USAID/Brazil -
FY2003-2008
Social
Marketing Assessment and
Behavior Change
[Social] Marketing Strategy Design
Steven C. Mobley
Synergy Project
Contract Award Number: HRN-C-00-99-00005-00
USAID/G/PHN/HN/HIV AIDS Division
March, 2002
Executive Summary
In 1985, men with AIDS in
The National Coordination board
for STI (Sexually Transmitted Infections) and AIDS (CN), a division of the
Ministry of Health, partially funds AIDS prevention activities with about 200
of the 1,000 or so AIDS related Non Government Organizations (NGOs) in
Changes in sexual behavior
practices have been the desired outcomes in AIDS prevention programming, yet
baseline research and project evaluations have rarely included behavioral
indicators, principally because of a lack of resources. Mass media and the
development of a behavior change [social] marketing strategy has also not been
implemented before now due to the previous low levels of funding. With the
increased funding levels proposed for FY2003-FY2008 AIDS prevention activities,
behavior change [social] marketing strategy can be implemented and bring into
play the powers of the commercial marketplace in collaboration with the social
sector to effectively utilize behavior theory and consumer psychology practices
to effect change: increased condom use in situations that may place the person
at risk of HIV infection or the promotion of abstinence, delayed onset of
sexual initiation, and fidelity.
Behavior theories, i.e.,
Diffusion of Innovation Theory, the Social Influence Model, and the Social
Network Theory, all point to the need for Key Influencers (KI) from whom
behavior can be modeled and a social norm can be established. This document
proposes that USAID work collaborative with the CN to establish an entity in
Due to many real or perceived
restrictions, we often focus on manageable tasks rather than deal with a
seemingly overwhelming problem. A problem can be dealt with head on if one can
identify its core. In the case of HIV/AIDS, the core is sexual behavior. Utilizing a private sector marketing strategy
for modifying the social norm is the solution.
Introduction
Statement of work:
The
Consultant conducted a Condom Social Marketing Assessment and provided support
for the USAID/Brazil Mission’s HIV/AIDS Strategy Design in
Objective:
1)
To assess the
performance of the current [procurements responsible for] Intermediate Result
(IR 3) "Sustainable Social Marketing of Condoms", within the
2)
To design a Social
Marketing strategy for the Mission’s next five-year Strategic Plan
(FY2003-2008) based upon lessons learned and results achieved within the
existing IR3; and
3)
To propose broader
usage of social marketing techniques as a tool for behavior change and health
promotion and prevention.
I.
Background
AIDS was first identified in
The epidemic has migrated from
the homosexual to the heterosexual community over the years. In 1985, men with
AIDS outnumbered women 25 to 1. Today the ratio is approaching 1:1 with a trend
that could have women outnumbering men in the near future. The trend is also
showing a disproportionate growth in communities under 50,000 inhabitants. And,
the South is the region with the highest increasing incidence of the epidemic.
Transmission of HIV/AIDS is
predominately through sexual behavior (75%) as opposed to blood contamination
via IDU or transfusion. Yet, as you can read in the UNAIDS “Best Practices”
document The Brazilian Response to
HIV/AIDS, IDU remains a serious contributor to the spread of AIDS. The
overwhelming preference for IDU is injectable
cocaine. Intravenous Drug Use[rs] (IDUs) account for about 21% of AIDS cases (Bastos et al., 1999 in Drugs:
Education, Prevention and Policy 6 (1):29-50.) From the mid-1980s to the
mid-1990s, Barcellos & Bastos
(1996) reported that the port city of
HIV Infection among Female Partners of Seropositive Men in Brazil, Mark Guimarães, et al.,
published in the American Journal of Epidemiology, Vol. 142, No. 5 in 1995
reported “The strength of the association
between anal sex and prevalent HIV infection in this population was of
considerable magnitude, suggesting that it may be a major route of heterosexual
transmission of HIV in Brazil” The rate of anal sex practice was 31% in the
period of the study and in most cases was without the use of condoms (83%).
