Evaluation and Program Planning 74 (2019) 20–26

Contents lists available at ScienceDirect

Evaluation and Program Planning

journal homepage: www.elsevier.com/locate/evalprogplan

Implementing condom distribution programs in the United States: T

Qualitative insights from program planners
Megan McCool-Myers
Emory University, School of Medicine, Jane Fonda Center for Adolescent Reproductive Health, 46 Armstrong Street SE, Atlanta, GA, 30303, United States

A R T I C LE I N FO A B S T R A C T

Keywords: With the growing number of sexually transmitted infections (STIs) among young people (15–24) in the US,
Condoms condom distribution programs (CDP) remain an integral part of prevention strategies. The objective of the study
Condom was to gather qualitative insights from CDP planners to inform effective CDP implementation. Ten semi-struc-
Contraceptive tured interviews with program planners were conducted via telephone (response rate of 58.8%). Condom dis-
Unplanned pregnancy
tribution channels included site-based distribution (n = 6), web-based distribution (n = 4), and distribution via
STD
STI
Uber (n = 1). Site-based distribution programs had distribution networks ranging from 100 to 3500 sites in a
HIV given jurisdiction. Planners of site-based CDPs experienced challenges with ensuring quality control at sites and
Prevention supplying condoms to sites. Web-based CDPs allow individuals to order free condoms online. These CDP
STD prevention planners reported growing demand for this discreet service, particularly among young people. Web-based CDPs
STI prevention leveraged e-mail surveys to collect data on sexual behavior and behavior change, yielding response rates as high
HIV prevention as 63%. All CDPs emphasized the importance of supplying a variety of products. Total supplies distributed (male
Condom distribution program condoms, internal condoms, lubricant sachets) ranged from 16,000 to 45 million per year. Novel channels of
Program planning
distribution should be explored to ensure reach to adolescents and young adults.
Health promotion
Social marketing
Monitoring
Evaluation
Adolescents
Young Adults
Teens

1. Introduction
Since 2013, sexually transmitted infections (STI) such as chlamydia,
gonorrhea and syphilis have continued to rise in the US, with an esti-
mated 20 million new infections each year (Centers for Disease Control
and Prevention, 2017). Half of these new infections impact adolescents
(15–19) and young adults (20–24) (Centers for Disease Control and
Prevention, 2017). While new HIV infections are on the decline
(Bavinton et al., 2018; Huang et al., 2018; New HIV Infections Drop 18
Percent in Six Years, 2017), approximately 60,000 youth in the US
currently live with HIV, and 51% of these youth remain undiagnosed,
presenting a risk of onward transmission (Centers for Disease Control
and Prevention, 2017). These high rates of STIs and undiagnosed HIV
infections reflect multiple barriers to accessing quality STI prevention
services, including lack of insurance or inability to pay, lack of trans-
portation, discomfort with facilities and services designed for adults,
and concerns about confidentiality (Centers for Disease Control and
Prevention, 2017; DiClemente, Salazar, & Crosby, 2007). Other factors
that place young people at heightened risk are sexual encounters with
multiple sex partners as well as biological factors, particularly among
women, which render them more susceptible to contracting STIs
(Centers for Disease Control and Prevention, 2017). Young people not
only carry a significant burden in terms of sexual health, but also in
terms of reproductive health. While teen pregnancy rates have declined
in recent decades, the US rate is still one of the highest in the developed
world (Teen Pregnancy, 2018). For teens and young women, access to
long-acting reversible contraceptives is hindered by high upfront costs
as well as fears surrounding pelvic examinations (American College of
Obstetricians and Gynecologists, 2015). One-third of young women still
use condoms as their only form of contraceptive (Lindberg, Santelli, &
Desai, 2018).
For any individual who is sexually active, condoms remain an in-
expensive and effective means to protect oneself against unwanted re-
productive or sexual health outcomes (Condom Distribution Programs,

E-mail address: megan.myers@emory.edu.

https://doi.org/10.1016/j.evalprogplan.2019.02.006
Received 6 July 2018; Received in revised form 27 January 2019; Accepted 9 February 2019
Available online 13 February 2019
0149-7189/ © 2019 Elsevier Ltd. All rights reserved.
