Condom-vending machines in Italy: a qualitative exploration of gender differences to improve promotion and use - Purdue University
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THE EUROPEAN JOURNAL OF CONTRACEPTION & REPRODUCTIVE HEALTH CARE
https://doi.org/10.1080/13625187.2020.1810226
RESEARCH ARTICLE
Condom-vending machines in Italy: a qualitative exploration of gender
differences to improve promotion and use
Jaziel Ramos-Ortiza , Olivia L. Strubeb, Nicole Kinmanb, Stephanie Meiera and Andrea L. DeMariac
a
Division of Consumer Science, College of Health and Human Sciences, Purdue University, West Lafayette, IN, USA; bSchool of Health
Sciences, College of Health and Human Sciences, Purdue University, West Lafayette, IN, USA; cDepartment of Public Health, College of
Health and Human Sciences, Purdue University, West Lafayette, IN, USA
ABSTRACT ARTICLE HISTORY
Objectives: The purposes of this study were to explore gender differences in condom purchasing Received 15 May 2020
from condom-vending machines (CVMs) and identify ways to improve CVM promotion. Revised 23 July 2020
Methods: Semi-structured interviews with 42 men and women aged 18–50 years (mean ± standard Accepted 10 August 2020
deviation, 29.1 ± 7.9) and living in or near Florence, Italy, were conducted between May and June
KEYWORDS
2019. Techniques from expanded grounded theory-guided data analysis allowed for a constant Condoms; cross-cultural
comparative approach to contextualise data and identify emergent themes. research; gender effects;
Results: Three themes emerged: (1) attitudes and barriers towards CVMs; (2) gender-specific pur- gender roles; qualitative
chasing influences and behaviours; and (3) CVM improvement and promotion. Women and men research; vending machines
described varied concerns surrounding CVM purchasing, illuminating reasons for hesitancy.
Focussing on CVM quality and improving product offerings were suggested by participants to
increase use.
Conclusion: Findings offer practical recommendations to guide CVM messaging to increase access
to and use of condoms and other personal care items. Men were cited as primary CVM users,
expressing practical concerns surrounding CVMs, while, for women, CVM visibility was as much an
advantage as a drawback. Reflecting consumer needs via diversified product offerings should be
considered a priority for increased CVM use. Working to promote CVMs requires clear messaging
that attends to gender norm limitations, details product safety and establishes CVMs as a reliable
condom purchase outlet.
Introduction Condom purchasing as an embarrassing act for consum-
ers is well studied [12–15], with men and women often
Despite awareness of the importance of condom use, 46%
exhibiting varied coping mechanisms [16]. Men and
of Italian men and women engage in unprotected sex [1].
women typically attempt to purchase condoms from a
Consistent condom use is among the most cost-effective
store clerk of the same sex to minimise shame, often mask-
and simple methods of preventing sexually transmitted
ing their purchase with other items [3,16,17]. Feelings of
infections, including HIV [2]; thus, encouraging condom use
embarrassment or shame can prevent condom purchasing,
via unique avenues is crucial. Condom purchase and use
practices can vary based on several factors, including acces- even when there is a condom need [16]. CVMs work to
sibility, preference and social norms [3–6]. While numerous minimise this embarrassment by functioning as a discrete
condom-purchasing outlets exist (e.g., grocery stores, phar- purchase outlet [14,17,18], improving consumers buying
macies, online retailers), condom-vending machines (CVMs) processes by allowing them to access condoms privately
represent a unique and somewhat novel option [6], as they and conveniently. Prior research has primarily explored
work to combat condom purchase barriers. In existence CVMs as viable outlets to improve condom-purchasing
since the early 1990s, CVMs are prevalent in European experiences within schools [19–22], jails [23–25] and devel-
countries, including Italy, and can expand condom access oping countries [26–28]. Italy provides a unique environ-
via locational and temporal flexibility [7]. CVMs sell con- ment for studying CVMs and their effect on condom
doms and other personal care items via unattended purchasing given their unique locations and widespread
machines, offering the opportunity to obtain condoms availability in public spaces, such as on street corners, out-
while reducing barriers commonly experienced by consum- side of pharmacy storefronts and inside restrooms [8].
ers. These machines have the advantage of increased hours Regardless of outlet, condom purchasing is affected by
of operation even after pharmacy and supermarket closure, gender-specific barriers impacting consumers and, in turn,
allowing condoms to be easily obtained. CVMs can also their sexual behaviours [14,16,29]. Feelings of awkwardness
mitigate the embarrassment consumers often feel when and embarrassment when purchasing condoms persist
purchasing from shop assistants, mimicking other efforts to across all genders and affect individual attitudes and dis-
reduce face-to-face contact when purchasing condoms (i.e., cussions about contraceptive and condom use, potentially
self-checkout, online purchasing) [8–12]. influencing their use or non-use during sexual activity [12].