A Knowledge-Attitude-Practices
(KAP) survey by Sinal Pesquisa,
funded by DKT do Brasil, reported in November 2001, that 70% of heterosexuals
in the South, 50% in the North/Northeast, and 35% in the Center West practiced
anal sex. Only 35% of those who self-identified as heterosexual reported always
using condoms. 36% of those who engaged in anal sex did not use condoms. And,
89% of bisexuals engaged in anal sex with women while 64% of them engaged in receptive
anal sex with other men as well.
Since 1997, Brazil has provided
free ARV therapy to those persons who meet the national medical guidelines for
treatment. The government of Brazil has realized a savings of health resources
amounting to US$422 million over the last three years from a reduction of AIDS
related health problems presented to the government run health facilities. It
needs to be noted the MOH reports (AIDS Epidemic in Brazil, p42) that a survey
in São Paulo revealed that fewer than 69% of patients had continued to adhere
to the treatment. Due to the high costs of providing ARV freely, only about 20%
of Brazil’s AIDS budget goes towards prevention.
Knowledge or awareness of the
impact of mass media has been evident in Brazil for over a decade. In 1989, Vilmar E. Faria published a
theory of the indirect effects of nationwide penetration of telecommunications
on reproductive outcomes in Brazil in his article “Government policies and
productive legislation: Unexpected consequences and unusual effects. The title
given is roughly translated by the
author of this document of the Portuguese article “Politicas de governo e regulação da fecundidade: Consequências não antecipadas e efeitos perversos,” Revista
de Ciência Hoje: 62-103). This article
generated a great deal of interest regarding the impact of television on
Brazilian society. Subsequently, telenovelas have
been credited with playing a substantial role in promoting ideological change
with respect to reproductive behavior (Neeru Gupta,
Sexual Initiation and Contraceptive Use Among Adolescent Women in Northeast
Brazil, Studies in Family Planning 2000;
31[3]:228-238).
Media promotion for AIDS
prevention has continued by the GOB and socially concerned and AIDS aware
commercial networks (Rede Globo,
MTV, Rede TV, etc.). Special events such as Carnival
and World AIDS Day receive special attention via the media. Actors and other
entertainers have given of their time free of charge for these media
presentations. There have been, as well, AIDS awareness and sensitivity
training workshops presented for journalists and other writers but without an
apparent strategic process that would include periodic reinforced messaging.
Media coverage overall (news, talk shows, etc.) seems to have decreased over the
years since the early 1990s, based on the observations of the consultant over
the past ten years.
Gay organizations in Rio de
Janeiro, São Paulo, and Bahia were the first to respond to the AIDS epidemic
and put forth that discrimination and prejudice were major obstacles of
prevention and that the entire population needed to be informed how to avoid
infection. The attempt to avoid stigmatization of vulnerable populations and
groups at increased risk of HIV/AIDS has made it challenging to deal directly with
highest risk behaviors, and often messages have been without a clear focus and
behavioral impact has not been evaluated.
Social Marketing of condoms was
first funded by USAID/Brazil in 1992 through DKT do Brasil. DKT has pursued the
problem of AIDS with, what appears to be a strategy based on price and, to some
degree, accessibility. USAID’s support of DKT has represented a large part of
USAID’s AIDS portfolio, yet it only represented about 10% of DKT’s budget. This
can be considered a huge leveraging of resources by USAID/Brazil. Most of DKT’s
mass media coverage and product promotion has come from PR activities for very
little cost to DKT. Neither a national nor a regional campaign has been carried
out by DKT due to a lack of funding. Nonetheless, the popular belief
(USAID/Brazil and the MOH/CN) is that DKT’s presence in the marketplace and
their pricing strategy has had a positive ripple effect in Brazil, contributing
to the overall decrease in the price of condoms and opening the door for new
brands to enter the marketplace. It has been projected by the GOB that there
were approximately 600 million condoms distributed in Brazil last year, with
350 million of that number via commercial networks.