M. McCool-Myers
2018). However, purchasing condoms in stores or pharmacies can be
challenging. Studies from two high STI/HIV-risk cities, Atlanta, Georgia
and New York City, New York, revealed that approximately 80% of
stores place condoms behind locks or cases or put them behind the
cashier’s counter (McCool-Myers, Myo, & Carter, 2018; Rizkalla,
Bauman, & Avner, 2010). These barriers act as deterrents in condom
acquisition for all individuals, but particularly for younger and less
experienced populations (Centers for Disease Control and Prevention,
2017; Moore et al., 2008; Picca & Joos, 2009; Reeves, Ickes, & Mark,
2016). Physical and environmental barriers lead to embarrassment in
purchasing condoms, which in turn negatively impacts condom car-
rying behaviors and ultimately condom use (Bell, 2009; Moore et al.,
2008; Moore, Dahl, Gorn, & Weinberg, 2006).
Through wide-scale distribution of free condoms, health depart-
ments and community-based organizations can lower the barriers to
condom acquisition (Condom Distribution Programs, 2018). Condom
distribution programs (CDPs) target individuals and communities with
high levels of STI/HIV risk. They leverage a multi-channel approach to
distribute condoms, for example at tabling events, via non-conventional
sites frequented by target populations (bars, clubs, etc.), through peers,
and more recently, through mail order. An essential element of CDPs is
the social marketing campaign surrounding condom distribution
(Condom Distribution Programs, 2018). Campaigns not only inform the
target population as to where and how condoms can be accessed, but
are critical for improving acceptability of condoms, i.e. reducing em-
barrassment around condom use. Across cultures, it has been shown
that condom acquisition is significantly more embarrassing than actu-
ally using the condom (Moore et al., 2008). Social marketing campaigns
can contribute to the normalization of condom use and promote a po-
sitive image of condom acquisition, carrying and use.
Several CDPs have targeted younger populations. For example,
nearly 90% of college campuses in the US offer some form of condom
distribution (Butler, Procopio, Ragan, & Funke, 2014). Some of these
university-based programs have used condom dispensers (Eastman-
Mueller, Gomez-Scott, Jung, Oswalt, & Hagglund, 2016; Francis, Noar,
Fortune, & Adimora, 2018; Park, 2018), campus mail service (Butler,
Mooney, & Janousek, 2018; Janousek, Mooney, & Butler, 2018), and/or
peers such as in the Great American Condom Campaign (Advocates for
Youth, 2018). Other CDPs such as Take Control Philly focus specifically
on adolescent populations in response to the limited access to sex
education and sexual health supplies in high schools. CDPs may also
target entire jurisdictions that report high rates of new STI and HIV
infections, e.g. New York City’s NYC Condom or Washington DC’s
Rubber Revolution.
There is evidence to show that CDPs not only lower the barrier to
condom acquisition, they also lead to an increase in condom use and a
reduction of risky sexual behavior in target populations (Butler et al.,
2018; Condom Distribution Programs, 2018; Charania et al., 2011;
Eastman-Mueller et al., 2016; Francis et al., 2018). Particularly among
younger populations, who experience some of the greatest hurdles in
condom acquisition and simultaneously the greatest risk of undesired
sexual and reproductive outcomes, CDPs can provide necessary access
to supplies and education. However, for CDP planners, staying abreast
of modern distribution channels/methods, new sexual health supplies
on the market, social marketing strategies as well as evaluation tech-
niques can be challenging. In the battle against increasing rates of STIs,
there is an opportunity to learn from the successes and hardships of
current condom distribution programs. The purpose of this qualitative
study is to gather insights and experiences from planners across the US
to inform effective CDP implementation.
