Implementation of Condom Social
Marketing in Louisiana, 1993 to 1996
Deborah A. Cohen, MD, MPH, Thomas A. Farley, MD, MPH, Jean Roger Bedimo-
Etame, MD, MSc, Richard Scribner, MD, MPH, William Ward, DrPH, Carl Kendall, PhD,
and Janet Rice, PhD
Social marketing uses the elements of
price, placement, promotion, and product to
introduce a product or behavior for the public
benefit.' Social marketing of condoms is a key
element of the global strategy for the control
of HIV,2 but it has not been widely adopted
in the United States.7 Elements of condom
social marketing that manipulate the price of
condoms, increase condom placement, and
target promotion of condoms to the population
at risk improve access to condoms to groups
who could benefit from their availability.
Surveys have found that persons at high
risk for HIV infection are already very
knowledgeable about the effectiveness of
condoms in preventing disease trans-
mission8'9; however, this knowledge is not
associated with condom use.'1'3 We hypoth-
esized that increasing condom accessibility
would increase condom use. First, removing
the structural barriers created by the high
cost of condoms and the low concentration
of condom outlets may increase the number
of condoms that persons obtain, thereby
increasing the likelihood that a condom is
available at the time of a sexual encounter.
Second, increasing the presence of condoms
in the environment may indirectly increase
individual condom use by implying that con-
doms are acceptable, thus influencing social
norms. In addition, when a trusted health
care provider supplies condoms, it lends
authority and credibility to the importance of
condoms in disease prevention.
Except for the issue of condom avail-
ability in public schools, improving condom
availability has not been a major focus of
HIV prevention efforts in the United States,
perhaps because many people believe that
condoms are already adequately available.
Although condoms are sold in most super-
markets and drugstores, there are still many
barriers to the purchase of condoms by indi-
viduals. These barriers include embarrass-
ment, lack of confidentiality, cost, and lack
of planning for sexual encounters. 3-15 The
widespread availability of free "self-service"
condoms may reduce embarrassment,
increase confidentiality, and minimize the
need for planning (given that condoms may
be accessible at many locations). 6
In response to the HIV epidemic and
the high rates of other sexually transmitted
diseases (STDs), particularly syphilis, the
Louisiana Department of Health and Hospi-
tals developed a statewide social marketing
campaign designed to increase accessibility
of condoms by providing them in a targeted
fashion at a vastly increased number of loca-
tions, particularly health clinics and small
businesses in neighborhoods with high rates
of STDs. This paper reports the process and
effect of the program from its inception in
1993 through 1996.
Methods
Condom Distribution
The basic intervention was the provi-
sion of free condoms in readily visible and
Deborah A. Cohen, Thomas A. Farley, and Richard
Scribner are with the Louisiana Department of Health
and Hospitals, Office of Public Health, New Orleans;
Deborah A. Cohen and Richard Scribner are also with
the Louisiana State University Medical Center, New
Orleans, as is Jean Roger Bedimo-Etame. William
Ward is with Tulane University Medical Center,
Program in Community Medicine, New Orleans. Carl
Kendall and Janet Rice are with Tulane University
School of Public Health and Tropical Medicine, New
Orleans.
Correspondence and requests for reprints
should be sent to Deborah A. Cohen, MD, MPH,
HIV Program Office, 1600 Canal St, New Orleans,
LA 70112.
This paper was accepted August 27, 1998.
February 1999, Vol. 89, No. 2