In the mid-‘90s a Brazilian NGO,
Sociedade Civil Bem Estar Familiar no Brazil (BEMFAM), International Planned
Parenthood (IPPF) affiliate in Brazil, entered the social marketing of condoms
arena with the main objective of cross-subsidizing their family planning clinic
operations. As a result, their product PROSEX,
was placed on the market at a slightly higher price than DKT’s Prudence. Aiming to increase its condom
social marketing initiatives, USAID/Brazil with FY2001 funding, also contracted
with BEMFAM to expand their existing social marketing operations in three
southern Brazilian states, which show increasing incidence of AIDS cases. Located in Rio de Janeiro, BEMFAM received
support for several activities, including social marketing, under the Mission’s
reproductive health program, which ended in FY2000. Both BEMFAM’s
Prosex condom and DKT’s Prudence brand continue to
gradually increase their market share in most areas of Brazil except for the
most populous and most HIV prevalent state of São Paulo. This has been
attributed to the lack of mass media coverage and promotion, and to occasional
blockage by the powerful and influential Johnson & Johnson brand Jontex. Jontex has the highest
market share of condoms in Brazil and its product is the most expensive.
The Coordenação Nacional de DST
e AIDS (CN) has made a proposal to condom importers and local manufacturers to
expand the condom market. The CN will [widely] promote generic condom use and
reduce taxes (which are currently beyond their control), if the condom sellers
will provide a product to the market for US$0.10 or R$0.25 per unit. In
addition, it is expected that condom sellers will identify more non-traditional
outlets while the CN will provide retailers with a symbol that can be placed in
their window or on their door that would identify them as a vendor of the CN
social sanctioned/advertised condom. The retailer would have to sign an
agreement to sell the product to the consumer for not more than US$0.10 or
R$0.25 per unit, rather than charge whatever the market will bear. A further
reduction in packaging costs by allowing individual unit sales and additional
tax relief has been counter proposed by some of the condom sellers as a means
of affording the suggested pricing. There is much work to be done on this
program before it can be realized. Issues regarding taxes, single unit sales,
brand development, and frequency of media coverage have yet to be ironed out.
The Ministry of Fazenda [domestic economy] and others have to agree and
facilitate some of the desired policy changes before the program can become
functional.
II.
USAID/Brazil’s Assistance Approach
USAID/Brazil oversees the
implementation of four strategic objectives (SOs)
over a five year Strategic Plan funding period (1998 to 2002) with total annual
program funding of approximately $15.0 million.
The four SOs include environment, energy, at
risk youth and child labor, and HIV/AIDS Prevention and TB Control.
In FY2001, Brazil was designated
an intensive focus country by USAID/ Washington, and the Mission’s level of funding
for HIV/AIDS prevention activities was increased to $3.7 million. It is anticipated that funding levels will
continue to be increased for the next several years. In addition, USAID/Brazil’s Health Strategic
Objective (SO3) was recently amended to provide a framework for TB control
activities with resources of $2.6 million allocated in FY2001. In FY2002, the combined total for HIV/AIDS
and TB is US$7.3 million (4.3 and 3 respectively).
The current five-year HIV/AIDS
Prevention and TB Control SO is: "Increased
sustainable and effective programs to prevent sexual transmission of HIV among
target groups and to control tuberculosis in target geographic areas". The achievement of SO3 is supported by four
Intermediate Results (IRs) of which IR#3 pertains to
Social Marketing:
IR#1 "Strengthened
institutional capacity to plan, implement and evaluate STD/HIV programs"
- implemented by Management Sciences for Health (MSH). This component focuses
on four state and six municipal secretariats of health in the states of Rio de
Janeiro and São Paulo, which have the highest number of HIV/AIDS cases, and in
Bahia and Ceará which are states that have large populations of the poor and
vulnerable. In addition, this IR works closely
with the MOH's National STD/AIDS Program in Brasilia.