2. Methods
2.1. Recruitment strategy and inclusion criteria
A semi-structured interview design was used to collect insights from
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Evaluation and Program Planning 74 (2019) 20–26
program planners of active CDPs in the United States. Inclusion criteria
were: 1) a planner of a condom distribution program, 2) able to de-
scribe characteristics and history of the program, and 3) available for a
telephone conversation. Program planners were recruited using a pur-
posive sampling strategy in order to ensure a wide variety of experi-
ences and insights, which could be applicable for other CDPs. Planners
were sought who represented programs with diverse distribution
channels (site-based, web-based, other), settings (college campus, city,
state) and longevity (< 1 year to > 10 years old). The planners were
first contacted by email or by phone, then an appointment for a 30-
minute interview was agreed upon.
2.2. Discussion guide
Discussion guides were tailored to each CDP, however the basic
discussion guide entailed 14 open-ended questions. Questions sought to
explore how programs were first created, how they were maintained
and expanded, how they are monitored and evaluated, and how they
are promoted to target populations. Descriptive information was col-
lected about each program, including geographical region, targeted
populations, location, setting, planning/managing institution, longevity
of program, and distribution methods. The basic discussion guide can
be found in the appendix.
2.3. Qualitative analysis
All interviews were performed on the phone. Shorthand notes were
taken during the phone call; detailed notes were then entered into a
word processor (Microsoft Word) directly following the call. Descriptive
data, as well as data on number of sites and number of distributed
condoms were analyzed with a spreadsheet (Microsoft Excel). All in-
terviews were performed by a single interviewer who employed an
iterative research approach over the course of the interviews (Brod,
Tesler, & Christensen, 2009). It was anticipated that approximately 12
interviews would be needed to reach thematic saturation (Guest, Bunce,
& Johnson, 2006).
Core categories were identified in the interview notes. Using a se-
lective coding approach rooted in Grounded Theory (Corbin & Strauss,
2008), all categories were then identified that conceptually related to
the core category. Similar categories across CDPs (e.g. similar ap-
proaches to problems) were reported in an aggregated format, whereas
unique categories (e.g. an alternative approach to problems) were de-
scribed in greater detail.
3. Results
Seventeen CDP planners were contacted for interviews between
February and May 2018. After three attempts to contact, efforts were
discontinued. Ten telephone interviews with CDP program planners
were ultimately performed, yielding a response rate of 58.8% (10/17).
The interview duration was 33 min on average [range 10–60 minutes].
Recruited planners represented a range of programs as shown in
Table 1.
Five core categories emerged from the qualitative data: 1) identifi-
cation of target population, 2) distribution channels, 3) type of con-
doms distributed, 4) messaging/promotion, and 5) monitoring/eva-
luation. Common approaches to CDP-related problems or to CDP
planning were tallied and summarized under each core category.
Alternative approaches, which may have application for targeting
young people, were described more extensively.
3.1. Identification of target population
All CDPs targeted individuals at risk, communities at risk, and/or
the venues where high-risk populations spend their time. Four CDPs
addressed the needs of adolescents and young adult populations, while
M. McCool-Myers Evaluation and Program Planning 74 (2019) 20–26

Table 1 conventional sites included bars, restaurants, nail salons, barbershops,

Characteristics of Condom Distribution Programs (CDP). tattoo parlors, clothing stores, churches, fitness studios and motels.
Program Characteristic N (N = 10) Planners described that the distribution network usually started with
conventional sites, with which partnerships already existed due to
Geographic location mutual health-related work, and then non-conventional sites were re-
Northeast 5
cruited.
Southeast 3
Midwest 2
Planners with site-based distribution generally reported positive
West 0 feedback and growing interest from new, non-conventional sites. In
Targeted populations order to become a distribution site, venues needed to fill out a regis-
General 6 tration form. These registration forms included basic items such as
Young adult (20–24 years) 3
name of venue, telephone number, opening hours and agreeing to abide
Adolescent (15–19 years) 1
Setting by the CDP’s policies for distribution. If approved, the CDP would
City/County 7 provide condoms to the site. Some also performed site visits before
University campus 2 approving the distribution site. CDP planning teams then mailed the
State 1
requested condoms to the site, delivered the condoms to the site, or
Type of institution planning/managing CDP
County/City Department of Health 5
asked the distributing site to pick them up at the CDP headquarters.
