,1417
and television ads
in three.
12,15,17
Study rigour
Overall study quality was low (Table 3).
ere were no randomized controlled
trials. None of the six studies followed
individual subjects prospectively; in-
stead they conducted serial cross-
sectional surveys. Only three studies
had a control or comparison group. No
study randomly assigned participants to
intervention arms; for studies on con-
dom social marketing interventions, a
group randomized trial would have been
needed. All studies randomly selected
participants for assessments. In the three
studies with a comparison group, study
arms diered sociodemographically at
baseline. Of the three studies with a pre-
post intervention design that included
a comparison group, only one reported
equivalent baseline rates of condom use
across study arms.
Meta-analysis results
Table 4 shows the results of the primary
meta-analysis for the outcome of inter-
est: condom use during the most recent
sexual encounter. In three studies, results
were reported separately by gender, and
we replicated this in the meta-analysis.
is yielded nine discrete eect size
estimates, ve of which showed statisti-
cally signicant eects of condom social
marketing on condom use. ORs across
the four signicant eect size estimates,
for the comparison of those exposed
versus those not exposed to a social
marketing intervention, ranged from 1.10
to 6.21. e random-eects pooled OR
for all studies was 2.01. e Q statistic, a
signicant 553.87, indicated the presence
of heterogeneity across studies.
Table 5 presents the results of the
meta-analysis using a composite mea-
sure of condom use. Interestingly, dif-
ferences across the two meta-analyses
were minimal, with a random eects
pooled OR of 2.10. In addition, the same
four ORs were statistically signicant,
whether a single or an average outcome
was used. e Q statistic, 645.4, was
statistically signicant and showed
heterogeneity across studies. e study
by Agha
12
only reported on condom
use during the most recent sexual en-
counter, and we used this outcome in
this analysis. When we ran a separate
analysis without the Agha
12
study, the
pooled OR was 1.96.
Table 6 presents the results of all
meta-analyses, including several sub-
analyses. When results were stratied
by gender, the odds of having used a
condom during the most recent sexual
encounter were 1.69 higher for males
and 2.18 higher for females who had
been exposed to condom social market-
ing than among males and females who
Table 3. Assessment of methodological rigour of studies on condom use
Study Cohort Control/
comparison
group
Pre–
post
design
Participants
randomly
assigned to
intervention
Participants
randomly
selected for
assessment
Follow-up
≥ 80%
Comparison groups
equivalent at baseline
Sociodemo-
graphically
In outcome
measure
Agha et al., 2001
12
No Yes No No Yes NA NA NA
Lipovsek et al., 2010
13
No Yes No NA Yes NA NA NA
Meekers, 2000
14
No No Yes NA Yes NA No NA
Plautz & Meekers, 2007
15
No No Yes No Yes NA No NA
Van Rossem & Meekers, 2007
17
No Yes
a
No NA Yes NA NA NA
Van Rossem & Meekers, 2000
16
No Yes Yes No Yes NA No Yes
NA, not available.
a
High versus low exposure to the same intervention.
Table 4. Random effects model meta-analysis of condom use during most recent sexual
encounter
Study Subgroup
within
study
Outcome Statistics
OR (95% CI) Z
a
P
Agha et al., 2001
12
Males and
females
Condom use last
sexual encounter
3.6 (2.7–4.8) 8.9 0.000
Lipovsek et al.,
2010
13
Males Condom use FSW
last 12 months
2.3 (1.8–2.9) 7.0 0.000
Meekers, 2000
14
Males Condom use last
sexual encounter
1.2 (0.9–1.7) 1.4 0.174
Plautz & Meekers,
2007
15
Females Condom use last
sexual encounter
6.2 (5.1–7.5) 18.8 0.000
Plautz & Meekers,
2007
15
Males Condom use last
sexual encounter
2.8 (2.3–3.3) 11.8 0.000
Van Rossem &
Meekers, 2000
16
Females Condom use last
sexual encounter
1.7 (1.0–2.8) 1.8 0.071
Van Rossem &
Meekers, 2000
16
Males Condom use last
sexual encounter
1.6 (1.0–2.6) 1.9 0.053
Van Rossem &
Meekers, 2007
17
Females Condom use last
sexual encounter
1.0 (1.0–1.0) 0.3 0.762
Van Rossem &
Meekers, 2007
17
Males Condom use last
sexual encounter
1.1 (1.0–1.2) 3.0 0.004
Pooled 2.0 (1.4–2.8) 4.0 0.000
CI, confidence interval; FSW, female sex worker; OR, odds ratio.
a
The Z-test is an additional test of heterogeneity and reflects the deviation from the mean of the combined
effect size divided by the standard error across included studies.
