Models of behavior change. Communication based on a proven model of behavior change can influence people's health behavior, including condom use (12, 75, 291, 415). An influential model of health behavior change, the Stages of Change Theory, developed by James O. Prochaska and colleagues from the field of psychotherapy, consists of five stages, as people first become aware of a new behavior and then go through a gradual process of adopting it (433).

The reproductive health field has adapted this five-step approach to guide promotional activities. For example, the Steps to Behavior Change framework, used by the Johns Hopkins Center for Communication Programs, involves five steps to changing health behavior—from knowledge, through group approval, intention, practice, and ultimately to advocacy (415). Another framework, Behavior Change for Communication, which guided the AIDS-prevention efforts of the AIDS Control and Prevention Project (AIDSCAP), also consists of five stages: knowledge, awareness of potential risk, motivation to change, trial of a new behavior, and adoption and maintenance of the new behavior (12).

Other models used in AIDS prevention include the Health Belief Model, the AIDS Risk Reduction Model, the Stages of Change Model, Social Cognitive Theory, Diffusion of Innovation, Harm Reduction, and the Theory of Reasoned Action (9, 242).

Research-based communication. Condom promotion can have the most impact when it identifies specific audiences and pretests messages with members of that audience. Audience research guides the development of the concepts, messages, and tone of the promotion. Focus-group discussions, in-depth interviews, and surveys assure that messages and materials meet the needs and concerns of each intended audience (415).

Messages and images that work for one group may not work for others. For example, the panther logo on some USAID-supplied condoms is popular in the Caribbean and Zaire, but in Burkina Faso and Malawi tests showed that men associated the panther with violence and danger (118, 380). Men in Liberia thought that the picture of the panther signified cat food (532).

Reaching key audiences. Many AIDS prevention campaigns have focused on key audiences who are at high risk (138, 248, 444, 505, 587). Such audiences include commercial sex workers (CSWs), adolescents, homosexual men, long-distance truck drivers, male migrants, military personnel, and miners and other workers far from home (138, 587). These campaigns illustrate how approaches can focus effectively on specific audiences. A danger in focusing promotion only on specific high-risk audiences, however, especially marginalized audiences such as CSWs, is that other people at risk may disregard the message.

Condom promotion campaigns among CSWs have had impressive results (581). For example, in Congo, a 3-year project in Kinshasa that provided free condoms and counseling to 531 HIV-negative sex workers increased the percentage who always used condoms from 11% to 52% after 6 months and to 68% after 36 months. The biggest obstacle was that many customers refused to use condoms (305, 587). In Bali, Indonesia, an education and condom distribution program among CSWs and their managers increased knowledge of HIV/AIDS and other STIs and raised rates of condom use from 18% to 75% of sex acts in one study area and from 29% to 62% in the other (181).

Media and messages. Effective condom promotion uses a variety of information channels to reach specific audiences with messages geared to their interests and needs (155, 286). Today, in many parts of the world condoms are promoted on radio and television, including as part of news programs, popular dramas, and comedies.

Promotion campaigns also use newspapers, posters, pamphlets, and presentations in schools (60). Other formats include songs (437), music contests, live plays and dramas (184, 185, 469, 470), videos, movies (178, 286), a "condom carnival" (361, 362), and even sermons in church (467). In short, any means that reaches the audience can be used.

Advertising for condoms often has focused on their role in disease prevention. Recently, recognizing the limited value of appealing to fear, condom advertisers in the mass media have begun to emphasize the positive side of condom use instead of focusing on disease-prevention (234, 527). In the US, for example, Durex has planned mass-media advertisements focusing on the emotional benefits of condom use (35, 151). Ansell has begun inserting posters into college newspapers. These posters stress relationships and pleasure (33).