University health services 2 Mailing condoms to sites was considered most convenient, yet it re-
Commercial marketing agency 1 quired additional funding that was not covered by all grants. An ex-
Non-profit organization 1 ample of an online site registration form from “Test Miami” can be
University hospital 1
found here: http://www.testmiami.org/condom-distribution-
Longevity of CDP
Less than 5 years old 3 application
5–9 years old 6 With expanding networks, maintaining and monitoring condom
10 years old or more 1 supply at all sites became a challenge for many CDPs. Some sites were
Distribution channel conscientious about ordering condoms when their supply was getting
Site-based only 5
Web-based only 3
low. Others needed to be called by the CDP team and reminded to
Site and web-based 1 monitor/refill their supply. One CDP reported that they performed spot
Other: Uber 1 checks of distribution sites to ensure that the condoms were not in di-
rect sunlight, not near moisture, were visible to the public, and were
not expired or damaged.
six targeted general populations (including young people) in jurisdic- Another channel used by four of 10 CDPs was web-based distribu-
tions with high STI/HIV risk. The target population for each CDP was tion, i.e. sending free condoms via mail. Individuals go to the CDP
determined either through a top-down or a bottom-up approach. website and select the types of condoms and lubricants they would like.
Eight out of 10 CDPs used a top-down, data-driven approach to They then enter their address and submit the order. For the university
determine their target population. The target population for these CDPs, a university ID was required to place an order. For the other two
programs was selected through evidence from surveillance data about CDPs, an address in the given city/state was required. Processing and
high-risk populations and/or through geospatial mapping of STI cases delivery of the condom order ranged from 4 days to 8 weeks. Number of
in a given location. Program planners analyzed data on reported STI supplies per order varied from 5 to 25 per order. Condoms were sent in
cases, collected by the department of health. The planners could iden- discreet packaging without return address or with a P.O. box as a return
tify high concentrations of STIs and new HIV infections within a jur- address. In the package, individuals would also find flyers/postcards,
isdiction. addressing topics such as condom instructions, consent, and STI testing
Two of the 10 programs developed organically or from the bottom sites. The university health centers used the campus mail system to keep
up. The programs came to fruition as a result of demands from the costs of delivery low. The other two CDPs used the US postal service.
target audience, which in both cases was young adult populations. In IT services were of utmost importance and often costly for the web-
one case, the students on the university campus complained that con- based CDPs. Planners worked with IT specialists to ensure that fake
doms were only available in one office on campus. In that office, the addresses, spam, and multiple orders in a short time window were
condoms were located in a fishbowl next to an administrative assistant. flagged. Due to the high volume of orders described by all four plan-
Students wanted a more discreet solution on campus. The resulting CDP ners, they had each found ways to streamline the processing and
offered students a web-based service so that condoms could be ordered packaging. The submitted address data were compatible with a word
online and sent via campus mail. In the second case, an Uber driver processing program so that address labels could be generated and
approached a health department on behalf of students. Uber drivers printed quickly. One CDP used an internal coding system on the address
sometimes offer water or sweets to the riders. Students in this college labels themselves that indicated which types of condoms should go in
town often asked the driver if he carried condoms in his car. A local that envelope. For example: assuming there were 5 different types of
cooperation developed between the department of health and Uber condoms available online, each one had a code (A, B, C, D, E). When a
drivers. user ordered condom C online, the letter C would automatically be
printed on the user’s address label in the corner. The packing team then
3.2. Distribution channels could print all the labels, put them on the envelopes, and then look at
the condom code on the labeled envelope to determine which condoms
CDPs used one or more channels for condom distribution: site-based should go in that envelope. This process helped to streamline packing
distribution through conventional and non-conventional sites (n = 5), and reduce errors in orders.