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Michael D Sweat et al.
had not. Similarly, the odds of using
condoms overall were 2.00 times higher
for exposed males and 1.88 times higher
for exposed females. e test for hetero-
geneity remained signicant within each
gender stratum.
Because studies reported on con-
dom use with dierent partner types,
we conducted an additional meta-
analysis with studies that reported on
condom use during the most recent
sexual encounter with a non-regular/
casual partner (including female sex
workers).
12,13,15
e odds of having
used a condom during the most recent
sexual encounter with a casual partner,
for males and females combined, was
3.45 times higher among those who
had been exposed to condom social
marketing interventions than among
those who had not. e intervention
eects remained signicant when the
outcome was restricted to males only
(OR = 2.56). is analysis was the only
one for which the Q statistic, 1.84, was
not statistically signicant.
An analysis for females only could
not be conducted because only one of
the studies included in the overall meta-
analysis reported on condom use during
the most recent sexual encounter with
a non-regular partner among females.
15
We also performed meta-analysis of the
results from studies that focused on the
general population by excluding stud-
ies conducted among specic high-risk
populations, such as miners
14
and clients
of female sex workers.
13
When the four
remaining studies were meta-analysed,
the odds of having used a condom dur-
ing the most recent sexual encounter
for males and females combined was
2.0 times higher than among the un-
exposed. When the meta-analysis was
restricted to males, the odds were 1.69
higher. A separate analysis for females
was not conducted because all studies
that included female participants were
performed in the general population
and are thus included in the analyses
for females only. For overall condom
use, the OR among studies of the general
population, for males and females com-
bined, was 2.01; the OR for males only
was 1.78. e results of meta-analyses
stratied by population type were simi-
lar to those of the overall meta-analysis,
which included all studies.
Discussion
Given the global scale and scope of con-
dom social marketing as an intervention
for the prevention of HIV infection, we
were surprised to nd only six studies
meeting our minimal inclusion criteria
that were suitable for meta-analysis.
Five of these studies were conducted in
sub-Saharan Africa, which makes the
results dicult to generalize to other
settings. Further, these six studies gen-
erally lacked methodological rigour.
ere were no randomized trials or
cohort studies. Only one of the studies
had a high degree of equivalence across
comparison groups in the baseline rate
of condom use.
16
We also had to elimi-
nate one study from analysis due to the
large and statistically signicant baseline
dierences in condom use across study
groups.
22
e limited number of studies,
lack of methodological rigour and lack
of more recent studies render it dicult
to denitively determine whether cur-
rent implementation of condom social
marketing is likely to increase condom
use across developing countries. Despite
these methodological weaknesses, the
meta-analysis revealed that participants
exposed to condom social marketing
had twice the odds of reporting condom
use when compared with either baseline
rates or comparison groups.
e overall eect of condom social
marketing on condom use was moder-
ate (OR approximately 2). In addition,
when the eect of the intervention was
examined by gender and type of sexual
partner, the results remained nearly
the same. Larger eects were seen for
condom use with casual partners. In
analyses by gender we found only minor
dierences in intervention eectiveness.
In addition, when studies of special risk
groups (sex workers or miners) were
removed from the analysis, the interven-
tion eect changed very little.
Over time social marketing of con-
doms can result in substantial changes in
condom use in the general population.
e follow-up time frame for these six
studies ranged from only 1 to 2 years.
It is possible that if this eect were
cumulative over a much longer period,
a sustained programme could substan-
tially increase the use of condoms. Cle-
land and Ali, in an interesting study of
long-term trends in condom use among
African women, examined data across a
host of surveys conducted in 18 African
countries between 1993 and 2001.
