Condoms, life jackets and face masks: compliance and adoption

CONDOMS, life jackets and face masks serve different purposes, but commonalities exist between the factors that influence their acceptance and use. Overcoming barriers to use is vital in supporting the health and safety of both individual users and members of the broader community.

In this article we examine the academic literature and mass media concerning the barriers to condom and life jacket use. We then explore the lessons learned from the marketing of these protective devices with a view to informing strategies for supporting mask use during COVID-19 and any future pandemic.

Just as a condom provides a level of protection for both the wearer and their sexual partner and life jackets reduce risk of drowning, wearing a face mask reduces the risk of virus transmission to the broader community, while potentially also providing the wearer with some protection. However, barriers to the adoption of all three of these protective devices have been documented. Studies on the use of condoms, life jackets and face masks all highlight perceptions around risk, perceived efficacy, self-efficacy and accessibility as key factors that influence use.

Given they are similar, what can we learn from life jackets and condoms for mask use in the COVID-19) era?

Wearing one won’t get in the way of a good time

Marketing for condoms and life jackets has focused on the fact that they will not inhibit enjoyment. In fact, normalising the wearing of life jackets whenever one is on or near the water is similar to the move to normalise mask wear outside the home during the COVID-19 pandemic.

Design improvements may increase acceptability and wear, but function over form must prevail

Advancements in design and marketing have seen life jackets and condoms becoming more accepted, such as the move to slim-fit inflatable life jackets and new materials such as polyurethane and female condoms that can be used by receptive sex partners. Similarly, masks manufacturers now allow the user to individualise their mask design. However, as designs change and manufacture and sales increase, we must maintain efficacy in design and ensure community understanding of how to choose the correct device in terms of suitability and fit (here and here).

These protective devices must be worn correctly and used consistently to reduce risk

Research indicates condom use must occur for every sexual episode that includes a risk of sexually transmissible infections (STIs) or unintended pregnancy. This is again analogous to face masks and life jackets, which require pre-planning (purchasing one and having it with you) and adhering to correct use “in the moment” – by using the device properly. Masks, like condoms and life jackets, can slip off, be worn inappropriately, and taken off too soon, all of which could negate risk reduction.

Wearing one doesn’t indicate weakness or illness

Messages to encourage the use of these devices must overcome a persistent perception: namely, that wearing one indicates deficiencies. During the first wave of human immunodeficiency virus (HIV) infection in gay communities in the 1980s, health promotion around condom use focused on the idea that correct and consistent condom use – “safe sex” – was the way to demonstrate that you were a responsible “sexual citizen”.

Behavioural research into low life jacket wear among adults has indicated that wearers’ concerns about being perceived as inexperienced boaters or as weak swimmers inhibited their willingness to wear life jackets. However, aforementioned changes in life jacket design as well as role modelling by big wave surfers and sports stars are strategies used to change such perceptions. When it comes to mask use, celebrities have also been involved in advocating use.

However, it has been suggested that men may associate the use of masks as being “unmanly”, shameful or a sign of weakness. Such negative emotions are more often present in countries without a culture of community mask use such as Australia, indicating the importance of normalising the wearing of such protective devices.

Supportive legislation alongside sustained evidence-based communication is key

As with all public health initiatives, ensuring ongoing communication is a vital component of increasing and maintaining wear rates over time. Such communication must be persuasive and linked to evidence to have an impact on users.

Condom research indicates that while people generally prefer barrier-free sex, the history of condom uptake to prevent HIV infection shows how health concerns for self and community can overcome this distaste. However, decreases in condom use in Australia associated with oral contraceptive pills for female high school students and pre-exposure prophylaxis (PrEP) for gay males highlight that condom use is directly related to risk perception. Sustained public awareness campaigns and supporting legislation regarding mandatory life jacket wear have resulted in increased wear rates and reduced boating-related drowning fatalities (here and here).

While there have been attempts to promote mask use as an altruistic low cost and useful strategy to reduce transmission in the community, adoption of the practice by individuals has been slow in some countries. To counter this issue, mandates have been introduced by 50 countries that require face mask use in public spaces. While it is currently too early to know whether face mask policies have an effect on human behaviour, preliminary data from a study in Berlin found that mask use actually promoted compliance with physical distancing requirements.

Communities impacted must be involved

Communities at increased risk need to be fully involved in developing appropriate communication adherence strategies. For example, the empowerment of gay men in the 1980s to produce their own health promotion materials saw condom use effectively marketed as a way to remain sexually active while reducing the risk of exposure to HIV. Life jacket research has highlighted the importance of working with communities at increased risk. Research with the Inuvialuit in the Canadian Arctic found that a community-based approach to life jacket use may lead to more effective risk messaging that reflects the needs, culture, and experiences of the target group, while promoting healthy behaviour.

The COVID-19 pandemic has again exposed underserved populations as being at higher risk, leading to ethnic and racial disparities in COVID-19-related deaths. Sadly, culturally and linguistically diverse (CALD) communities in Australia have not been sufficiently involved in developing COVID-19-related communication materials. It has been suggested by a range of organisations, including community and CALD groups, that there has been a lack of consideration for CALD communities around access to appropriate and reliable COVID-19 information. While COVID-19 information had been translated and made available online in multiple languages, doubts have been raised about the reach of the information and whether it sufficiently supports CALD communities in a way that enables them to fully understand what is required of them. There is a critical need to ensure that engagement strategies are engineered to ensure the voice of all community members is captured to support future efforts to promote public health measures.

As the COVID-19 pandemic continues globally, and until a vaccine is available, the need to wear a mask will continue. Lessons learned over the past 40 years from condom and life jacket use should be used to inform efforts to increase mask wear.

Dr Amy Peden is an injury prevention lecturer in the School of Population Health, UNSW Sydney, with a focus on drowning prevention, alcohol and rural and remote communities.

Dr Holly Seale is a social scientist and Senior Lecturer at the School of Population Health, UNSW Sydney, with a focus on infectious diseases and infection control.

Dr Bridget Haire is a senior research fellow at the Kirby Institute, UNSW Sydney, specialising in bioethics. Bridget is currently conducting research into the impacts of quarantine.

Dr Audrey Giles is a Full Professor in the School of Human Kinetics at the University of Ottawa. Her research is focused on injury prevention and health promotion with communities in northern Canada.

The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless so stated.