IR#2 "Strengthened
institutional capacity to provide integrated Reproductive Health and STD/HIV
services in Bahia and Ceará " - implemented by Pathfinder
International, which provides technical assistance and training for municipal and
state public health units to integrate sustainable STI/HIV health services into
the larger overall reproductive health programs in these two Brazilian
states. In FY2002, Pathfinder is also
working with four Brazilian NGOs in HIV/AIDS prevention activities that target
lower-income women, adolescents, drug users and sex workers (SWs).
v
IR#3 "Sustainable social marketing of
condoms" - implemented by Population Services International (PSI)
through its AIDSMARK project and its subcontractor in Brazil, DKT International,
located in São Paulo, which with USAID/Brazil funding socially markets male and
female condoms in the four states of Rio de Janeiro, São Paulo, Bahia and
Ceará. DKT also works with local AIDS
NGOs in their HIV/AIDS Prevention outreach activities.
IR#4 "Sustainable and
effective institutional capacity to diagnose, treat, control and monitor
tuberculosis in target areas using DOTS" - implemented through a collaboration of
several partners, including the MOH, the Pan American Health Organization
(PAHO), the Centers for Disease Control (CDC), the TB Coalition for Technical
Assistance (TBCTA), the Gorgas Institute, BEMFAM and
MSH. This two-year strategy focuses on
improving the political commitment to Directly Observed Therapy (DOTS), the
World Health Organization’s recommended strategy for TB control, expanding DOTS
coverage in the target state of Rio de Janeiro.
IV. Social Marketing Assessment
A. Findings
Based on over thirty years of behavior change [social]
marketing/communications experience, formal education in psychology,
management, marketing, and the visual arts, teaching university undergraduate
marketing and graduate MBA global business principles, and personal
observations, the consultant analyzed and identified below a partial listing of
stakeholders which are important participants in a strategic [social] marketing
effort for behavior change. Not all of these stakeholders have, as yet, played
a role in Brazil’s AIDS prevention efforts. Their importance is based upon
their influence over policy issues, financial support, distribution networks,
know-how and experience, contribution and potential contribution to AIDS
prevention efforts.
Key Stakeholders:
Coordenação
Nacional de DST e AIDS (CN): This is
Brazil’s national AIDS control program and it is of paramount importance in
anything that is done in Brazil regarding HIV/AIDS prevention activities. It is
critical therefore that there is an understanding amongst all stakeholders of
the need for a fully funded strategic effort that would entail a focus on
behaviors rather than demographic grouping, possibly requiring product
diversification for the purpose of discretely addressing those sexual
behaviors, and mass media networking and promotion that would appropriately
influence the adoption of new behaviors that would center on condom usage, and
also entail delay of onset, fidelity, partner reduction, etc. The CN can
facilitate price control of social marketed products to the consumer through
their planned development of a loosely constructed manufacturer’s model of
social marketing. The “manufacturer’s model” was first introduced by the
Future’s Group during their Social Marketing for Change (SOMARC) projects. It
is an attempt of the social sector to negotiate with private sector commodity
suppliers to lower the price, of a product that is perceived to be needed by a
population, to be more accessible to the working poor, in exchange for
advertising support, education and training with respect to their product. It has
never been sustainable as far as this consultant is aware.
United
States Agency for International Development (USAID): The US government has made resources available for AIDS
prevention through USAID/Brazil since 1987. The agency has worked with a number
of partners in its fight against AIDS, including: Population Services
International (PSI), Family Health International (FHI), Population Council,
Pathfinder International, Management Sciences for Health (MSH), Partners of the
Americas, Asociação Brasileira Interdisciplinar de
AIDS (ABIA), Sociedade Civil Bem
Estar Familiar no Brazil (BEMFAM), Institute of
Health and Social Development (ISDS), Associação Saúde da
Família, Comunicação e Cultura, GAPA-Bahia, GAPA-Ceará, and Gestos
Soropositividade, among others. USAID has also been
working with regional neighbors of Brazil, where USAID has a presence. Sex
work, trucking operations, drug trafficking, and low quality health services in
border areas have led to the increase of HIV/AIDS in those areas. USAID support
has led to the expansion of the condom market and has sponsored products which
have kept prices within reach of the working poor.