23
ey
found that over these eight years the
median proportion of women who used
condoms to prevent pregnancy rose sub-
stantially, from 5.3% to 18.8%. However,
the median annual increase in condom
use was only 1.4%. e authors attribute
these changes to sustained condom
Table 5. Random effects model meta-analysis of overall condom use composite measure
Study Subgroup
within
study
Outcome Statistics
OR (95% CI) Z
a
P
Agha et al., 2001
12
Males and
females
Condom use last
sexual encounter
3.6 (2.7–4.8) 8.9 0.000
Lipovsek et al.,
2010
13
Males Condom use
composite with
FSW
3.7 (3.2–4.2) 17.7 0.000
Meekers, 2000
14
Males Condom use
composite
1.5 (1.1–2.1) 2.4 0.014
Plautz & Meekers,
2007
15
Females Condom use
composite
4.0 (3.3–4.8) 14.5 0.000
Plautz & Meekers,
2007
15
Males Condom use
composite
2.9 (2.5–3.4) 12.6 0.000
Van Rossem &
Meekers, 2000
16
Females Condom use
composite
1.5 (1.0–2.3) 1.8 0.080
Van Rossem &
Meekers, 2000
16
Males Condom use
composite
1.9 (1.2–3.0) 2.9 0.004
Van Rossem &
Meekers, 2007
17
Females Condom use
composite
1.1 (1.1–1.2) 4.3 0.000
Van Rossem &
Meekers, 2007
17
Males Condom use
composite
1.0 (1.0–1.1) 1.9 0.062
Pooled 2.1 (1.5–2.9) 4.4 0.000
CI, confidence interval; FSW, Female Sex Worker; OR, odds ratio.
a
The Z-test is an additional test of heterogeneity and reflects the deviation from the mean of the combined
effect size divided by the standard error across included studies.
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Condom social marketing in developing countries
Michael D Sweat et al.
promotion associated with reproductive
health campaigns, and they note that
short-term evaluations can obscure the
long-term cumulative benets of such
intervention programmes. If the same
is true for condom social marketing,
the results presented herein speak to
the need to evaluate systems that track
changes in behavioural outcomes over
the duration of these interventions.
Moreover, having more information
on how condom social marketing dif-
ferentially aects uptake by partner
type would be valuable. Without such
longer-term follow up of behavioural
impacts by partner type it is dicult to
accurately assess programme success.
Basic ongoing behavioural sentinel sur-
veillance would be relatively aordable,
and the methods for conducting such
evaluations have been well dened and
tested.
24,25
e limitations of this synthesis and
meta-analysis include the potential for
publication bias, self-reporting bias, and
an inability to identify some aspects of
the interventions originally studied. In
our overall synthesis project examin-
ing a variety of interventions for the
prevention of HIV infection, of which
this review is a part, we also purposively
focused on developing countries, which
represent a neglected area of research
and are uniquely dierent from wealthy
countries socially, politically and eco-
nomically. Furthermore, the most severe
national epidemics of HIV infection
have occurred in developing countries.
Publication bias may have also aected
this analysis, since studies with nega-
tive ndings are seldom published,
26
although other studies have not found
systematic publication bias
27
and this
is an area of some controversy. Aer
initially attempting to cull data from
unpublished sources, we found that the
quality of data identied was always
below that required by our inclusion
criteria. We also found that conference
abstracts oen reported results that
diered substantially from the reports
on the same study that appeared later
in the peer-reviewed literature. Such
unpublished reports also tended to
lack the requisite level of detail on the
intervention and results. Self-reporting
bias and social desirability bias may
have also been present. Finally, many
of the published reports also failed to
fully describe the interventions tested
or to report on important aspects of the
study ndings and study populations.
We did not always succeed in contacting
authors to obtain missing data, and new
studies have emerged since 2010. One
nal limitation is the heterogeneity in
the study results. While this is a concern,
a positive association between condom
social marketing and condom use was
found in all studies, albeit not always
statistically signicant.
Conclusion
There is evidence that condom so-
cial marketing can increase condom
use, although such evidence comes
from studies lacking sufficient rigour.
Community-randomized controlled
trials of condom social marketing
would provide much stronger evidence,
but they are expensive, so large-scale
condom social marketing programmes
are supported by little evidence. More
studies in subpopulations would also
be valuable to the field. Our meta-
analyses did show a positive and sta-
tistically significant effect of condom
social marketing on increasing condom
use, and all individual studies showed
trends for a positive effect. Although
the effect size across studies was mod-
erate, the cumulative effect of condom
social marketing could be substantial
in longer-term evaluations. It is regret-
table that with so many resources being
devoted to condom social marketing
for so long that there is not a larger
evidence base available, especially in
light of the debates over the relative
benefits of abstinence versus condom
use. We also recognize that in many
cases the groups working diligently to
provide and promote low cost quality
condoms in developing country set-
tings have not been given the resources
to fully evaluate their programmes. We
strongly encourage more, and more
robust, research and evaluation of the
efficacy of condom social marketing
programmes.