CONTACT Andrea L. DeMaria ademaria@purdue.edu Department of Public Health, College of Health and Human Sciences, Purdue University, 812
West State Street, West Lafayette, IN 47907, USA
! 2020 The European Society of Contraception and Reproductive Health2 J. RAMOS-ORTIZ ET AL.
Although there is a feeling of embarrassment for both men Table 1. Sociodemographic characteristics of the 42 study participants.
and women, women typically feel it is more difficult to Characteristic Value
obtain condoms because of lack of anonymity and per- Sex
Female 23 (54.8)
ceived judgement and disapproval [29,30]. Prior research
Male 19 (45.2)
suggests Italian women may prioritise privacy over the con- Age, years 29.1 ± 7.9
venience of CVMs [8], indicating that the public nature of Sexual orientation
Heterosexual 40 (95.2)
CVMs may pose a threat to their utility. Further under- Bisexual 2 (4.8)
standing of the hesitation surrounding CVM use is key in Marital status
developing efforts to improve CVM promotion, uptake and Single 16 (38.1)
In a relationship and not living with a partner 10 (23.8)
widespread use. Exploring ways to improve access to CVMs Living with a partner 15 (35.7)
and combat barriers to their use can benefit all CVM users, Married 1 (2.4)
whether already proponents or otherwise. There is limited Sexual relationship status
Exclusive/monogamous sexual relationship 26 (61.9)
research investigating effective CVM promotion; however, Sexually active, not monogamous 7 (16.7)
prior work suggests instilling trust and improving the user Not currently/never sexually active 5 (11.9)
experience in CVM purchasing may provide a foundation Having sex with several people 4 (9.5)
Pregnancy
for CVM promotion [8]. Have been pregnant/partner pregnant 3 (7.1)
Education
High school 5 (11.9)
Theoretical framework College/undergraduate 28 (66.7)
Postgraduate 9 (21.4)
The framework used to guide this study was social cogni- Employment status
Employed full time 21 (50.0)
tive theory, which suggests that basic processes in changes Employed part time 4 (9.5)
of health behaviour relate to individuals’ continuous inter- Self-employed 3 (7.1)
active cycle with various environmental, social and internal Not currently employed 4 (9.5)
Student 10 (23.8)
factors [31]. Observational learning and behavioural model- City of residence
ling suggest individuals learn by observing others. Self-effi- Florence 37 (88.1)
cacy, or confidence to perform the behaviour, is a critical Other Tuscan town/city 5 (11.9)
component [32] which has been successful in interventions Data are presented as mean ± SD or n (%).
increasing condom use [33]. Thus, this framework may offer
opportunities for improving condom promotion and use. while five (11.9%) had completed high school. Table 1
shows participants’ sociodemographic information.
Study purpose
Participant recruitment
The purpose of this study was to explore gender differen-
ces in condom purchasing from CVMs and identify ways to The study protocol was approved by the institutional ethics
improve CVM promotion. Although individuals are more review board of Purdue University, which included a letter
likely to use condoms if they are easily accessible [34], use of support from the in-country Italian partner institution,
among Italians remains low. As little is known about men’s Florence University of the Arts, and abided by all appropri-
perceptions of CVMs and CVM use, there is an opportunity ate human participant research ethical standards.
to better understand men’s voices to inform gender-spe- Participants were recruited through flyers in both English
cific CVM promotional efforts. The current study used quali- and Italian, in-person recruitment, emails, snowball sam-
tative methodology: researchers conducted semi-structured pling [35] and social media postings. Flyers were placed in
interviews to investigate Italian men’s and women’s per- universities, libraries, shops and caf!es around Florence city
ceptions, attitudes and behaviours regarding CVMs. centre. In-person recruitment consisted of researchers
approaching Italian men and women in public spaces, such
as caf!es and shops, and inviting them to participate in the
Methods study. Study participants were reproductive-aged (18–50
years), lived in or near Florence, used the Italian health
Sample
care system and were proficient in conversational English.