accessible sites through health care facilities
and private businesses serving populations at
high risk for STDs and HIV.
Public sector. In May 1993, the secre-
tary of the Louisiana Department of Health
and Hospitals mandated that condoms would
be made accessible to all clients of publicly
funded health department clinics. Condoms
were made available at no charge in all
parish (county) public health clinics (n = 93),
community mental health centers (n = 39),
and public substance abuse treatment centers
(n = 29). Over the course of the project, 35
private physicians, 105 community health
care centers, and at least 27 housing projects
also made condoms available. Training on
condom use, condom efficacy, and increas-
ing condom accessibility was conducted
throughout the state. We encouraged staff to
make condoms freely available, not to limit
the number that people could take, and to
allow clients to take them without asking
permission (this included posting signs
announcing that the condoms were free). We
also encouraged staff to take condoms home
and distribute them to anyone they knew
who might need them. In addition, we asked
staff to notify us of any complaints or prob-
lems that might arise. Condom availability in
public clinic sites was assessed by standard-
ized annual observation surveys.
Private sector. Businesses in neighbor-
hoods with the highest rates of STDs were
invited to distribute condoms at no charge to
their customers. The program was piloted in
one area of New Orleans in 1993 and then
gradually expanded statewide in 1994. On
average, approximately 1000 businesses
were actively participating in the program at
any time. Participating businesses included
324 convenience stores; 388 bars, night-
clubs, and liquor stores; 145 beauty salons
and barbershops; as well as other businesses
such as tattoo parlors, dry cleaners, and low-
cost motels. In addition, all community-
based organizations involved in HIV/STD
prevention activities such as street outreach
or other types of interventions were supplied
with large quantities of condoms for distribu-
tion in their programs.
We tracked the number of condoms dis-
tributed as well as where they were distributed
at the parish level statewide. We obtained data
for a 2-year period on the number of condoms
distributed commercially through wholesalers
to 60% of the Louisiana supermarkets and
drugstores from Towne and Oller, Associates,
a marketing research firm.
Evaluation
Surveys were conducted to deternine
whether there was a change in self-reported
February 1999, Vol. 89, No. 2
sexual behavior during the course of the
intervention, particularly in condom use at
the last sexual encounter and in number of
sex partners in the previous 12 months.
Clinic survey. In 27 public clinics, sur-
veys were distributed to women who visited
the clinic for family planning or prenatal vis-
its, who brought their children for immuniza-
tions or well-child visits, or who came for
required visits for the Women, Infants, and
Children (WIC) Program. Clinics were
selected to represent all 9 geographic regions
of Louisiana and to include both urban and
rural parishes. Because approximately 70% of
all Louisiana children receive immunizations
through the public health clinics, this sur-
veyed population was fairly representative of
the state's females of childbearing age, an
important subset of the young, sexually active
general female population. The questionnaires
were anonymous and self-administered.
Adults were given the questionnaires by the
registration clerk and asked to drop them in a
box when completed. Refusal rates could not
be calculated because attendance logs at these
clinics were not available. The questionnaires
were distributed 2 to 4 times each year over a
1- to 2-week period from February 1994
through December 1996. The data were ana-
lyzed for each 12-month period. Logistic
regression was used to control for type of ser-
vice received at the clinic, race, education,
and marital status when measuring changes in
self-reported condom use and changes in the
number of sex partners over time.
Street survey. We conducted inter-
viewer-assisted street-intercept surveys of
African American men, aged 15 through 45
years, in targeted areas of New Orleans. The
selected neighborhoods for these surveys
were those with the highest rates of gonor-
rhea in New Orleans, including one zip code
in which 100 businesses had been recruited
to distribute free condoms in 1994 (Area A)
and sociodemographically matched compari-
son areas in which businesses had not been
recruited during this first year of the program
(Area B). These surveys were repeated in
both areas in 1995 and 1996. Each year, par-
ticipants were recruited on 20 selected street
corners (10 Area A, 10 Area B). Refusal
rates were between 10% and 20% each year.
Results
Condom Distribution
Before the statewide condom social
marketing program was initiated, approxi-
mately 323 000 condoms had been dis-
tributed in 1992. Our program increased dis-
tribution to 8 735 000 condoms in 1994,
Condom Social Marketing
11 900 000 condoms in 1995, and 13 360 000
condoms in 1996. Although most condoms
were distributed through health clinics, more
than 2 million condoms were distributed by
private businesses in high-risk neighbor-
hoods in both 1995 and 1996 (Figure 1).
During the period of the sharpest increase in
free condom distribution (May 1993 through
June 1995), the number of condoms sold
commercially in Louisiana stayed constant at
a rate of approximately 2 million per year.
Before the program started, free con-
doms were provided in small quantities at
the discretion of the health care providers.
After the first year of the program, 96% of
all public clinics provided condoms; by the
end of the second year, all clinics had acces-
sible condoms, and 67% made arrangements
for clients to help themselves to condoms
without having to ask.
Despite the controversial nature of con-
dom distribution, elected officials made only
a few complaints during the first year of the
project. These were addressed by providing
facts about the STD and HIV epidemics in
Louisiana. Since that time, we have received
no complaints about the distribution of free
condoms from citizens, religious groups, or
elected officials.
In contrast, many health care workers
complained about the program, but as
patients showed appreciation, acceptance by
health care workers improved. Again, we
received no complaints after the first year.
In the private sector, approximately 50%
of businesses approached agreed to partici-
pate. Over time, many business owners who
heard about the condom distribution program
contacted staff and requested that they be
included. Because some of the businesses
involved were operating on a marginal scale,
approximately 10% dropped out of the pro-
gram annually because they closed or
changed management, and fewer than 1%
dropped out because of customer complaints.
These businesses were readily replaced in the
program by other businesses.
Table 1 shows the number of outlets par-
ticipating in the private-sector program in the
comparison areas of New Orleans in 1994
through 1996. We initially tried to limit con-
dom distribution to Area A. However, the
intervention was popular and desired by local
businesses. Community-based organizations
recruited sites in our comparison area (Area
B), so that by 1996, the number of commer-
cial outlets in Area B began to approach the
number in Area A.
Evaluation
Clinic survey. Respondents in the clinic
survey were women who reported having
American Journal of Public Health 205
Cohen et al.