Acknowledgements
We wish to thank the following indi-
viduals for their help throughout the
various stages of our systematic review
Table 6. Summary of meta-analysis results, by outcome and target population
Outcome No. of
studies
OR (95% CI) Q P for Q I
2
Used a condom during
last sexual encounter
Overall
males and females 6 2.0* (1.4–2.8) 553.87 < 0.001 98.56
males only 5 1.7* (1.1–2.7) 129.75 < 0.001 96.92
females only 3 2.2 (0.5–8.7) 340.18 < 0.001 99.41
With casual partner
a
males and females 3 3.5* (2.2–5.4) 55.24 < 0.001 94.57
males only 2 2.6* (2.1–3.1) 1.84 0.175 45.72
In general population
b
males and females 4 2.1* (1.4–3.1) 519.62 < 0.001 98.85
males only 3 1.7 (0.8–3.5) 103.32 < 0.001 98.06
Overall condom use,
composite score
Overall
males and females 6 2.1* (1.5–2.9) 645.37 < 0.001 98.76
males only 5 2.0* (1.0–4.0) 416.63 < 0.001 99.04
females only 3 1.9 (0.7–4.8) 162.29 < 0.001 98.77
In general population
b
males and females 4 2.0* (1.5–2.8) 398.39 < 0.001 98.49
males only 3 1.8 (0.8–4.0) 150.41 < 0.001 98.67
CI, confidence interval; OR, odds ratio; * P < 0.05.
a
Includes only studies that reported on condom use at the most recent sexual encounter with a casual/
non-regular partner or a sex worker.
b
Excluding Meekers (study population: male miners)
14
and Lipovsek et al. (study population: clients of
female sex workers).
13
Note: The Q statistic indicates the presence or absence of study heterogeneity in meta-analysis, whereas
I
2
represents the degree of study heterogeneity. I
2
ranges between 0% and 100%, with lower values
representing less heterogeneity.
Bull World Health Organ 2012;90:613–622A | doi:10.2471/BLT.11.094268
620
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Michael D Sweat et al.
project: Samantha Dovey, Jewel Gaus-
man, Jennifer Gonyea, Andrea Ippel,
Ruxy Kambarami, Erica Layer, Elizabeth
McCarthy, Amy Medley, Devaki Nam-
biar, Amolo Okero, Alexandria Smith
and Alicen Spaulding.
Funding: is research was supported by
the World Health Organization, Depart-
ment of HIV/AIDS; the US National
Institute of Mental Health, grant num-
ber 1R01MH090173; and the Horizons
Program. e Horizons Program was
funded by e US Agency for Interna-
tional Development under the terms of
HRN-A-00–97–00012–00.
Competing interests: None declared.

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

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
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


       
       




摘要
1990-2010 年发展中国家有关安全套使用的安全套社会营销的效果:系统回顾和元分析
目的 检查安全套社会营销计划和安全套使用之间的关系。
方法 使用标准的系统回顾和元分析方法。回顾包括含安全
套销售、开发本地安全套品牌、通过促销活动增加销售量
等干预措施的研究。对干预措施进行定义,在选定的研究
中遵循标准纳入条件。从每个合格的研究中提取数据,对
结果执行元分析。
结果 六个研究符合纳入标准,合并样本量为23048。其
中一个研究在印度开展,五个在撒哈拉以南的非洲开展。
所有的研究都是横断面或系列横断面研究。有三项研究设
有比对,但是所有研究组都缺乏社会人口学特性的等效
性,。所有研究都随机选择评估的参与者;但所有研究
都没有将参与者随机指定到干预措施组。最近性行为的
安全套使用的随机效应汇集优势比为2:01(95%置信区
间,CI:1.42-2.84),而复合的所有安全套使用的优势
比为2:10(95% CI:1.51-2.91)。异质性检验中两个元
分析都产生显著的效果。
结论 有关安全套使用的安全套社会营销效果的证据基础很
小,这是因为严谨执行的研究很少。元分析显示出增加安
全套使用的积极和统计学意义的效果,所有各个研究都表
明了积极的趋势。安全套社会营销持续多年的累积效应可
能会很大。我们强烈鼓励使用高度严谨的研究设计对这些
计划展开更多评估。
Résumé
Effets du marketing social du préservatif sur l’utilisation du préservatif dans les pays en voie de développement: examen
systématique et méta-analyse, 1990-2010
Objectif Étudier la relation entre les programmes de marketing social
du préservatif et l’utilisation du préservatif.