Overall, 42 reproductive-aged men and women, 29.1 ± 7.9 Men and women who participated in the study were
years of age (mean ± standard deviation [SD], range 20–50 encouraged to refer their eligible family and friends to par-
years), participated in in-depth individual interviews. Most ticipate. The use of multiple sampling methods allowed the
(88.1%, n ¼ 37) resided in Florence, Italy, during the study study to encompass a diverse population of participants
period. The majority of participants indicated that they and represent the perceptions, attitudes and behaviours of
were in an exclusive, monogamous relationship with a Italian men and women regarding CVMs.
partner (61.9%, n ¼ 26), while some were sexually active
but not in a relationship (26.2%, n ¼ 11) and some not cur-
Qualitative study design
rently sexually active (11.9%, n ¼ 5). Only three participants
(7.1%) had ever been pregnant or made a partner preg- Interviews were conducted in English from May to June
nant. Almost all participants identified as heterosexual 2019. All interviews were conducted in various locations
(95.2%, n ¼ 40), while two (4.8%) self-identified as bisexual. convenient for participants, lasted approximately 45–60 min
Most participants had begun or completed a university and followed a semi-structured format. The format enabled
undergraduate or postgraduate degree (88.1%, n ¼ 37), the participants to fully express their viewpoints and theTHE EUROPEAN JOURNAL OF CONTRACEPTION & REPRODUCTIVE HEALTH CARE 3
Table 2. Interview topics and corresponding questions.
Topic Question
Condom-purchasing experiences Where have you typically purchased or acquired condoms in the past?
[If CVMs] What percentage of your condoms are purchased from CVMs compared with other outlets?
Condom-purchasing norms Is condom purchasing typically a man’s responsibility? A woman’s responsibility?
How do you decide on which condoms to use? What do you look for in terms of quality, type or comfort?
CVM purchasing experiences Have you ever purchased a condom from a CVM? If not, would you please share why?
Why did you choose to purchase from a CVM?
What products would you want to see in a CVM that are not currently available?
CVM purchasing barriers/facilitators What would stop you from using CVMs to purchase condoms?
What would influence you to use a CVM to purchase condoms?
In an ideal world, how would you prefer to purchase condoms from a CVM?
researcher to add, omit or restructure interview questions Data analysis
based on organic conversational flow. By doing this,
Researchers transcribed interviews verbatim, including
researchers were able to capture new ideas and participant
observer comments and memos to record verbal and non-
narratives. After receiving participants’ written informed
verbal information and initial patterns in the data. All inter-
consent, interviews were recorded using the Apple
views were included in the data analysis. Techniques from
SoundNote iOS application. The interview began with gen-
grounded theory allowed for a constant comparative
eral questions about the participant’s daily routine, health,
approach to data analysis [36]. Researchers used
health care access and use. Participants were then asked HyperRESEARCH, version 4.0 (Research Ware, Randolph,
about their CVM attitudes, perceptions and use, after which MA, USA), to assist in data management and analysis.
participants shared their current condom-purchasing habits Aligning with the goal of grounded theory to prioritise par-
and offered suggestions for CVM improvements. Interview ticipant voices and experiences, researchers used partici-
questions are detailed in Table 2. Social cognitive theory, pant words and phrases, following an initial reading of all
as the guiding theory, aided in interview-question develop- transcripts, as the basis for a codebook [36]. Additionally,
ment, allowing interviewers to hone in on self-efficacy and concepts from extant literature were included in the code-
environmental, social and internal factors influencing CVM book related to the research aims. Researchers first com-
use and condom purchasing [31]. After interview comple- pleted open coding by attaching codes to various portions
tion, participants were asked to complete a brief sociode- of related transcript content [36]. Then, researchers com-
mographic survey to capture participant characteristics pleted axial coding to identify relationships within the
(e.g., age, education, marital status, sexual orientation, sex- data, including broader categories and patterns, which
ual behaviours). All research materials collected via inter- assisted in thematic identification [36]. Researchers met fre-
views and demographic surveys were kept confidential and quently to discuss emergent themes. All themes were dis-
separate from identifiable information, to minimise risk. cussed by the research team and discrepancies were
Each participant received e20 as compensation to thank resolved via consensus.
them for their time and contributions.