DKT
do Brasil: DKT is the prime social
marketing organization in Brazil based upon their market share and the respect
they have earned from the MOH/CN and USAID/Brazil. They are in place to expand
to whatever level is necessary, either directly or indirectly, via an as yet
un-named entity. They are a price and distribution focused social marketing
organization. DKT has, with USAID support, been at the forefront of positive
changes made in the condom industry in Brazil, in that they have widely offered
a product at a social marketing price which earned them greater and greater
market share forcing the competition to lower its prices to maintain their own
share of the market. Assuming that USAID wants condoms to remain affordable to
the working poor in Brazil, DKT do Brasil represents the only organization in
Brazil, other than the CN, that has a mandate to do that. The part of DKT’s
efforts that is carried out on behalf of USAID should be focused on behavior
change outcomes, non-traditional distribution expansion via the likes of Aliança Luz (see below) and others, with an emphasis on the
development of promotions featuring positive role models in the entertainment
and media communities. Low pricing should stay important to the program yet
quality issues should be addressed publicly to strengthen the positive
perception of their brands, which was shown to be lacking in a recent KAP
commissioned by DKT.
Aliança
Luz: This organization is based in Ceará
and its activities are exclusive to that state. It has a small staff that
lobbies Mayors of municipalities and Secretariats of Health to strengthen
family planning and STI/AIDS programs. Funding for their activities come from a
partnership between JICA (Japan International Cooperation Agency) and DKT do
Brasil. They also open non-traditional condom sales outlets such as gasoline
stations, snack shops, small pharmacies, etc., in rural areas around the state.
It is the kind of organization that directly addresses the need of the emerging
trend in HIV/AIDS migration to smaller communities. The trend of “interiorization” is nationwide and this NGO has the
experience and skill which needs to be expanded, particularly in the South.
Centro
Corcini: This
AIDS clinic and care facility is located in Campinas,
Brazil. The nationwide Hot Line run by this organization under contract to DKT
is underutilized, given its tremendous potential to generate data. They
currently receive approximately 2,000 calls per month. They have estimated that
their current volume is around 3,000 calls with 30% receiving busy signals.
Several researchers have expressed an interest in utilizing their network to
investigate condom use behavior and other relevant issues. The line is a
national “800” number for the purpose of addressing condom failures and any
other sexual behavior issue that the caller might have. This
mechanism might be useful in identifying what are the principle motivators for
a person initiating condom use.
Population
Council/Brasil: The research team at PopCouncil/Brazil is carrying out a GOB-USAID co-funded
situational analysis study on cross-border migration of HIV/AIDS in several
parts of the country. They also have a great deal of institutional knowledge of
the AIDS situation in Brazil, the SW community, and female condom use and
efficacy. The local office in Campinas is also
involved with the Horizons Program, which is carrying out various studies in
Brazil involving NGO strengthening, care and support, and gender equity issues.
Recent completed studies involving the female condom have not been released to
the public. The local office may be overcommitted and understaffed, causing the
delay in dissemination of information useful in many other organizations’
programming efforts. Dissemination of research findings to other implementers
needs to be expanded in a meaningful way. The “Janeway”
is a new female condom device/panty that this office of the Population Council
had been looking into as a possible new contraceptive for study. Stimulation of
this initiative could result in a more attractive, lower cost alternative to
current female controlled barrier methods.
BEMFAM (Sociedade Civil Bem Estar Familiar no Brazil):
This Rio de Janeiro based family planning organization is a long time recipient
of USAID support. The Prosex condom, introduced by
BEMFAM in the mid-90s to generate funds to subsidize their family planning
activities, is a repackaging of a local product from the manufacturer INAL.
BEMFAM has invested a great deal in infrastructure (packaging and printing
equipment) and they are prepared for growth that may or may not be forthcoming.
