Does Mass-Media Public Communication Campaign Normalize Discussion, Attitude and Behavior about Condom Use among Married Men in India?

"The effectiveness of mass media campaigns for normalizing condom discussion is largely mediated by demographic and socio-economic variables. Future campaigns need to address these variables to be more effective."

Noting that "condom" is a stigmatised topic in India and that open discussion about its use and promotion is considered inappropriate, this study examines the association between exposure to public service announcements (PSAs) around condoms and discussion, attitudes, and behavioural intentions about condom use among married Indian men by their age and socio-economic status (SES). It explores a communication intervention carried out as part of the "Advocacy and Media" component under the Avahan HIV prevention intervention (2003-2014) using the British Broadcasting Corporation (BBC) World Service Trust (WST) [now called BBC Media Action] condom normalisation survey data. (Further details about Avahan and the Condom, Condom! campaign may be found under Related Summaries, below.)

In short, launched on the eve of World AIDS Day in 2007 with a competition designed to make condoms normal and to get men to talk about condoms, the campaign sought to changee perceptions about condoms and promote condom use among the general population in the reproductive age group (15-49 years) and high-risk men having multiple sex partners. The media campaign was consisted of a series of PSAs named as 1) Riddle, 2) Kabaddi, 3) Ringtone, and 4) Dog. The first 2 PSAs were designed to promote talk about condoms. In the first PSA, Riddle, the audience has to answer a riddle whose answer was condom, and in the second PSA, Kabaddi (Kabaddi is a contact sport that originated in ancient India in which the player chants the word "Kabaddi"), the audience has to chant the word "condom" instead of "Kabaddi". These PSAs contained starting elements like "Jo bola wahi Sikander" ("The one who spoke is a winner."), "Hum mard nahi bolenge to aur kon bolega" ("We masculine men will not speak, then who will?"), and "Mard bano khul ke baat karo" ("Be a masculine man and speak up openly."). The remaining 2 PSAs, "Ringtone" and "Dog", were designed to change the social norms around condoms by adding starting elements such as "Jo samja wohi sikandar" ("The one who understood is a winner."), "Condom matlab samajdhari"("Condom means responsibility."), and "Samajhdaar log condom se nahin sharmate" ("Responsible men do not shy from the condom."). The third PSA consisted of a unique cell phone ringtone ("condom"), and the last PSA featured a woman who called a dog by his name, "condom". The media campaign was broadcasted in 4 phases in 2007 and 2008 in 4 high HIV prevalence states (Andhra Pradesh, Karnataka, Maharashtra, and Tamil Nadu).

A sub-sample of monogamous married men (N=2,502) was obtained from 2009 BBC WST's condom normalisation survey among men in the 4 project states. Multiple logistic regression models were used to analyse the association of exposure to the PSAs with discussion, attitudes, and behavioural intentions about the condom and its usage. More than half of the married men who participated in the survey (55%) were younger (<=35 years), having better SES (educated above secondary levels and employed) (55%) and exposed to the PSAs (64%). Exposure to the PSAs was associated with greater likelihood to seek condom information (adjusted odds ratio (AOR): 1.33; p=0.010), positive attitude (AOR: 1.24; p=0.008), higher self-efficacy (AOR: 1.53; p=0.006) in using and, last time, condom use (AOR: 2.15; p=0.023) among men: with a better SES, with a positive, caring attitude (AOR: 1.27; p=0.010), who experienced ease in purchasing condoms (AOR: 2.04, p=0.009), who were older (35+ years), and who were younger men reporting last time condom use (AOR: 1.85; p=0.037).

To present some of these results - the data stratefied by age - in another fashion: Among the younger married men (<=35 years), ever discussed condoms (79% vs. 53%, AOR: 3.0, 95% CI: 1.0-9.2) and ease in purchasing condoms (56% vs. 38%, AOR: 2.0, 95% CI: 1.4-2.8) were associated with communication campaign exposure. However, among the older married men (35+ years), campaign exposure was associated with caring attitude towards others about condom use (64% vs. 58%, AOR: 1.3, 95% CI: 1.1-1.4), ease in purchasing condoms (48% vs. 30%, AOR: 2.0, 95% CI: 1.5-2.7), and high self-efficacy about condoms (44% vs. 38%, AOR: 1.2, 95% CI: 1.1-1.5). However, in both the groups of younger and older married men, campaign exposure was not associated with positive discussion about condoms, behavioural intention toward condom use, or attitude towards condoms. The odds of last time condom use (84% vs. 74%, AOR: 1.8, 95% CI: 1.1-3.1) was higher among exposed men than unexposed men in younger married men. No association was found between campaign exposure and condom use behaviours in older married men.

Similarly, the sub-group analysis of SES suggests that among married men having "poor" SES, campaign exposure was significantly associated with high attitude towards condom use, but less consistent with condom use. This finding proved the effectiveness of campaign exposure in terms of disseminating information about condoms and their usage to less educated married men and simultaneously also relates the economic condition as a barrier to consistent condom use due to the cost factor. On the contrary, among married men having "better" SES, campaign exposure is significantly associated with discussion and high likelihood of seeking information about condoms, high self-efficacy and attitudes towards condoms, and ease in purchasing condoms.

The findings of the study highlight a contention that linkage between mass-media campaigns and promotion of condom normalisation through discussion, seeking information, and intention to use and its usage goes beyond a behaviour change strategy to include dimensions of age, educational attainment, and SES. "[T]he study supports the effectiveness of campaign exposure on attitude towards condom as a tool to care about others and high self-efficacy about condoms; especially among the older married men. Further, it highlights the importance of socio-economic status in seeking the information, attitude and self-efficacy about condoms and shaping safer sexual practices, particularly among married men having 'better' socio-economic status....These results have implication[s] for policies and programs and provide effective strategies of increasing the access to free condoms and providing the educational and work opportunities and further recommends the comprehensive mass-media campaign, which could be targeted married men by focusing on their demographic and employment variables."