Results
Three primary themes emerged from the data: (1) attitudes
Research team and barriers to CVM use; (2) gender differences in CVM pur-
chasing behaviours; and (3) CVM improvements. Themes
Data were collected and transcribed by 16 female under-
and subthemes are presented with illustrative quotations.
graduate students and two female graduate students as
part of an interdisciplinary, research-based women’s health
study abroad programme. Students were trained in gradu- Attitudes and barriers to CVM use
ate-level qualitative research methodologies and had to
Women’s positive CVM attitudes
successfully pass a practice interview experience, with feed-
Women with previous experience of CVM use generally
back from the principal investigator (ALD), prior to being held a positive attitude towards CVMs, often due to the
cleared to conduct a research interview. All members of convenience and ability to access condoms at any time,
the interdisciplinary (i.e., nursing, public health, health sci- enhancing utility. One participant expressed how conveni-
ences) research team were fully involved in data collection ence played a role in her CVM use: ‘We can find [the
and transcription. During the data collection period, the CVMs] easily, everywhere. In the night, if all these [stores
research team resided in Florence and were immersed in are] closed you can go to find it in the machine, so no
the community and Italian culture. All authors of this problem’ (female, age 36). Participants also felt CVMs were
manuscript were part of the larger research team and were a useful tool in reducing embarrassment that may occur
responsible for all coding and data analysis on this topic. when purchasing condoms in person: ‘I think it’s easier
Authors used data tables, code manuals and mind map- because you can go [to the CVM] even at 4 in the morning.
ping to ensure a complete understanding of data analysis I don’t have to wait. You don’t have to feel embarrassed’
procedures. The primary author (JRO) oversaw and con- (female, age 20). This suggests that providing an alternative
firmed the procedures and outcomes to account for to purchasing condoms without inducing embarrassment
adequate research practice and reliability. was valuable to female participants. Not all female4 J. RAMOS-ORTIZ ET AL.
participants had used a CVM, but, regardless, these partici- Thus, distrust in CVM functionality, along with perceived
pants expressed positive opinions: ‘No one I know uses social stigma, comprised barriers to CVM use among female
them, but everyone I know has a positive opinion about participants.
them’ (female, age 27). Despite her lack of personal use,
this participant voiced the benefits of CVMs to the
Men’s positive CVM attitudes
broader community.
Similar to women, men who reported positive experiences
with CVMs also shared positive attitudes, claiming CVMs
Women’s CVM barriers enhanced convenience and reduced embarrassment. Male
Despite many positive opinions, female consumers experi- participants appreciated how easily accessible condoms
enced compounded barriers when purchasing from CVMs, were via CVMs, commenting on the abundance of the
typically related to social implications, such as lack of priv- machines around Florence city centre, as they are ‘very
acy, distrust and concerns about self-image when purchas- common so you can find one every three blocks, more or
ing from CVMs. Female participants often conceded that less, which is an easy walk’ (male, age 30). This suggests
while CVMs allowed for purchasing without potentially that, similarly to women, men value the availability and
embarrassing face-to-face contact, a lack of privacy was accessibility of CVMs. Male participants also commented on
inevitable because of CVMs’ public locations. One partici- their ease of use: ‘I usually go to the machines. It’s more
pant who had never used a CVM stated: ‘I was, like, “okay, easy, faster and cheaper’ (male, age 32). One of the most
this is weird”, especially because everybody can see you’ attractive things about CVMs to male participants was their
(female, age 33). This concern was common, whether par- ability to reduce contact with other people, thereby lessen-
ticipants had previously used CVMs or not, with one female ing the embarrassment and shame felt by some when pur-
participant who had previously used a CVM expressing: ‘If chasing condoms. One man explained: ‘It’s way much more
[you buy condoms in the] vending machine … anyone comfortable to be able to insert a couple of coins and buy
[can be] there so anyone can see me. It could be just a lit- [a] box of condoms without even having eye contact with
tle embarrassing because people watch you … look at a person’ (male, age 28). The reduction of negative feelings
you in a strange way’ (female, age 23). was a benefit of CVM use. Men who had previously used
Female participants were also afraid of being seen by CVMs also discussed that despite others’ concerns about
people they knew while using a machine, believing it could the products inside CVMs being defective, they were often
negatively influence their image: ‘Maybe seeing part of my good-quality products. One participant voiced these experi-
family [would stop me], like if my mom was there, I’d be, ences, stating: ‘Some people think, no, because they are
like, “eh, I’ll buy later”, probably’ (female, age 26). One exposed to the sun, so they can [get] hot inside. But, hon-
female participant cited the influence of the CVM’s appear- estly, when I buy them, they’re always fresh, like coming
ance on her image as a primary deterrent to its use: ‘The out from the fridge. So, I trust them. I have never had
thought of [CVMs] makes me think of … bums or home- problems (male, age 25).
less people around. I don’t know why, but, like, that’s my Thus, the ability to purchase without embarrassing inter-
association. So, I wouldn’t get it from there because it actions coupled with the reliability of condoms within the
makes me look like some sort of poor person’ (female, machines was valuable to male consumers, contributing to
age 33). use frequency.