Méthodes On a recouru à des méthodes de méta-analyse et d’examen
systématique standard. Lexamen comprenait des études d’interventions
dans le cadre desquelles des préservatifs étaient vendus, un ou des
noms de marque locale étaient développés pour les préservatifs, et
les préservatifs étaient commercialisés par le biais d’une campagne
de promotion visant à augmenter les ventes. Une définition de
l’intervention a été élaborée et des critères d’inclusion standard ont été
appliqués dans la sélection des études. Les données ont été extraites de
chaque étude éligible, et une méta-analyse des résultats a été effectuée.
Résultats Six études, avec une taille d’échantillon combinée de
23 048, ont rempli les critères d’inclusion. Une étude a été effectuée
en Inde et cinq en Afrique subsaharienne. Toutes les études étaient
transversales ou transversales en série. Trois études disposaient d’un
groupe de comparaison, mais aucune n’avait d’équivalent en termes de
Bull World Health Organ 2012;90:613–622A | doi:10.2471/BLT.11.094268
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Michael D Sweat et al.
caractéristiques sociodémographiques entre segments de l’étude. Toutes
les études choisissaient aléatoirement les participants aux évaluations,
mais aucune ne désignait aléatoirement les participants aux segments
d’intervention. Le rapport des cotes regroupé à effets aléatoires pour
l’utilisation du préservatif était de 2,01 (intervalle de confiance de
95%, IC: 1,42–2,84) pour la dernière relation sexuelle et de 2,10 (IC de
95%: 1,51–2,91) pour un composé de tous les résultats d’utilisation du
préservatif. Les tests d’hétérogénéité ont donné des résultats significatifs
pour les deux méta-analyses.
Conclusion La base probante de l’effet du marketing social du
préservatif sur l’utilisation du préservatif est faible, car peu d’études
rigoureuses ont été menées. Les méta-analyses ont montré un
effet positif et statistiquement significatif sur l’utilisation accrue du
préservatif, et toutes les études individuelles ont montré des tendances
positives. Leffet cumulatif du marketing social du préservatif sur
plusieurs années pourrait être considérable. Nous encourageons
fortement de nouvelles évaluations de ces programmes avec des
plans d’étude très rigoureux.
Резюме
Влияние социального маркетинга презервативов на использование презервативов в развивающихся
странах: систематический обзор и мета-анализ, 1990-2010 гг.
Цель Изучить связь между программами социального маркетинга
презервативов и использованием презервативов.
Методы Были использованы стандартные методы
систематического обзора и мета-анализа. В обзор были
включены исследования мероприятий, связанных с продажей
презервативов, разработкой местных марок презервативов
и рекламными кампаниями для увеличения продаж. Было
разработано определение термина «вмешательство» и
использованы стандартные критерии включения при отборе
исследований. В качестве исходных данных выступали данные,
полученные по каждому удовлетворяющему критериям
исследованию, и на их основе был проведен мета-анализ
результатов.
Результаты Критериям включения соответствовали шесть
исследований с общим размером выборки, равным 23 048.
Одно из них было проведено в Индии, а пять – в Африке южнее
Сахары. Все исследования были кросс-секционными или
последовательными кросс-секционными. В трех исследованиях
присутствовала группа сравнения, однако в них всех отсутствовало
равенство социально-демографических характеристик между
исследуемыми группами. Во всех исследованиях участники
для оценки отбирались случайно, однако ни в одном из них
не был случайным отбор участников в интервенционные
группы. Обобщенное отношение шансов с учетом случайных
эффектов для использования презерватива составляло 2,01 (95%
доверительный интервал, ДИ: 1,42-2,84) для последнего полового
акта и 2,10 (95% ДИ: 1,51-2,91) для суммы всех случаев, когда
использовался презерватив. Проверка гетерогенности показала
значимые результаты для обоих мета-анализов.