web-based distribution where condoms are ordered online then sent by Web-based CDPs did have some disadvantages. First, individuals
mail (n = 3), both site-based and web-based (n = 1), and distribution who order condoms online must plan ahead of time to account for
via Uber, a ride share service. Local events provided periodic dis- processing and delivery, which may take several days. Second, the
tribution platforms for some CDPs. planners of web-based CDPs experienced difficulty in predicting de-
In total, six out of 10 CDPs distributed condoms through conven- mand within the given jurisdiction. Generally, the larger the jurisdic-
tional and non-conventional sites. Conventional sites included depart- tion, the greater variability in demand. Two programs were set on
ments of health, STI testing sites, hospitals, and doctor’s offices. Non- university campuses, which limited the maximum number of potential

22
M. McCool-Myers
orders to the student population (32,000–37,000). However, one city-
based CDP (population 6 million) offered web-based services for three
months, then returned to site-based only as a result of overwhelming
demand and exhaustion of financial resources. A state-wide program
(population 28 million) had to increase the delivery time to 8 weeks,
due to the overwhelming demand that arose when they expanded their
jurisdiction from a city to the entire state.
3.3. Condoms
All planners emphasized the importance of condom variety and
supplies. While some programs only offered one type of condom at their
debut, all programs ultimately expanded their selection to offer greater
variety.
Of the CDPs that distributed name-brand condoms, condoms from
Trojan® and One® were cited as being favored. Several planners men-
tioned a high demand for XL condoms. They said that this may not be
due to body size or comfort, but rather to the social desirability of using
large condoms over standard size condoms. Distribution sites that ca-
tered to LGBTQ audiences tended to have a higher demand for dental
dams than other sites. Internal condoms (FC2®) were often distributed
in sites catering to men who have sex with men (MSM), as these are
used for anal intercourse. Two web-based CDPs intentionally added 2
FC2® condoms to every order to increase awareness of internal con-
doms. CDP planners also mentioned the appeal of both flavored and
non-flavored lubricants. Suppliers noted by CDPs were Total Access
Group and Global Protection Corp. Four CDPs voiced difficulties in
accessing FC2® in 2018. This may be due in part to the manufacturer’s
decision to sell the condoms as prescription-only.
Considering the importance of condom variety, the four web-based
CDPs provided personalized orders. Some CDPs permitted unique or-
ders of supplies, e.g. 2 Trojan® Enz, 1 Trojan® Magnum, 2 FC2®, 1
package of strawberry lube. Other planning teams – in an effort to
streamline processing – offered a selection of pre-packaged sets, e.g. 5
Trojans Enz with 5 non-flavored lubricant sachets. All web-based CDPs
offered pre-selected variety packs to allow individuals to test out a se-
lection of condoms and decide which one suits them best.
Planners had mixed views on the trade-offs of program-branded
condoms. Two CDPs offered condoms that were specifically branded for
the program. The remaining eight offered name-brand condoms with
standard commercial packaging from the manufacturer (Trojan®,
LifeStyles®, One®, FC2®, etc.). Two CDP planners, who distributed name-
brand condoms, explained that they had considered creating program-
branded condom foils. However, through focus groups, they discovered
that program-branded condoms were perceived negatively by target
audiences and were viewed as “second-class,” “discounted,” or “gov-
ernment-made.” One planning team further advocated for name-brand
condoms, because individuals need to be able to recognize their pre-
ferred brands in a store, should they run out of the free condoms. One
CDP found a compromise by putting small program-branded stickers on
to the name-brand condoms to promote their CDP while not detracting
from the trusted packaging.
3.4. Messaging and promotion
All CDPs were promoted on websites, albeit to varying degrees.
Some CDPs had a prominent campaign website, while other CDPs were
listed among the many services on the department of public health
website. CDPs used websites to: map the locations of free condom
distribution sites, promote condom use through social marketing, share
sexual health information, and/or allow sites to place condom orders.
Mapping distribution sites is an essential component of site-based
distribution, yet two of six CDPs did not have functioning maps on their
websites. CDPs with maps supplied the address of each distribution site
and the hours of operation. One CDP embedded additional information
in the map, describing where the condoms were located within the sites
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Evaluation and Program Planning 74 (2019) 20–26
specifically, e.g. in the bathroom, at the back door. Some distribution
sites did not wish to be listed, mapped or put programmatic stickers on
their doors. These storeowners were concerned that individuals would
only come for the condoms but would not purchase any goods or ser-
vices. CDP planners expressed some difficulty in maintaining maps due
to frequent changes, limited personnel and IT barriers.