Thus, the machine’s image and appearance related to
negative perceptions of who would likely use them, sug- Men’s CVM barriers
gesting this as a perceived cost of using them. Women While female consumers chose not to use CVMs primarily
also expressed issues of distrust in CVM efficacy as reasons based on preconceived notions about CVMs and image
for discontinued use: ‘I bought them [at the CVM] and it concerns, male consumers decided against using CVMs
doesn’t work very good, because it broke while I was using based on prior negative experiences. Some male consum-
it. It was my first time using a [CVM]. It was with a friend. ers stopped using CVMs after the machine malfunctioned,
And I paid, I did the number of what I wanted and when failing to give the correct, or any, products: ‘I didn’t get the
they fell down, the door didn’t open’ (female, age 20). condoms out of the machine’ (male, age 24). Another ech-
Expressing distrust in the functionality, and building on oed concerns about receiving the correct product: ‘At the
a poor experience, prevented confidence in future use. supermarket, you see them, you can take them. In the
Other women highlighted the products contained within machine, you are pushing a button, so you don’t know
the machine may not be properly maintained, preventing what’s going to come out of the machine’ (male, age 24).
trust in the products: ‘In those sketchy machines, I’m not Other male consumers held doubts over the quality of the
sure if they have the expiration date on it, if it’s been sit- products within the machine: ‘I was always scared [to use
ting there forever. And then they … are broken or what- CVMs] because at the beginning they were outside, with
ever’ (female, age 35). the sun and everything. There were stories on the news-
Distrust in CVM products was associated with frustra- paper that the sun [can] melt the rubber of the condom. It
tions concerning the type and timeliness of products came out in the newspaper that a lot of condoms [would]
stocked: ‘Things are not overstocked. Because there’s no break because of this thing about being hot and in the
space [in] these vending machines. If you open them up, sun’ (male, age 29).
like, I’m sure they’re very small on the inside, like there’s One man expressed his frustration about the machines
not that much space to have a mega stock’ (female, not carrying the products he desired: ‘In the [CVMs], you
age 27). have the Durex condoms, which [are] usually the standardTHE EUROPEAN JOURNAL OF CONTRACEPTION & REPRODUCTIVE HEALTH CARE 5
six to eight different types and very little variety between purchasing from CVMs: ‘If you asked me [about my CVM
them. So, flavoured condoms or lube or any other device purchase experience], like 2 years ago, [I would say] prob-
that you’d usually be able to find at a pharmacy is not as ably people walking near me were judging me. But now,
common … it’s usually just the same standard products’ after my experience, [I use] the machine. And people just
(male, age 30). walk around and see me. [I don’t] experience any problem
Some men experienced the same embarrassment with choosing it. I think if I see a girl, especially a girl, or
women expressed, although much less, as one participant even a boy, buying condoms from a [CVM], there’s no
explained: ‘It’s not something that … makes you awkward problem, I feel, like, “Good. You are doing good. Good
or super uncomfortable. But it’s something that you know job”’ (female, age 20).
you do carry a stigma when you’re doing [it]’ (male, age Some women noted they purchased condoms to keep
30). This implies that while men express practical concerns at home to be prepared for sexual encounters, whether
about CVMs, some image and embarrassment limitations they were currently in a relationship or not: ‘Well [having
also remained consistent among men. my own condoms is] something quite normal. I have them
at home’ (female, age 20). By doing this, they felt as
though they were in control of their sexual health, choos-
Gender differences in CVM purchasing behaviours ing to highlight purchasing independence and the feeling
Male CVM purchasing behaviours of responsibility accompanying preparation.
Men continue to be the primary CVM consumers, indicating Most female participants also noted their male partners
their overall comfort with using them. Participants also typically purchased condoms in their relationship, sharing
related this to perceived purchasing responsibility. Many similar sentiments to those of male participants, as women
male participants felt it was the man’s responsibility in a felt they had other purchasing pressures to worry about.
heterosexual relationship to purchase condoms. One male Some female participants noted men should purchase con-
participant calculated, ‘Mathematically, I would say 90% of doms because of the expression of personal preferences
the time, [it] is the male that goes [to] buy condoms’ related to their type and fit: ‘I think … it’s not necessarily
(male, age 28). Another male participant felt that both men my responsibility. It’s just that the man knows what it does
and women agreed with this condom purchase responsibil- to him. For example … they needed a larger size and I
ity norm: ‘I feel that from my experience it’s generally the bought … so I mean, okay, well, that’s what he knows. So,
concession, for both the females and the men that I’ve the ones I bought are still in my cupboard’ (female,
talked to, that, you know, the condoms are the responsibil- age 33).