sex in the past 12 months. The distribution of

14
other demographic characteristics by the r-DOther
year of the survey is shown in Table 2.
Although the distribution of respondents'
,° 12 iCBO
race did not differ across each year, the 10 usiness

respondents' marital status and type of clinic CHinic

E
visited differed during the study period. laSY
In the 3 study years, the proportion of
women reporting 2 or more sex partners did
not show a temporal trend (17% in 1994, 0

12% in 1995, and 18% in 1996). However,

there were race-specific changes in respon-
dents' reporting of condom use. From 1994 z

to 1996, self-reported condom use at the last 0

sexual encounter did not change among 1992 1993 1994 1995 1996

White women (18% in both 1994 and 1996) Year

but increased among African American
women (from 28% to 36%) and increased
sharply (from 30% to 48%) among those
African American women who reported 2 or
more partners in the previous year (Table 2).
After logistic regression was used to control
for marital status, type of clinic visited, race,
and education, there remained a substantial
increase in condom use in 1996 compared
with 1994 among all women with 2 or more
sex partners (odds ratio [OR] = 1.36; 95%
confidence interval [CI] = 1.10, 1.67) and
among African American women with 2 or
more sex partners (OR= 1.42; 95%
CI = 1.13, 1.91). The number of sex partners
over the 3 years did not change among
respondents (OR = 1.1; 95% CI = 0.98, 1.22).
Among all respondents, other measures
increased, indicating greater program expo-
sure and increased access to condoms. Fig-
ure 2 shows consecutive increases in the per-
centage of women who used condoms at the
FIGURE 1-Number of free condoms distributed by type of distribution site,
1992 through 1996 (CBO = community-based organization).
last sexual encounter (P < .04), had condoms Table 1 shows the secular trend in self-
(P< .0001), obtained free condoms (P< .0001), reported condom use at the last sexual
knew where to get free condoms (P< .0001), encounter and the number of sex partners in
and reported that their friends used condoms the previous 12 months among survey respon-
(P<.0001). dents. Condom use increased from 40% to
Street survey. Each year, between 500 56% in Area A (the area in which the private-
and 600 men answered the street-intercept sector program was initiated) between 1994
survey in New Orleans. The respondents did and 1995 (P< .0001) and decreased slightly to
not differ across years or between Area A and 52% the following year (P= .45). In Area B,
Area B, except in year 1 when the median in which the private-sector program was
age in Area B was slightly older than that in implemented in 1995, condom use increased
the intervention group (29.3 vs 28.7, from 41% to 48% between 1994 and 1995
P = .01). The percentage of respondents with (P=.06) and increased to 55% in 1996
less than a high school education and the per- (P <.003 for 1996 vs 1994). The percentage of
centage unmarried did not vary significantly persons reporting 2 or more sex partners was
across years or between Areas A and B (see similar between the 2 areas and did not change
Table 1). significantly during the survey periods.