They are competition for DKT and a diffusion of USAID resources directed at
achieving sustainable social marketing operations in Brazil. Yet, BEMFAM has an
important place in Brazil’s reproductive health community and the condom market
is big enough to support both organizations on a cost recovery basis but not much
more. Each organizations social agenda and low gross profit margins results in
even lower net profits, once overheads are covered. Intensive impact driven
AIDS promotion marketing will always require external support given these low
profit margins, and lack of internal cross-subsidy options, of both DKT and
BEMFAM. For the Prosex line of products to contribute
significantly to BEMFAM programming, it will have to expand, diversify its line
of products (for cross-subsidy purposes), and maintain a commercial margin of
profit.
Instituto
Ethos: [Companies for Social
Responsibility] was created to help businesses to understand and to incorporate
the concept of social responsibility in the day to day administration of their
respective organizations. The practice of social responsibility is
characterized by a permanent concern with the ethical quality of their
relationships with workers, public collaborators, customers, suppliers, the
environment, and communities where the businesses reside. Founded in 1998 by a
group of entrepreneurs, Instituto Ethos now has
hundreds of associated companies, whose combined revenue is approximately R$
250 billion or 25% of Brazilian GDP. These companies employ approximately one
million persons. This organization presents an opportunity for Social Marketers
to access workplace environments with behavioral impact messaging and product.
Conselho
Empresarial Nacional en VIH/SIDA: The National HIV/AIDS Business Council - The GOB/MOH has
announced that this group comprises 24 large firms which run AIDS prevention
activities to over four million employees. This is an effort to decrease
discrimination against those in the workplace living with HIV/AIDS. It presents
an interesting venue for the Social Marketing Organization (SMO).
JSI/Brasil: JSI is the local representative for SSL Durex condoms and they have won several bids to supply the
GOB with condoms. They may become a player in the social marketing mix of
providers in Brazil in the near future. Miguel Fontes, JSI/Brazil Director, plans
to have an approach based on behavior change rather than price alone. However,
it is unclear if they have the wherewithal in resources or strategic
development to accomplish this goal successfully. Miguel Fontes is also the
founder of Instituto
Promundo based in Rio de Janeiro, and he has written
a book in Portuguese on some new directions in social marketing, while his
Deputy, Cecilia Stodart, in Brasilia has a background
in Health [behavior change] Communications.
Local
Condom Manufacturers/Importers: These
organizations include INAL (Olla brand and others), Blowtex (a major supplier
of commodities to health posts via contract), Blausiegel (Preserv
brand), Life Med (FunnyLove brand), Trade Center
(Eros brand – NE focus), and Johnson and Johnson (Jontex
brand – market leader). Jontex is the market leader
and has the highest prices of all brands on the market. They engage in extreme
tactics to maintain their market share. Example: 300 cases of Prosex were returned to BEMFAM by a retailer, when Jontex discovered that their “market” in São Paulo had been
penetrated. J&J covered the retailer’s expenses and assured their market
share. Large retailers in São Paulo require vendors/suppliers to purchase shelf
space to display their products guaranteeing a minimum coverage of overheads.
High sales volume and diversification of one’s product line assures the
supplier of good shelf space, lower rates, and non-competitive product
agreements with the retailers. Social marketing organizations will have to
break into the market that these competitors control before they can be
securely sustainable. To do this, they have been told by the distributor
network that mass media advertising would be required.
Quality
Control Laboratories: There are at least
three important labs engaged in testing products for Brazilian consumption. These are Instituto Falcão
Bauer (SP), Laboratório Falcão Bauer (SP), and INT in
Rio de Janeiro. Brazil has some of the most
stringent testing requirements in the world for imported condoms. Each imported
“lot” (a quantity of condoms produced at the factory from the same
batch/formulation of raw material) of condoms must be tested before it can be
released to the marketplace. Certain exceptions have been noted, however, such
as the GOB importation of condoms, which arrived at the last moment for
distribution during Carnival 2002. Although protectionist trade practices have
somewhat been abolished by legislation in Brazil, the “Administrative Culture”
of the bureaucracy tends to still favor local producers and economic powers in
the local economy. The lot by lot testing assures a quality product and is very
costly to importers, such as social marketing organizations. Local
manufacturers have periodic checks made at their factories instead of lot by
lot testing, reducing their cost to bring a product to market.
