Context and challenge

A high prevalence of sexually transmitted infections (STI) and a high fertility rate remain major global public health challenges, especially for young women. STIs are considered a persistent and endemic threat to global health with one million new STIs annually. Additionally, fertility rates remain high in many developing countries and more than 200 million women have an unmet need for contraception in developing countries, with women aged 20-24 years old presenting the largest unmet demand. The picture for Pakistan is not encouraging: 35% of women and 11% of men who engage in sexual intercourse have an STI. Moreover, Pakistan has an annual population growth rate of 2%,  the highest in South Asia and one of the highest in the world. Disease and unmanaged fertility present real economic and social costs.

Male condoms can help address both challenges by reducing the chance of disease transmission and helping manage fertility. Condoms provide a safe and effective means to prevent transmission of STIs such as HIV. If used correctly, they are also an effective method of birth control, preventing pregnancy 98% of the time.

However, the modern contraceptive prevalence rate in Pakistan is amongst the lowest in South Asia, at just 25%,  compared to a regional average greater than 50%,  and women of reproductive age in Pakistan have an unmet need for family planning which increased from 2.8% to 17.3% between 2012 and 2017.

Low uptake of modern contraceptives, including condoms, is a result of multiple factors including women’s attitudes,  husband’s attitudes,  a lack of knowledge about contraceptive technologies,  isolation,  fear of side-effects and influence of mother-in-law. Interventions to improve contraceptive uptake tend to center on counseling but little has been tried beyond this.

One avenue to improve contraceptive uptake that has not been tried is addressing consumer shyness, which is well documented in Pakistan. Embarrassment in buying condoms is “commonly mentioned by men” in Pakistan, and the process of buying condoms has been described as “terrifying” for some. Thus, shyness and embarrassment related to condom buying is a potential barrier to uptake. Additionally, surveys on family planning reveal that men and women demand doorstep delivery of services, which at present is not being leveraged. More generally, Pakistan is a conservative society and sex is a taboo subject. There is little space to talk about and engage with topics such as STIs and contraception. Certainly, in the long run, there is a need for cultural change. But in the short run, overcoming existing barriers – such as anxiety and shyness – is critical. We did this in a study that we conducted in Lahore, Pakistan.

Home-delivery service

In our study, we attempted to make accessing condoms an event that induced less social anxiety by providing married couples with an anonymized phone-based and free-of-cost door-step delivery service for condoms. Couples were provided coupons with unique serial numbers on them along with a phone number. Calling the phone number would result in the delivery of a six-pack box of condoms inside a plain envelope (to hide it and maintain discreteness). This delivery service had two variations to it: one group of couples was provided a service in which we completely removed the need to even mention contraceptives (the word “condom”) by advising the caller to simply report the coupon number in order to have them delivered at home (discrete-delivery service); and a second group of couples got a service that did not have this discreteness – callers could carry the expectation to use the word “condom” when calling to order (explicit-delivery service). We also had a third group of couples who were provided shop-redeemable coupons for free condoms, which we thought approximated the business-as-usual anxiety causing situation requiring an interaction at a shop to get condoms. For the technically minded, this study was structured as a randomized controlled trial, so in essence we could make fair, apples-to-apples comparisons of buying condoms between the couples in the three groups. The study ran for a relatively short 6-month window.

What we found and its implications

First, we found that shop-redeemable coupons were more popular than either of the home delivery options. This suggests that either: (a) that our shop-based coupon inadvertently reduced social anxiety by simplifying the interaction at the shop (debriefs with shopkeepers suggested that conversations with coupon-carrying customers tended to be briefer and did not use the words “condom” suggesting that the anxiety may have been bypassed); or, (b) we were not truly able to overcome anxiety with discrete and explicit home delivery i.e., perhaps home delivery exacerbated social anxiety by bringing more focus to condom buying. Regardless, what this implies is that designing home delivery services for contraceptives is nontrivial. We were not able to simply “switch on” home-delivery and find that it was more popular than more traditional channels for acquiring condoms such as buying at a shop (which the shop coupons approximated). So, while people in Pakistan demand doorstep delivery, it is not a given that home delivery of contraceptives will outperform traditional channels such as shops. The design, marketing and delivery of such services will need to be carefully thought through.

However, in contrast to the above, we found that couples with young women responded positively to the two home delivery options. If we split our study sample into couples with younger women (under 30-years) and older women (over 30-years), we find that the home delivery options were much more popular among couples with younger women. Something about the discreteness and home-delivery worked well for couples with young women. We should note that this is not simply a case of younger people in general preferring home-delivery – when we run the same analysis for couples with younger men vs older men, we do not see this pattern emerge. So, it is very specifically the presence of young women in a couple that drives this. Additionally, this is not about women’s mobility playing a role: none of the delivery orders made over the phone nor the coupons redeemed at shops were by women: it was the men in the couple who did.

So, why might this be? The incentives certainly line up i.e., younger women are most at risk of unintended pregnancy and STIs. In fact, we find that couples with women aged 20-24 years i.e., those who have the largest unmet need for contraception globally, saw even higher usage of the discrete home delivery service. So, young women certainly have the greatest incentive. But that’s true for all young women across all three groups of the study, yet we did not see couples with young women respond so positively to the provision of shop coupons (again, we note that mobility restrictions do not play a role since most orders were made by the male member of the couple). So, the question remains – why is it that the discrete home delivery specifically enabled couples with young women? Unfortunately, we do not have additional data to understand this fully and can only conjecture. These young women did not directly call to make these orders, so any “action” of the discrete coupons occurred couple-side i.e., as a conversation that the couple had. Our guess is that it might be that the discrete delivery coupon enabled young women to discuss the use of this option with their partners, and the discrete nature of the delivery process might have been leveraged in that conversation to enable acquiring them. 

This is a useful insight. As we think about tools and options to improve contraceptive uptake, perhaps, we need to explore ways to enable couples to discuss seemingly difficult and taboo subjects like sex and contraception. In our case, we may have ended up providing them language – through something as simple as a coupon – to enable them to have those conversations and access needed contraceptive options.

What is clear is that young women can play a powerful role in driving uptake of contraception. In our quite limited study setting, young women with the greatest need really drove uptake. What we need to do now is figure out ways to enable them.

Agha Ali Akram is an applied economist with over 10 years of experience in the climate change, agriculture, and public health sectors. He is currently a senior researcher at Mathematica Policy Research.