ity of the men to have, to purchase, and, if they don’t have Noting how the condoms she had purchased remained
it, to go get them’ (male, age 30). unused reinforced her decision to allow her partner to con-
Many male participants expressed that it was their tinue choosing his condoms. More women in relationships
responsibility to uphold the ideals of chivalry and courtesy, explained how the personal preference of their male part-
which translated to a duty to purchase condoms: ‘Here in ners did not bother them as long as the product was
Italy we have our role of cavalleria [chivalry]. You have to effective, explaining: ‘For my side [I care] that [it] doesn’t
break and that it’s good quality and resistance. [Other than
be very kind with the girls … but, in general, I like to offer
that] it is his choice. That’s the thing, so … yes, to take
… like a coffee. You won’t offer for me a coffee. But no, I
the one that is more comfortable’ (female, age 26).
offer you. Because I am the male’ (male, age 20).
While some women preferred to purchase and supply
Another man stated he purchased condoms in his rela-
their condoms, the cost of purchasing menstrual products,
tionship as an act of equality, as women were already
coupled with a desire to adhere to male partners’ personal
charged with purchasing expensive menstrual hygiene
condom preferences limited condom-purchasing frequency
products: ‘I feel like it’s a fair thing to do because women
among women.
have the burden of always paying for their own tampons
and anything that has to do with the menstrual cycle. So
since it’s something that’s in the same area, I would say, I CVM improvements
think it’s just fair that the guy buys them’ (male, age 32).
Whether citing chivalry or Italian gender expectations, Although most participants held positive attitudes towards
participants described men as the primary purchaser of CVMs, many felt that CVM use could be improved through
condoms, ‘I think more men use them [CVMs]’ (male, age product variation and cost adjustment. While condom
24), suggesting a culturally derived consensus of accept- brand and type were major CVM purchase influencers, the
able behaviour for men permeated into con- number of condoms and cost were also important aspects
dom purchasing. of condom choice. Most reported that CVMs provided con-
doms with packs containing anywhere from six to 12 con-
doms, ‘You have to buy a six-pack minimum. You cannot
Female CVM purchasing behaviours buy [a] single one’ (male, age 29), expressing how they
Some women desired more autonomy or partnership in wished to see smaller packs sold in the machines for
condom purchasing through sharing condom costs with urgent cases: ‘I would like to see a single or double little
partners and through their condom supply: ‘I would say, I condom packs for e3. That will be [great]’ (male, age 29).
mean in general I’m just a responsible person so I have Another participant added: ‘[When] you’re in [an] emer-
them [condoms]’ (female, age 23). Some women high- gency, you want one – you don’t want the whole package’
lighted a shift in the narrative of female condom-purchas- (female, age 26). Many participants commented on the
ing behaviours, expressing newfound confidence when extra expense incurred when purchasing condoms from a6 J. RAMOS-ORTIZ ET AL.
CVM specifically: ‘Maybe something I would say [that is pharmacy could reduce apprehension. Clearly showing and
problematic] is the cost, the price of the condoms’ (male, documenting that CVMs are regularly serviced may increase
age 25). Another female participant agreed, acknowledging source credibility, enhancing consumers’ confidence in their
the importance of CVMs for condom access but noting the decisions to trust and use CVMs [39].
high cost: ‘[Having CVMs] is important [so we can be] Some women did not want to be associated with nega-
responsible by ourselves to take care of our health and tive societal judgements perceiving women who carry con-
buy [condoms]. But maybe the price could be lowered’ doms to be sexually promiscuous, as they felt they would
(female, age 36). In addition to a reduction in condom be judged more harshly than their male counterparts
pack size and cost, participants desired more variety in the [8,30]. Specifically, women’s fear of being judged as pro-
types of condoms offered, as one participant detailed: miscuous or in a negative light for purchasing condoms
‘Definitely non-latex ones and maybe more natural kinds of led to hesitation in condom-purchasing behaviours and
condoms’ (male, age 32). Basic and allergen-free condoms CVM use. Thus, for women, the accessibility and visibility of
were favoured by participants, while different flavours and CVMs were as much an advantage as a drawback.
textures were usually purely experimental. One participant Decreasing negative stigma around female condom pur-
reflected: ‘I tried a lot of them, but I usually buy the classic chasing can help women gain the confidence to purchase
one [from CVMs]’ (female, age 23). Thus, diversifying prod- their condoms [40], even at CVMs. Recognising gendered
uct offerings based on the amount, type and price may preferences when purchasing condoms can help in target-
increase the utility of purchasing from CVMs. ing condom-marketing tactics, particularly by addressing
potential stigma via identity cues [41]. Including stigma-
Discussion tised-identity cues in CVM marketing messages can signal
an awareness of a stigma to female consumers and further
Findings and interpretation position CVMs as a worthwhile solution [41].