Market
Research Organizations: Market research
is necessary to understand trends in the marketplace. Condom salesmen use the
statistics generated to negotiate distribution, shelf space, and price at the
distributor level. Some also do behavioral analysis of the marketplace and can
help a sales organization design packaging, advertising, and identify new
markets or places/areas where the product might be sold. The Nielsen
organization leads this group in influence. Others that are important in the
various “niches” they target are: Sinal, Research
International, CEPAC, CPM Research, Indicator, Alpha Leader, IBOPE, Gallup, and
CBPA. The services these organizations provide range from focus groups to KAP
surveys to media reach surveys. Many are expensive and out of the reach of
social marketing organizations’ budgets. It might be effective to partner one
of these private sector research organizations with a social sector researcher
to bring together the best each has to offer.
Major
Advertisers: The website http://www.ibest.com.br/site/parceiros/listasoesp.jsp
lists 132 pages of advertisers in São Paulo alone. There are local resources
available for all aspects of the behavior change marketing promotion and
advertising component of the social marketing strategy. [Brazilian] Consumer
psychologists may have to be utilized for technical assistance on an as needed
contract basis.
Consumer
Psychologists: A consumer psychologist
is one who analysis consumer behavior patterns to determine the most effective
way of presenting messages in a given context. The Brazilian Psychological
Association and/or the American Psychological Association (APA) and the Society
for Consumer Psychology could be valuable partners in the analysis and approach
to addressing sexual behavior patterns in Brazil and the remedy for low condom
usage. The “Society for Consumer Psychology” is concerned with fostering
scientific research, development, and practice in the field. This Division of
the APA is concerned with those aspects of individual and social psychology
demonstrated by people as consumers of goods and services. It represents
psychologists and other consumer researchers working in the fields of profit
and nonprofit marketing, advertising, communications, consumer behavior, and
related areas.
B. Key Issues
The situations presented here have both positive and
negative influences on the implementation of a comprehensive [social] marketing
strategy for AIDS prevention.
§
policy – US policy
and commitment to address abstinence, fidelity, and delayed sexual debut is not
readily embraced by Brazil’s NACP and CN. A priority of the GOB is to develop
the MOH sanctioned social marketing condom. They do not yet have the authority
to offer the benefits that would attract importers and local manufacturers to
participate in the effort however. Placing condoms on the MOH’s “essential
medicines [commodities] list” has been talked about in Brazil for the past ten
years and remains an unresolved issue.
§
resource availability –
The existing network of NGOs and PVOs involved in
HIV/AIDS prevention do not appear to be positioned to address the
communications needed to implement a comprehensive Behavior Change [Social]
Marketing strategy. The social sector partners do not currently use Consumer
Psychologists for example, nor do they maintain a network of contacts within
the media and cinema production companies. There are however sufficient
resources within the greater private sector community of Brazil to recruit
from.
§
private sector involvement - Generally
speaking, the private sector has a lot to offer AIDS prevention efforts in
Brazil. There are large networks of socially aware enterprises which have
already expressed some interest in dealing with the issue of AIDS.
Approximately four to five million employees are represented through these businesses.
Additional involvement can come through media organizations, actors’ guilds,
etc. which has been done on a limited basis in the past. The “private sector”
should also include resources not typically utilized in social sector,
international development programming, and that is private sector scientists
involved in the research and analysis of consumer behavior, such as consumer
psychologists.
§
geographic distribution – Although social marketing efforts are nationwide, AIDS prevention
messages are concentrated in areas funded directly by USAID to DKT and BEMFAM.
São Paulo is grossly neglected in this sense due to market forces beyond the
current control of either of the SMOs. The increased budget for social
marketing activities may open the São Paulo market, which is the largest and
most important in the country. It also represents one of the most highly
infected areas of Brazil. No area of AIDS prevention programming should receive
less funding than it currently receives, however the South and border areas
need special attention due to their own set of problems as outlined in this
document.