While social marketing is an integral part of an effective CDP
(Condom Distribution Programs, 2018), not all CDPs offered this (3 did
not). To drive the acceptability of condoms, social marketing campaigns
employed candid messaging about condoms. Examples of this were
straightforward slogans such as “put it on” or billboards that showed an
unwrapped condom up close. Sex-positive communication with hu-
morous slogans or erotic photos could be seen in campaign advertise-
ments; non-judgmental language was used to encourage individuals to
get tested. Due to recent media attention, sexual consent has become a
focus of sexual health campaigns, sex education, and state and national
legislation (Rose, 2018). One CDP created printed material with ex-
amples of phrases that can be used to validate consensual sexual be-
havior.
Limitations in condom social marketing were due in part to budgets.
One CDP stated that its marketing budget goes entirely to promotion of
pre-exposure prophylaxis (PrEP) and STI testing. Marketing activities
were often limited to the CDP website, local event participation, and
printed materials (flyers, stickers, condom wallets, etc.). Some CDPs
leveraged free social media (Twitter, Facebook, Instagram) to gain
greater visibility. Here, clicks and views provided some insight as to the
reach. Advertisements in newspapers, on buses, or on billboards were
costly and their effect was difficult (and expensive) to measure.
3.5. Monitoring and evaluation
CDPs had varying degrees of process and outcome evaluations. Data
collection included: number of supplies distributed, number of sites,
program awareness, and/or demographics of users. Changes in sexual
behavior could be assessed in some CDPs. Biological outcomes such as
reduced STI and HIV rates and reduced unplanned pregnancy rates
were generally not measured.
All 10 CDPs stated that they tracked the number and type of con-
doms that were distributed, albeit with varying degrees of precision. All
programs stated that there was an increase in the number of sexual
health supplies distributed year over year. Total supplies distributed
(male condoms, internal condoms, lubricant sachets) ranged from
16,000 to 45 million per year [average 6.1 million, median 650,000].
The estimates provided (n = 8) were the numbers most readily avail-
able to the planner at the time of the call and may not have been from
the most current full year (2017).
Site-based CDPs kept track of the number of sites that were dis-
tributing condoms. The site-based distribution programs served be-
tween 100 and 3500 sites in the given jurisdiction [average 690,
median 145]. These also reported a continual increase in the number of
sites. One large CDP pointed out that a common challenge of site-based
CDPs is that while there was a steady flow of new registrations, there
are sites that discontinue distribution but are not removed from lists.
This not only skews the numbers of the distribution sites, but it can lead
to complaints from individuals who visit these sites and discover that
there are no condoms available.
Program awareness of site-based CDPs was measured through sur-
veys at events or at clinics. These surveys use convenience samples
rather than representative samples, which can introduce a bias to the
study results. Large-scale market research studies with representative
samples were performed by one CDP, yet the planners did not continue
due to the high cost of market research.
Demographic information of users is difficult to capture in site-
based distribution. Community-based organizations or centers pro-
viding care are able to describe the audiences they serve, e.g. MSM,
drug users, HIV-positive individuals. However, in non-conventional
M. McCool-Myers
sites, such as restaurants or hotels, CDP planners cannot gather demo-
graphic information about patrons. Other methods have been at-
tempted in an effort to capture demographic information. One CDP
tried including QR codes on campaign posters in the city to collect data
from their target audiences. However, this method was found to be
ineffective, yielding insufficient response rates. Another CDP required
website users to enter their age, gender, and race before the map of
distribution sites would appear. The CDP planners have since removed
this function from the website as they believed this created a barrier for
the target population.
Three of the 4 web-based CDPs used survey mechanisms to capture
data on demographics, program awareness, sexual behavior and even
behavior change. One web-based CDP sent out a single, extensive
survey by email along with the confirmation of the order. The survey
covered numerous topics including demographics, sexual behavior,
awareness of PrEP, intent to seek testing, as well as where the user first
heard about the CDP. The response rate for the most recent year re-
ported was 63%. Two university-based CDPs used a baseline and
follow-up survey strategy to measure changes in sexual behavior. For
example, once the condom order was placed, users received an email
with a confirmation and a link to a survey. Four weeks after the order
was placed, users received a follow up email with a link to a different
survey. Response rates reported for these surveys reached as high as
41%. Outcomes from one of these CDPs have recently been published in
a peer-reviewed journal. Users of the web-based CDP reported im-
proved access to condoms and greater ease is practicing safer sex
(Butler et al., 2018).