Вывод Доказательная база для оценки эффекта социального
маркетинга презервативов на использование презервативов
мала, поскольку не проводилось достаточного количества
основательных исследований. Мета-анализ показал
положительное и статистически значимое влияние на увеличение
использования презервативов, причем все отдельные
исследования показали позитивные тенденции. Кумулятивный
эффект социального маркетинга презервативов в течение
нескольких лет может оказаться существенным. Мы настоятельно
рекомендуем проводить дополнительные исследования этих
программ на основе строгих научных планов исследования.
Resumen
Efectos de la comercialización social de los preservativos sobre el uso de los mismos en países en desarrollo: examen
sistemático y meta-análisis, 1990–2010
Objetivo Examinar la relación entre los programas de comercialización
social del preservativo y el uso del mismo.
Métodos Se aplicaron diversos métodos de meta-análisis y de examen
sistemático estándar. El examen incluyó estudios sobre intervenciones
en las que se vendieron preservativos, en las que se desarrollaron una o
varias marcas locales para los preservativos y en las que los preservativos
se comercializaron mediante una campaña promocional para aumentar
las ventas. Para seleccionar los estudios, se desarrolló una definición
de intervención y se siguieron unos criterios de inclusión estándar. Se
obtuvieron datos de todos los estudios que cumplían los requisitos y
se realizó un meta-análisis de los resultados.
Resultados Seis estudios con un tamaño muestral combinado de
23 048 cumplieron los criterios de inclusión. Uno se realizó en India y
cinco en África Subsahariana. Todos los estudios fueron transversales
o transversales seriados. Tres de ellos contaron con un grupo de
comparación, si bien todos ellos carecieron de equivalencia en las
características sociodemográficas dentro de las ramas del estudio. Todos
los estudios seleccionaron a sus participantes para las evaluaciones de
manera aleatoria, aunque ninguno asignó aleatoriamente participantes
para las diversas ramas de intervención. La razón de posibilidades
acumulada de efectos aleatorios para el uso del preservativo fue del 2,01
(Intervalo de confianza, IC del 95%: 1,42–2,84) para el encuentro sexual
más reciente y del 2,10 (IC del 95%: 1,51–2,91) para el conjunto de todos
los resultados del uso del preservativo. Las pruebas de heterogeneidad
arrojaron resultados significativos para ambos meta-análisis.
Conclusión La evidencia del efecto de la comercialización social
del uso de preservativo es reducida porque se han realizado pocos
estudios rigurosos sobre el tema. Los meta-análisis mostraron un efecto
positivo y estadísticamente significativo sobre el aumento en el uso
del preservativo. Además, todos los estudios individuales mostraron
tendencias positivas. El efecto acumulativo de la comercialización
social del preservativo durante muchos años podría ser considerable.
Alentamos encarecidamente la realización de evaluaciones de estos
programas con modelos de estudio de elevado rigor.
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Table 2. Characteristics of studies on condom use included in quantitative synthesis
Study Setting Population Intervention description Study design
Agha et al.,
2001
12
Mozambique (all 10
provinces)
Adults, youth, and high-risk populations National condom social marketing programme for JeitO condoms. Communications strategy
included peer education debates known as fogo cruzado (crossfire) and community based
street theatre with messages promoting safer sex. The project invested heavily in training
and materials development for both interpersonal and mass media communications. Mass
media advertising, particularly through radio, was positioned to complement behaviour
change activities at the individual level. Radio spots were aired thousands of times in 10 local
languages as well as in Portuguese to promote safer sex and the use of JeitO condoms. Other
media used by the project include print, outdoor advertising and televisions.
Cross-sectional assessment comparing
provinces in which the CSM campaign
was active for 18 months to those where
it was active for less than 6 months.
Overall sample, n = 5 142. Random
selection of study participants.
Gender: 45.3% male, 54.7% female
Age: NR
Lipovsek et al.,
2010
13
India (Andhra
Pradesh, Karnataka,
Maharashtra, Tamil
Nadu)
Male clients 18 years and older of FSW in
southern India
Integrated behaviour change communication programme targeted at adult male clients
of female sex workers. Programme used multiple media channels including interpersonal
communication, outdoor static promotional materials and mid-media activities to deliver
message around consistent condom use which were changed every 3 months. Programme
introduced affordable condoms in > 65 000 retail outlets.
