Acceptability of male condom: An Indian scenario

Abstract

The National Family Planning Programme of India had introduced condom as one of the family planning methods in the late1960s. Condom was promoted as a family planning method through social marketing since its inception. With the increasing prevalence and incidence of sexually transmitted infections (STIs) including HIV/AIDS, condom was also promoted as a dual method for protection against both unintended pregnancies as well as sexually transmitted infections. Despite efforts at various levels, the overall use of condom among couples in India is low. Here we present literature review of studies to understand the condom acceptability among couples in India. Specifically, the paper assesses research and programmes that have been carried out to increase the use of condom among couples; determinants of condom use; reason for not using condom; and perception versus experience of condom failure. The reported problems related to condom use included non acceptance by partner, perceived ineffectiveness, less comfort, lack of sexual satisfaction, husband's alcohol use, depression, and anxiety, and not available at that instant. The role of media in the promotion of condom use was indicated as an important way to increase awareness and use. Multiple strategies would help in acceptance of male condom.

Introduction

The National Family Planning Programme of India had introduced condom as one of the family planning methods in the late1960s. In India, the prevalence of condom use has increased from 2.1 per cent in 1992-19931 to 5.2 per cent in 2005-20062. Worldwide, around 4.4 billion condoms were used for family planning and 6.0 billion condoms for HIV prevention3. It has been estimated that approximately 18 billion condoms will be needed in low and middle-income countries in 20154. The acceptability of condom depends on the quality, accessibility, cost of condom.

Studies conducted so far to understand the determinants of condom acceptability among couples in India have been reviewed to assess the determinants of condom use, reasons for not using condom by the couple and perception vs experience of condom failure.

Role of government to promote condom use

Condoms were available in India since decades ago. It was accessible at a cost of 25 paise by a few wealthier populations while population growth rate was highest among the lower income groups. To meet the demand, International agencies extended their help and recommended “social marketing” of condoms. The Indian Institute of Management (IIM) team suggested to the government to import condoms and sell them at 5 paise per condom which was affordable to the average Indian5. In 1968, 400 million condoms were imported as branded ‘Nirodh’. A distribution system was worked out which involved one-fourth free supply to health centres, and remaining three fourth for social and commercial marketing6.

Hindustan Latex Ltd (HLL), a government undertaking, was set up in Thiruvananthapuram, Kerala, India during 1966 as the first condom factory with the objective of producing good quality condoms for the National Family Planning Programme with an annual production of 144 million pieces6. Through the Nirodh Marketing Programme in March 1972 it was estimated that monthly average use of condoms was up to 7 million pieces7. Hence, another manufacturing unit in Belgaum, Karnataka, was set up in 1985. The current total production of HLL is 800 million pieces6. At present there are numerous industries manufacturing national and international branded condoms in India.

Social marketing to promote condom use

The social marketing of condom had begun with the launch of ‘Nirodh’ condoms by the government in 1968. The strategy of social marketing was to promote condom in reducing barriers that facilitate behaviour change. Promotional activities were initiated through mass media (television, radio, print media) and interpersonal communication (health workers) to creating demand for the condom and, therefore, facilitating the social marketing strategy's success. To create awareness of ‘Nirodh’, in late 1980s several TV commercial were developed, however, the message from these advertisements was not clear like what is condom, who use it, where to get it or distributed free of cost7.

It was found that barrier to use condom included the embarrassment in buying condom and perception that condoms were for non-marital sex only and there is no need not use it in regular relationships8,9,10. Numerous public awareness campaigns were launched to tackle the inhibitions and taboos that were associated with condoms and to encourage the use of condom. In 2004, Corporate Voice Weber Shandwick (CVWS), in association with United State Agency for International Development (USAID) project Private Sector Partnership-One (PSP-One), ICICI Bank and the Union Ministry of Health and Family Welfare, launched a campaign mainly focused on married couples as its slogan ‘Ek Duje Ke Liye’, encouraging husbands to care for the sexual health of their wives and also with the message that condom should be used within marital relationships11. To create a positive image of condom users “Yahi Hai Sahi” (This is the Right Choice) developed by ICICI Bank in partnership with JK Ansell Limited, Hindustan Latex Limited (HLL) and Tiruvellore Thattai Krishnamachari-London International Group (TTK-LIG) Limited, the largest private condom manufacturers in India in 200511. In 2006, to remove the feeling of embarrassment while buying a condom, the “Condom, Bindaas Bol” (condom-Just Say It) campaign was launched12. It was the most effective advertising campaign in 2006, addressing the first level barrier to say the word ‘condom’. To reduce the hesitation in using the word “Condom” in rural India, the advertisements were designed and messages were communicated through the lawyer, police and coolie characters. Increase in sale of condom had been recorded due to the effect of the campaign9.

BBC World Service Trust (BBC WST) launched a campaign connecting the confidence and the smartness needed to talk freely about condoms to being a “real man” in March 200811. Further, they launched the “condom- condom” ringtone aimed to engage people on a taboo topic through a direct-response method11. Use of condom was significantly higher among those couple who were exposed to mass media than their counterparts12,13.

Condom promotion as sexual pleasure

The ‘KamaSutra’ brand condom was launched by J K Ansell Ltd (JKAL), Aurangabad in 1991 and advertised as linking condoms to pleasure for the first time rather than safety as a marketing strategy for condoms14. Within the next decade, the market was flooded with a wide range of condom brands manufactured internationally and nationally. Varieties of flavoured condoms were also manufactured and promoted for sexual pleasure. At present HLL produces the world's largest variety of condoms6.