4. Discussion
This qualitative study aimed to collect experiences and novel stra-
tegies from CDP planners in the US to inform effective condom dis-
tribution. Many of these innovative strategies can be leveraged to reach
adolescents and young adults, particularly in regard to the channels of
distribution.
Web-based distribution is a channel that offers the convenience and
discretion of online shopping. Considering that 67% of Millennials
prefer shopping online to going in stores (Wallace, 2018), there is
reason to believe that this channel could have greater appeal to young
people than visiting distribution sites. Initial results from web-based
programs show that accessing condoms through a web-based condom
distribution is perceived as substantially more comfortable and con-
venient compared to going to a university health center, a drug store/
grocery store, or even buying online from a retailer (Butler et al., 2018;
Janousek et al., 2018; Mooney, 2014). A weakness of web-based dis-
tribution is that it requires forethought and planning, on the part of
individuals. This may not be conducive to sexual spontaneity. For this
reason, web-based distribution should not be viewed as a replacement
for site-based distribution but instead an expansion of distribution
channels. For planners, web-based distribution demands a high level of
organization, IT support, and ability to respond to surges in orders to
avoid delays in delivery of supplies.
Measuring the behavioral and biological impact of CDPs on sexual
and reproductive health outcomes was described as difficult and ex-
pensive. A Cochrane review of site-based CDPs in the US revealed very
low quality of evidence of the programs’ effectiveness (Malekinejad
et al., 2017). Web-based CDPs may provide a cost-effective and robust
alternative for collecting significant amounts of data on behavioral
outcomes, condom use, and risk behaviors (Butler et al., 2018). In ad-
dition, the programs interviewed in this study reported response rates
as high as 63%, nearly twice as high as meta-analytical estimates for e-
mail survey response rates (33%) (Shih & Fan, 2009). With validated
surveys and sufficient data, web-based programs can contribute to a
larger body of evidence for CDPs’ impact on sexual and reproductive
health behaviors.
Ride-share services are another channel which should be explored
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Evaluation and Program Planning 74 (2019) 20–26
further. One out of every three Uber riders is between the ages of 16–24
(McGrath, 2017), overlapping perfectly with high STI/HIV- risk popu-
lations (15–24 years old) (Centers for Disease Control and Prevention,
2017). In addition to being used by millions of Americans, ride-sharing
services cut across gender and race, providing reach to a broad demo-
graphic population (Smith, 2016). Cooperation between ride-sharing
providers and health departments could offer a novel method for dis-
tribution, yet to our knowledge, no official cooperation has been es-
tablished. Ride-share drivers are individual entities or businesses, so the
decision to provide condoms to passengers is a choice freely made by
the driver. Our research team reached out to both Uber and Lyft to ask
about potential collaborations with departments of health. At the time
of publication, no response regarding an executive decision by either
provider had been received.
Not all CDPs promoted their activities or launched a social mar-
keting campaign, yet these tools are crucial to the success of a CDP
(Condom Distribution Programs, 2018). Social media platforms should
be selected based on the demographics of users. To reach younger po-
pulations, recommended platforms would be Instagram and SnapChat,
both of which primarily reach under 24 year olds (The Social Audience
Guide, 2018). Google Maps is another free service which would allow a
CDP to map out and edit distribution points. These maps can then be
embedded into other websites easily. Several CDPs expressed a will-
ingness to share their marketing materials and social marketing cam-
paign concepts with other CDPs; CDPs interviewed can be found in the
Acknowledgements.
Funding for staff and marketing were limiting factors for most CDPs.