Putting condom purchases on display only heightens
A total of 42 men and women participated in semi-struc-
embarrassment and fear among women that they will be
tured interviews investigating consumer perceptions of
judged for their sexual responsibility and choices. CVMs
CVMs as a purchasing outlet, and condom-purchasing
reduce purchase embarrassment and contact with other
behaviours among men and women living in Florence,
individuals, a benefit most other purchasing outlets do not
Italy. Results consisted of three main themes, which extend
possess. A messaging strategy emphasising this perceived
prior research suggesting that individual- and community-
benefit may increase confidence in CVM preference and
level factors must be considered when explaining condom
use among target consumers. It may also encourage subse-
access and use [37]. The first theme identified attitudes
and barriers to CVM use among both men and women. quent condom use, particularly in situations where per-
Findings also examined the purchasing behaviours of men ceived stigma and embarrassment cause consumers to
and women, with men displaying more practical reasons forego purchasing condoms in immediate situations.
for using, or not using, CVMs, and women perceiving social Additionally, normalisation of female condom purchasing
stigma around CVM use, which influenced their purchasing via visual marketing (e.g., posters, social media advertise-
behaviours. Finally, participants described future product ments) may also serve as a successful promotional effort.
suggestions for CVMs, as well as potential CVM improve- This suggests shifting the narrative surrounding women
ments to increase use. who purchase and carry condoms: contradicting this view
Both men and women shared their beliefs that condom may encourage increased CVM use among female consum-
acquisition was a man’s responsibility. Reasons cited by ers. CVM barriers may be mitigated through direct,
men often included cultural norms, feeling responsible for thoughtful improvement of CVM marketing, promoting
an object used on their bodies, and a desire to lessen the female consumerism and dispelling damaging perceptions
financial burden on their female partners. Because men of condom-holding women while also benefiting vulner-
were cited as primary CVM users, they tended to express able consumer populations.
practical concerns surrounding CVMs themselves, as well as As CVMs are often used as the last option of condom
the products within. Men are more likely to have an idea purchasing, primarily for last-minute or late-night use, there
of their preferred condom brand and type before purchas- is a need for CVM marketing and promotional efforts to
ing [38], suggesting that marketing messages should focus cater to the consumer needs of decreased cost, greater
on the reliability of CVMs as a viable purchase outlet for selection and improved efficacy of products. Male partici-
condoms. Quality and trust in CVMs and condoms available pants expanded upon the importance of their specific
within them were influential aspects of purchasing, particu- needs and preferences when purchasing condoms from
larly for men. The possibility of sun-damaged or exposed CVMs. Most participants acquired Durex-branded condoms,
condoms in CVMs due to their outdoor location played an owing to their reliability and popularity in Italy.
important role in quality concerns. Distrust in condom Hypoallergenic and latex-free condoms were a common
quality was particularly common, as participants were need along with a thinner type of condom. Textured, col-
unsure of how long the condoms had been in the oured and flavoured condoms were not frequently consid-
machine. Shifting CVM locations to shaded or reliable ered when choosing a condom. Condom preferences
areas, as well as including clear messages on the machine among consumers often point to the consistent usage of
stating that products inside are temperature-controlled and one brand of condoms [18], indicating that limited trial of
indicating when a machine is checked and stocked by different condom features and attributes is common. Some
qualified personnel, could mitigate these practical con- participants mentioned condom brand selection available
cerns. For example, CVMs being located directly outside a in CVMs, both the variety and the differences in theTHE EUROPEAN JOURNAL OF CONTRACEPTION & REPRODUCTIVE HEALTH CARE 7
number of condoms in a box, as being determinants of Implications for policy-makers
use. Boxes with fewer condoms were preferred, as most
A targeted messaging strategy may be a critical opportun-
participants wanted only one or two condoms for single-
ity to address gendered preferences when purchasing con-
use purposes instead of having a surplus. Stocking pack-
doms from CVMs. Marketing messages for men should
ages with smaller amounts may encourage purchasing and
focus on CVM reliability, quality and trust. Shifting CVM
mitigate the immediate expense for last-minute or late-
locations to private areas or reliable areas (e.g., directly out-
night users. Allowing for smaller packs of condoms
side a pharmacy) and using visual marketing, detailing tem-
addresses both concerns over cost and excess condoms
purchased. CVMs provide consumers with basic needs, yet perature control guarantees and quality cheques may
to enhance CVM usage, reflecting consumer needs regard- mitigate these practical concerns. Negative societal judge-