Serial cross sectional study design.
Sample for each cross-sectional design:
Apr 06, n
= 2 401; Dec 06, n = 1 756; May
07, n = 1 741, Feb 08, n = 1 779; Nov 08,
n = 2 382. Random sampling of hotspots
and systematic sampling of individuals.
Gender: 100% male
Mean age range: 29–31 years
Meekers, 2000
14
South Africa
(Welkom)
Male miners Distribution of “Lovers Plus condoms to traditional and non-traditional outlets and promotion
of their use through peer education and distribution, and mass media campaigns (including
point-of-sale materials, a radio campaign, press advertisements and billboard messages,
and road shows using video show, question and answer sessions, and condom use
demonstrations in hostels and mining areas).
Serial cross-sectional study design.
Baseline, n
= 928; follow-up, n = 200.
Random selection of study participants.
Baseline and follow-up sites were not
the same, but were similar types of
mining operations.
Gender: 100% male
Age: NR
Plautz & Meekers,
2007
15
Cameroon (Douala
and Yaounde)
Unmarried adolescents aged 15–24 The 100% Jeune programme included peer education sessions, a weekly radio call-in show,
a monthly magazine, 100% Jeune, Le Journal, and a serial radio drama titled Solange, Let’s Talk
about Sex. In addition, integrated television, radio, and billboard campaigns and a network of
branded youth-friendly Vendeurs des Amis des Jeunes condom outlets supported intervention
activities. Programme activities were integrated into a pre-existing national contraceptive
social marketing programme. Condoms were available and sold in youth-friendly distribution
points.
Serial cross-sectional study design with
surveys spaced 18 months apart in 2000
(n
= 1956), 2002 (n = 3 237), and 2003
(n = 3 370). Random selection of study
participants.
Gender (2000, 2002, 2003):
Male: 54.0%, 54.2%, 55.0%
Female: 46.0%, 45.8%, 45.0%
Age (2000, 2002, 2003):
15–19: 57.3%, 61.1%, 60.3%
20–24: 42.7%, 38.9%, 39.7%
Van Rossen &
Meekers, 2000
16
Cameroon (Edéa and
Bafia)
Young adults Gender: NR Youth-targeted behaviour change communication and promotion, distribution of “Prudence
Plus” condoms and “Novelle oral contraceptives, peer education, youth clubs (club members
received promotional items as T-shirts,caps, belt-packs, carrying the logo of the Prudence
Plus condom), mass media advertising and information, education and communication
campaigns. All campaign messages were disseminated through youth-oriented promotional
events, peer education and counselling, radio talk shows, brochures and other media.
Serial cross-sectional study design
comparing two communities
(purposefully sampled). Baseline,
n
= 1 606; follow-up, n = 1 633. Random
selection of study participants.
Age: NR
Van Rossem &
Meekers, 2007
17
Zambia (nationwide) Women aged 15–49 and men aged
15–59 in the Demographic and Health
Survey of 2001–2002 in Zambia.
Social marketing and health communication campaigns targeted at general population and
high-risk groups including women, adolescents, young adults, truck drivers and commercial
sex workers. Included four radio and four television programmes aired nationwide. In
addition, it included a condom social marketing campaign that used intensive mass media
and interpersonal communications and distributed subsidized condoms.
Cross sectional design. Overall sample
9 803 (females = 7 658; males = 2 145)
Respondents were drawn from a
2001–2002 Zambia Demographic and
Health Survey. Probability sampling
comparisons made by level of exposure
to intervention.
Gender: 21.9% male, 78.1% female
Age: females, 15–49; males, 15–59
FSW, female sex workers; NR, not reported.