At a national level, funding cuts for sexual and reproductive health and
policies which restrict reproductive rights have been proposed by the
current administration (Girard, 2017). In addition, the Department of
Health and Human Services has allocated $10 million dollars for ab-
stinence-only education programs (Belluck, 2018). Increasing emphasis
on abstinence education limits the ability for young people to make
informed decisions about their sexual health, putting them at greater
risk for STI/HIV infections and unplanned pregnancy (Johnson, Scott-
Sheldon, Huedo-Medina, & Carey, 2011; Stanger-Hall & Hall, 2011).
CDPs therefore carry an added responsibility to provide not only sup-
plies, but also comprehensive information that will equip young people
to make healthy sexual and reproductive choices (Centers for Disease
Control and Prevention, 2017). This further underlines the importance
of harnessing novel distribution channels for young people and lever-
aging opportunities to demonstrate programmatic successes through
tangible results.
4.1. Lessons learned
Implementing a successful CDP requires a substantial amount of
work, but it is not necessary to reinvent the wheel with each program.
Growing the site-based distribution network may require recruitment
efforts as well as online forms to facilitate ordering and refilling sup-
plies. Discrete, online ordering services are in high demand, particu-
larly among risk populations between the ages of 15–24. Web-based
distribution can be implemented alongside site-based distribution,
however planners should have sufficient resources (IT, staff, supplies,
funding) to meet a potentially rapid increase of online orders in their
jurisdiction; delays in delivery or technical problems in ordering could
result in distrust from target populations. Social media is a necessary
component of a CDP which contributes to the availability, acceptability,
and accessibility of condoms. CDPs should provide information about
services and supplies on free social platforms that are commonly used
by target audiences, e.g. Facebook, Instagram, SnapChat, and Google
maps. Evaluating the impact of CDPs remains a challenge, yet web-
based services may provide an innovative method for gathering data
about users of the service.
M. McCool-Myers
4.2. Limitations
Three limitations warrant mentioning. A higher number of inter-
views as well as interviews from all regions of the US (no CDPs from the
western US) may have provided additional insight. The interviewer
used detailed note-taking during each telephone interview, but the calls
were not recorded. If the calls had been recorded, there may have been
findings which could have elaborated upon further. There is also a
possible reporting bias. Interviewees may have over or under-estimated
the number of condoms distributed or number of sites, and/or they may
have chosen not to disclose certain information about the success or
challenges of their programs.
5. Conclusion
Condoms remain an inexpensive and effective method for the pre-
vention of unplanned pregnancy and sexually transmitted infections.
Particularly for adolescents and young adults, who experience high
levels of financial, physical, and psychological barriers in accessing
care, effective condom distribution programs have a vital role to play in
reducing the stigma associated with condoms, improving knowledge
about condom use, and ultimately lowering the rates of unwanted
sexual and reproductive outcomes in this vulnerable population. The
findings from the interviews with CDP planners underline the wealth of
knowledge housed within each CDP and importance of cooperation
across the field of condom distribution.
Funding
This research did not receive any specific grant from funding
agencies in the public, commercial, or not-for-profit sectors.
Conflict of interest
The author has no conflict of interest to declare.
Acknowledgements
The authors would like to thank all 10 CDPs for contributing their
insights to this study and, more importantly, for continuing their efforts
in improving availability, accessibility and acceptability of condoms:
Boston University’s Condom Fairy, University of Georgia’s Condom
Express, Washington DC's Rubber Revolution, Philadelphia’s Take Control
Philly, Texas Wears Condoms, Free Condoms Memphis, the Brazos County
(TX) Health Department, and the Allegheny County (PA) Health
Department.
Appendix A. Supplementary data
Supplementary material related to this article can be found, in the
online version, at doi:https://doi.org/10.1016/j.evalprogplan.2019.02.
006.
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Megan McCool-Myers, PhD, MPH is an Assistant Professor at the Jane Fonda Center for
Adolescent Reproductive Health at Emory University. Her research focuses on condom
availability, accessibility and acceptability. Together with her research team, she explores
innovative strategies for reducing the STI epidemic in the Southeast US. Prior to Emory,
Dr. McCool-Myers completed her PhD on “The epidemiology and care of female sexual
dysfunction” at the University of Regensburg in Germany.