Counselling/intervention to promote condom use

Numerous studies had been done to promote condom use as dual method for protecting from sexually transmitted infections (STIs) and unwanted pregnancies by counselling men and women both. The idea was to involve men in reproductive health to increase acceptability of condom use. A study conducted in urban community of Mumbai showed that knowledge about correct use of condom was significantly increased in the intervention area i.e Mohili village Bail Bazar than control area Asalfa village15. Various forms of intervention like street plays, small group meetings, health education programmes and inter-personal communication and clinic based counselling for men and couples once in a week were held to educate men and couples in reproductive health programmes. In another interventional study, the percentage increase in knowledge of condom use for dual purpose were 24 and 30 per cent in control area (Abhyudaya Nagar) and interventions areas (Naigaum) respectively, from baseline to endline10.

Sexuality transmitted diseases and promotion of condom

‘Sangram’ was established by 16 peer educators in 1992 in Sangli, a District of Western Maharashtra with the objective of focusing on peer education and empowerment work among sex workers16. Two other groups, in collaboration with Sangram, were established: Veshya AIDS Mukabala Parishad (VAMP), a collective that manages peer interventions among the sex worker community; and Muskan, a peer education group for men who have sex with men (MSM) were set up in 2000. In 2002 and 2006 due to some policy reasons free condom distribution to sex workers was stopped on the grounds that the condoms were only for contraceptive use16.

In 1992, the National AIDS Control Organization (NACO) was set up to manage and oversee policy and programme efforts associated with the prevention and treatment of HIV/AIDS17. During 1999-2006, NACO focused its efforts on targeted interventions with high-risk groups, and behavioural change campaigns to increase awareness of HIV and AIDS, promote safe behaviours, and promoting condom use. They provide free supply of condom in STI/RTI clinics through social marketing, involving government medical machinery at the State level, and by promoting and facilitating commercial sales through non-traditional outlets (paan shops, lodges, etc.). To overcome the embarrassing situation of buying condoms, NACO has established 11,025 Condom Vending Machines (CVMs) in ten States under a national programme. Refusal of condom use by the male partner, and to avoid the risk of STI/HIV among female, a female condoms was manufactured and promoted as social marketing amongst female sex workers17.

Determinants of condom use

The use of condom depends on the knowledge and attitude of users towards condom. Knowledge of condom is universal, but there are rural-urban differences observed in the knowledge. Approximately, 85 and 69 per cent women from urban and rural areas, respectively had heard of condom2. Currently, 9.8 urban and 3.2 per cent rural married women are condom users2. It was also observed that among sexually active unmarried population, 72.4 per cent women and 98 per cent men used condom2.

The use of condom varies from State to State of India. The use of condom was higher in central and western India (15.7% in Uttarakhand, 11.7% in Himanchal Pradesh, 5.6% in Maharashtra, 4.8% in Madhya Pradesh) than south India (2.3% in Tamil Nadu, 1.7% in Karnataka and 0.5% in Andhra Pradesh)2. It may be because of accessibilities, availability, policies and political influence affect the prevalence of condom use. This apparent variation may be due to the use of condom primarily for pregnancy prevention in the north and for HIV prevention in the south.

Reasons for using condoms

Reason for choosing condoms over other spacing family planning methods includes the fear of side effects of other modern spacing methods. The most common reason for discontinuing oral pills, and intrauterine devices (IUDs) within one year of beginning their use was concerns with side effects or health concerns2. Urban condom users reported pharmacies or drugstores (45.4%) as the source of condoms, while 35.7 per cent of women reported they did know the source from where their husband brought the condom2. The potential factor contributing to the condom's popularity may be active social marketing programmes and commercial advertising of condoms.

Reasons for not using condom

The most significant barriers like lack of privacy in stores and social stigma were associated with condom use14,15,18. The reported problems related to not using condom include not accepted by sexual partner, perceived ineffectiveness, less comfort, lack of sexual satisfaction with condoms, husband's alcohol use, depression, anxiety, and not available at that instant19. Further, female sterilization is the dominant family planning method in India20. Couples in whom either the husband or wife has been sterilized may not be motivated to use condoms. They perceive that asking for use of condom indicates the infidelity or having multiple partners21,22.

Perception versus experience: Condom failure

Two-third of men aged 15-54 yr have reported that if a male condom is used correctly, it protects against pregnancy most of the time2. Perception of condom failure is also prevalent in the community and affects its usage2,15. It was found that 3.4 per cent of condom users experienced condom failure within 12 months after beginning its use2. Incorrect usage of condom leads to condom failure. The majority of condom failures were due to human errors23.

A cross-sectional study conducted in four districts of Karnataka among female sex workers reported the experiences of the condom breakage in the last sexual act. It was most common among female sex workers (FSW) aged less than 20 yr, divorced/ separated/ widowed, regular alcohol users, sex worker herself put on the condom to the client, inconsistent condom users, and had never seen a condom demonstration24, the condom being too small or too big and rough sex25. Different sizes of condoms are available, and it is important to make sure that the condom being used is the correct fit26.

Conclusion

The acceptability depends on the awareness, knowledge, and positive attitude towards condom. Various strategies had been adopted to create awareness and spread correct knowledge of condom. Promotion of condom use for preventing unwanted pregnancies is somewhat curbed by promoting it to prevent HIV/AIDS. This creates some confusion in acceptability among married couples. More focus has been given to female sex workers (FSW) and men to men sex. The focus of female condom was also on the female sex workers17. This created a negative image that female condom was only for FSWs. To increase the acceptability of condom (male and female), there is a need to create a positive image that use of condom (male or female) could prevent unwanted pregnancies and sexually transmitted diseases for sexually active population. Further, there is a substantial proportion of men who do not know how to use condoms correctly and at risk of condom failure. Thus, there is a need to educate men on the correct usage of condom. Multiple strategies would help in acceptance of male condom in India.