TABLE 1-Characteristics of New Orleans Street Survey Respondents and Condom Outlet Density, 1994 Through 1996
1994 1995 1996
Area A Area B Area A Area B Area A Area B
Condom outlets/1 000 persons 1.93 0.54 1.89 0.90 1.67 1.07
Education
<HS 122 (40%) 155 (40%) 103 (35%) 124 (43%) 84 (33%) 95 (39%)
>HS 185 (60%) 233 (60%) 191 (65%) 166 (57%) 168 (67%) 150 (61%)
Age, y
15-24 122 (40%) 146 (37%) 144 (46%) 163 (55%) 124 (49%) 122 (49%)
25-34 91 (29%) 135 (34%) 77 (25%) 67 (22%) 67 (26%) 49 (20%)
.35 95 (31%) 115 (29%) 91 (29%) 68 (23%) 62 (25%) 76 (31%)
Marital status
Married 61 (20%) 63 (17%) 60 (19%) 52 (18%) 58 (23%) 53 (22%)
Unmarried 243 (80%) 299 (83%) 251 (81%) 242 (82%) 194 (77%) 191 (78%)
Condom use at last sexual encounter
Yes 122 (40%) 161 (41%) 169 (56%) 142 (48%) 131 (52%) 135 (55%)
No 184 (54%) 232 (59%) 135 (44%) 153 (52%) 119 (48%) 110 (45%)
Sex partners in last year
1 98 (33%) 110 (28%) 80 (28%) 65 (24%) 80 (32%) 61 (25%)
22 202 (67%) 276 (72%) 207 (72%) 210 (76%) 171 (68%) 185 (75%)
Note. HS = high school.

206 American Journal of Public Health February 1999, Vol. 89, No. 2
 Condom Social Marketing

When we combined data from the 2

areas, we found other changes over the sur- TABLE 2-Characteristics of Statewide Clinic Survey Respondents, 1994
Through 1996
vey years suggesting that respondents were
obtaining and using the program's condoms. 1994 1995 1996
From 1994 to 1996, the percentage of
respondents who identified the brand of con- Total no. surveyed 1614 1706 1787
dom being distributed through the health Race
department program as the one they used last African American 710 (45%) 677 (40%) 763 (43%)
increased from 40% to 61% (P <.0001), the White 813 (51%) 954 (57%) 957 (54%)
Other 61 (4%) 51 (3%) 50 (3%)
percentage who reported they had obtained
free condoms increased from 61% to 74% Age, y
15-24 NA 813 (51%) 877 (50%)
(P < .001), the percentage who knew where 25-34 NA 622 (38%) 652 (37%)
to obtain free condoms increased from 63% >35 NA 202 (12%) 211 (12%)
to 82% (P< .000 1), and the percentage who Marital statusa
reported not owning any condoms decreased Married 570 (44%) 844 (50%) 808 (46%)
from 32% to 22% (P< .0002). Unmarried 739 (56%) 859 (50%) 968 (54%)
Type of clinic service
WIC/immunization 1211 (80%) 1283 (76%) 1141 (66%)
Discussion FP/Prenatal 230 (15%) 280 (17%) 435 (25%)
Other 82 (5%) 109 (7%) 146 (8%)
We successfully implemented a state- Education
<High school 455 (30%) 509 (31%) 474 (28%)
wide condom distribution program and found >High school 1076 (70%) 1131 (69%) 1221 (72%)
that the program was associated with Condom use at last sexual encounter
increases in self-reported condom use in African Americanb 697 659 748
high-risk populations, without being associ- 1 sex partner 149 (27%) 173 (32%) 183 (33%)
ated with increases in number of sex partners. .2 sex partners 46 (30%) 42 (39%) 89 (48%)
These results indicate that condom social
marketing in the United States is indeed fea- Note. NA = not available; WIC = Women, Infants, and Children; FP = family planning.
sible, acceptable, and a promising interven- aNot collected from the first 305 respondents.
tion to decrease transmission of STDs, bincludes only women who have been sexually active in the past 12 months.
including HIV. Our conclusions are based on
(1) consistent increases in reports of knowl-
edge and behavior associated with condom We were unable to conduct a controlled only a portion of neighborhoods in New
use (e.g., knowing where to obtain free con- trial of this intervention, in part because of Orleans with high rates of STDs, even for the
doms, obtaining free condoms, owning con- the popularity of the program as a response to purpose of determining effectiveness.
doms), (2) increases in reports of condom an urgent and critical public health problem. Nonetheless, the delayed implementation of
use, and (3) the temporal and spatial relation- Community-based organizations working to the program in Area B in New Orleans did
ship between increases in self-reported con- prevent AIDS did not consider it ethical to allow us to compare the timing of the intro-
dom use in the New Orleans street-intercept limit large-scale free condom distribution to duction of condom availability with changes
surveys and the availability of free condoms
at neighborhood business sites.
Our evaluation was based to a large 90
extent on self-reported condom use in sur-
veys. Although this measure is commonly ........

used to evaluate HIV prevention programs, it 1.19951

may not necessarily reflect actual condom 0
use.17 Objective markers such as rates of
other STDs support the validity of increases ,50
in self-reported condom use. From 1992 to
1996, rates of primary and secondary
syphilis decreased from 63/100 000 to CL
13/100 000 (-79%), and rates of gonorrhea
decreased from 343/100 000 to 222/100 000
f30 . . .