ing diversified product offerings should be considered a ments posed the most prominent barrier to CVM use
priority. Matching preferences related to product count and among women, indicating that the accessibility and visibil-
pricing in CVMs may better align with consumer goals, ity of CVMs worked as a drawback more than an advan-
positively affecting attitudes towards CVM use [42]. tage. Marketing messages for women should focus on
Exploring and incorporating consumer insights and voices decreasing negative stigma and increasing confidence in
allow for continued cycles of improvement related to CVM CVM use. Emphasising the reduction in purchase embar-
use, product availability and marketing messages [43], fur- rassment and interpersonal contact CVMs provide may be
ther integrating personal preferences into a busi- a viable consumer-informed strategy, which may also
ness model. encourage subsequent condom use. Visual marketing
efforts (e.g., posters, social media advertisements) normalis-
ing women as agentic condom purchasers may also serve
Strengths and limitations as a successful promotional effort. Finally, diversified prod-
uct offerings reflecting consumer needs related to product
The results of the study provide an increased understand-
count and pricing in CVMs may better align with consumer
ing of CVM attitudes and consumer behaviours among a
goals, positively affecting attitudes towards CVM use.
novel set of participants: men and women living in and
Implementing CVMs and encouraging their use could free
around Florence, Italy. The research offers valuable contri-
up pharmacist time for clinical consulting in other areas
butions for improving the effectiveness of an alternative
[47]. Using individual voices may allow policy-makers and
purchasing outlet for sexual products while shining a light
practitioners to better address condom-purchasing social
on gender differences for improved CVM targeted promo-
concerns, increase access to safe and effective products
tion. There are limitations of this study due to the nature
and empower men and women in their family planning
of qualitative research, geographical location and specific
and sexual health decisions.
demographics of the participants (e.g., employment and
residence status, marital status, prior experience with
CVMs, heterogeneity of the sample, limited number of par- Future research
ticipants). Thus, the study findings cannot be applied to
the entire population. Additionally, claims from participants Understanding the barriers of purchasing from CVMs can
might have differed from their actual feelings and opinions. aid in the development of more accessible machines in
However, to mitigate potential social desirability bias, par- secure locations, ensuring that condom quality is not com-
ticipants were reassured there were no right or wrong promised and purchase embarrassment is avoided. Future
answers and assured that all responses would remain confi- research should focus on methods for increasing CVM con-
dential [44]. Language barriers might have resulted in dom purchasing and subsequent use, in Italy and beyond.
some inconsistencies, as participants were not interviewed By conducting interviews in Italian and by a diversified
in their native language. Additionally, individuals who interview team (e.g., age, gender, ethnicity), researchers
speak a second language well enough to be interviewed may be able to capture richer insights and expressions.
may have a higher socioeconomic status, which might Targeting men’s and women’s condom-purchasing needs
have introduced selection bias into our sample. Conducting by addressing practical and social concerns may contribute
interviews in English also might have resulted in a limited to decreased CVM barriers across genders, improving con-
vocabulary; therefore, some insights on CVM use and per- dom use. Consumer-informed marketing strategies may be
ceptions might not have been adequately captured in the explored to highlight the convenience and accessibility of
interviews. All interviews were conducted by female stu- CVMs, as well as the efficacy of products and cost–benefit
dents who were between the ages of 18 and 26 years, of products within CVMs. Future studies should track con-
which might have influenced the direction, flow and con- sumer CVM usage to analyse the effectiveness of improved
tent of the research data. Participants might have used the marketing messages and diversified product offerings.
interviewers’ gender identities as a cue for how to orient Application and evaluation of CVM promotional efforts may
their narratives; however, some research suggests that provide improved insight into consumer behaviour, pur-
interviewer age and identity may not influence findings chase and use.
when well trained and well informed [45], and that men
may feel more likely to open up during qualitative inter-
Conclusion
views conducted by women [46]. Nevertheless, the findings
illuminate unique insights related to CVM attitudes, pur- Findings offer practical recommendations to guide CVM
chasing behaviours, and CVM promotion and use messaging in Italy to increase access and use to condoms
improvements. and other personal care items. Men were cited as primary8 J. RAMOS-ORTIZ ET AL.
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No potential conflict of interest was reported by the author(s).
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