    • "Social marketing of contraceptives, considered a high impact practice for family planning (HIP, 2013c) is a proven practice. Social Marketing has had positive effects on knowledge of and access to contraceptive methods , including condom use (Pelon et al., 1999; Harvey, 2008; Chapman, 2003; Madhavan, 2010; Sweat et al. 2012 ). Social marketing is intended to fill the gap between public sector and commercial sector programming . "
    [Show description] [Hide description] DESCRIPTION: This paper reviews 47 current activities, programs and evidence that affect men’s use of contraceptive methods. The review includes three methods that men use directly, namely condoms, vasectomy and withdrawal, and one that requires their direct cooperation, namely the Standard Days Method. A companion review by Perry et al., 2016, includes a more detailed review of vasectomy programming. Evidence comes from: a review of published and grey literature documentation of interventions focused on men as users of contraception in low- and middle-income countries; and interviews with organizations and institutions that are conducting programming and research in the area of men as users of contraceptive methods.
    Full-text · Working Paper · Sep 2016 · Journal of Health Economics
    • "When we looked at the frequency of included studies by health area, HIV stands out for the numbers of included studies. Other reviews and meta-analyses have investigated the role of social marketing in HIV prevention in low and middle-income countries previously and found the results to be mixed (Bertrand et al. 2006; Noar et al. 2009; Sweat et al. 2012; Evans et al. 2014). Our results coincide with these findings, but we were able to compare HIV-related studies to those in other areas of global health investment to assess how evaluations of social marketing are distributed across health and disease areas. "
    [Show abstract] [Hide abstract] ABSTRACT: Social marketing is a commonly used strategy in global health. Social marketing programmes may sell subsidized products through commercial sector outlets, distribute appropriately priced products, deliver health services through social franchises and promote behaviours not dependent upon a product or service. We aimed to review evidence of the effectiveness of social marketing in low- and middle-income countries, focusing on major areas of investment in global health: HIV, reproductive health, child survival, malaria and tuberculosis. We searched PubMed, PsycInfo and ProQuest, using search terms linking social marketing and health outcomes for studies published from 1995 to 2013. Eligible studies used experimental or quasi-experimental designs to measure outcomes of behavioural factors, health behaviours and/or health outcomes in each health area. Studies were analysed by effect estimates and for application of social marketing benchmark criteria. After reviewing 18 974 records, 125 studies met inclusion criteria. Across health areas, 81 studies reported on changes in behavioural factors, 97 studies reported on changes in behaviour and 42 studies reported on health outcomes. The greatest number of studies focused on HIV outcomes (n = 45) and took place in sub-Saharan Africa (n = 67). Most studies used quasi-experimental designs and reported mixed results. Child survival had proportionately the greatest number of studies using experimental designs, reporting health outcomes, and reporting positive, statistically significant results. Most programmes used a range of methods to promote behaviour change. Programmes with positive, statistically significant findings were more likely to apply audience insights and cost-benefit analyses to motivate behaviour change. Key evidence gaps were found in voluntary medical male circumcision and childhood pneumonia. Social marketing can influence health behaviours and health outcomes in global health; however evaluations assessing health outcomes remain comparatively limited. Global health investments are needed to (i) fill evidence gaps, (ii) strengthen evaluation rigour and (iii) expand effective social marketing approaches.
    Full-text · Article · Jul 2016
    • "Brent (2009) estimated individual conditional demand for social marketing condoms in Tanzania and found a price elasticity around 1 with a strong influence of quality on willingness to pay, but did not allow price elasticity to vary by gender, though 86% of respondents (condom purchasers) were men. Sweat et al. (2012) reviewed the literature on the contribution of condom social marketing on condom use and their meta analysis showed that, though the evidence is weak, in particular for estimating the cumulative effect over time, exposure to a condoms social marketing programme doubled reported condom use among the general population. Differences in responsiveness between contraceptive products targeting men and women have been explored. "
    [Show abstract] [Hide abstract] ABSTRACT: Despite condoms being cheap and effective in preventing HIV, there remains an 8billion shortfall in condom use in risky sex-acts. Social marketing organisations apply private sector marketing approaches to sell public health products. This paper investigates the impact of marketing tools, including promotion and pricing, on demand for male and female condoms in 52 countries between 1997 and 2009. A static model differentiates drivers of demand between products, while a dynamic panel data estimator estimates their short- and long-run impacts. Products are not equally affected: female condoms are not affected by advertising, but highly affected by interpersonal communication and HIV prevalence. Price and promotion have significant short- and long-run effects, with female condoms far more sensitive to price than male condoms. The design of optimal distribution strategies for new and existing HIV prevention technologies must consider both product and target population characteristics.
    Full-text · Article · Apr 2016
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