10
(-35%) in Louisiana. Because our interven-
tion was statewide, it is impossible to esti-
mate what might have happened to these Used Has Got fre Knows Friends use
rates if we had not implemented the pro- condom condoms condoms where to condoms
gram. However, taken together with the last sex get free
condoms
increased reports of condom use among
high-risk men and women, these findings
suggest that condom distribution does not FIGURE 2-Percentage of female respondents In clinic survey reporting
increase risk behavior and may have con- knowledge and behaviors about condoms, 1994 through 1996.
tributed to reduced STD transmission.

February 1999, Vol. 89, No. 2 American Journal of Public Health 207
Cohen et al.
in condom use. We found a large increase in
self-reported condom use following a sudden
increase in condom outlets in Area A, and a
gradual increase in self-reported condom use
paralleled the slower, but steady, increase in
condom outlets in Area B. These findings
suggest that the increases were more likely to
be a result of the program itself than of unre-
lated secular trends in condom use.
Large numbers of free condoms were
distributed through this program. The pro-
gram had no apparent effect on commercial
sales of condoms at a time when condom
sales were declining nationally.'8 This sug-
gests that for persons already purchasing con-
doms, the availability of free condoms did not
lead them to stop purchasing them. Rather, it
appears that the program reached a group that
was not purchasing condoms previously.
Many small businesses in neighbor-
hoods with high rates of STDs participated,
indicating that the approach of distributing
free condoms through private distribution
sites is both feasible and acceptable. Many
business owners noted that the program was
an opportunity to serve their communities,
and some believed it helped their businesses
by providing an additional incentive for
customers.
We were surprised at the relatively small
opposition to the program from groups tradi-
tionally opposed to condoms. We believe that
our strategy of confining the program to
health facilities, neighborhoods with high
rates of STDs and HIV, and businesses (such
as bars and alcohol and tobacco outlets) that
serve adults with other high-risk behaviors
contributed to tolerance of the program. The
program's low profile made it relatively
invisible to persons not already involved with
or concemed about HIV and STDs.
Some may argue that a large-scale free
condom program is unrealistic and unsus-
tainable. Condoms purchased in bulk cost
$0.05 each. The estimated value of prevent-
ing a case of HIV infection, however, is as
high as $80 000 for medical costs alone.19 If
distributing 1.6 million condoms prevents
only one case of HIV transmission, the pro-
gram would be cost-effective. In Louisiana
in 1996, we distributed 13.4 million con-
doms, or approximately 3.1 condoms per
capita. If states and territories that receive
HIV prevention funds from the Centers for
Disease Control and Prevention used only
208 American Journal of Public Health
25% of their award in fiscal year 1995 for
condom purchases, they would be able to
buy from 2.6 (South Dakota) to 6.4 (New
York) condoms per capita.20 Thus, a program
of this magnitude is achievable within exist-
ing public health budgets.
Given the strong, positive response that
this program has received in terms of com-
munity participation and acceptance, we con-
clude that interventions to increase condom
accessibility are feasible in the United States
and hold significant promise in prevention of
HIV infection and other STDs. L]
Contributors
Deborah Cohen designed and supervised the interven-
tion, planned and supervised the evaluation, assisted in
analyzing the data, and wrote the paper. Thomas
Farley assisted in planning and implementing the inter-
vention and the evaluation, analyzing the data, and
writing the paper. Jean Roger Bedimo-Etame analyzed
the data and assisted in writing the paper. Richard
Scribner assisted in designing the evaluation, analyz-
ing the data, and writing the paper. William Ward
assisted in designing the evaluation and supervised the
street surveys in New Orleans. Carl Kendall assisted in
designing the evaluation. Janet Rice assisted in design-
ing the evaluation and analyzing the data. All authors
are guarantors of the integrity of the research.
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