§
Focus – The social marketing efforts in Brazil, due to market
demands for sustainability, are generalized, for the most part, with the SMOs
subcontracting to a number of population specific NGOs for niche market
penetration. By definition, these niche activities do not produce “impact” in
that they do not reach a very large segment of the population at the national
level. NGO involvement via social marketing does not seem to be part of a
strategic design but, rather, an opportunistic effort to address specific
problems. The comprehensive behavior change [social] marketing strategy
presented in this document can change this phenomenon by facilitating the focus
on behavior change at every level of NGO involvement.
As with many things,
there are exceptions. The DKT hotline, operated by Centro Corcini,
has a national reach and shows great promise in making contributions to
knowledge, attitudes, and practices research regarding condom use and sexual
practices. And, Aliança Luz, a Ceará based NGO,
satisfies the need to open social marketing condom non-traditional
distributorships in the smaller communities, following the trend of the
epidemic. Currently the latter NGO only operates in one NE state.
C. Conclusions
Consensus
is needed on the part of the stakeholders to look into issues that are
important to both the Brazilian government and the US government, with USAID/
Brazil’s assistance. The CN along with the activist NGO community is committed
to condom use as the [primary] means of combating AIDS. It is unlikely they
will participate in messaging that does not involve condom use as an
option/requirement. The sentiment that the Church has and continues to damage
AIDS prevention efforts through its campaign to discredit condoms was expressed
frequently during this assignment. Bishop Jayme Chemello, President of the National Conference of Bishops
in Brazil, said in his March 2002 interview in Veja
magazine that “condoms stimulate youth to have sex before they are ready” and
he went on to say that they should never be used. However, in some places
around the world, the Church has said “Use condoms to prevent death, not to
prevent life.” A fully participatory
strategic [implementation] planning workshop by major stakeholders will be
necessary, following the preparation of a series of documents which would
provide a Brazilian context for the Consumer Psychology [behavior change] applied
theory.
There
is a place for diverse ideologically founded AIDS prevention activities. The
need is for a technically competent behavior change marketing specialist or
consumer psychologist to facilitate the development of effective theory based
behavior change messaging protocols for each of the concerned parties in
Brazil. This could be a
local/international advertiser or an individual (PSC), or foreign service
officer who would develop performance based contracts/ subcontracts with local
implementers in counsel with relevant stakeholders. The technology and the
science are available if the social sector can adapt that which has been
successful in the private sector commercial marketplace.
The
social marketing organizations in Brazil are not presently equipped, with
personnel or institutional knowledge, to handle the demands of a long term
strategic marketing/ communications campaign. The local SMOs are sales and
distribution organizations and, although they can contract additional personnel
to handle the effort, it could negatively impact their efforts for long term
sustainability. A behavior change marketing operation apart from the SMOs could
provide technical assistance to all behavior change [social] marketing
activities and reach well beyond product sales objectives and facilitate the
transference of new skills to the NGO community.
The
goal of the behavior change marketing strategy is to impact behavior at the
social and cultural level. Individual behavior change will be patterned after
what individuals perceive to be the norm. These things happen season by season
in the fashion world and they can happen as fast and with greater permanence,
with strategic message reinforcement protocols in AIDS prevention programming.
V. Behavior Change [Social] Marketing
Strategy
A guide is needed for all levels of HIV/AIDS programming
and strategic planning. If a known
guideline were followed, the results might be more consistent on a global
scale. The social [behavior change] theories that form the foundation for the
strategic approach addressed in this document are:
- Diffusion of Innovation
Theory (Rogers, 1983): People are more likely to adopt new behaviors based
on a favorable response to the idea presented by key influencers in
society at large or persons in
society whom they respect. It has been projected that changes in behaviors
which place a person at risk of HIV transmission can be initiated when
enough key opinion leaders adopt and endorse the more protective set of
behaviors. The desired behavior(s) domino through the community to
establish the “norm.”
- Social Influence Model
(Howard, 1990): This is an educational model based on young peoples’
engagement in behaviors because of general societal influences, and
specifically from their peers. “Peers” in this case refers to slightly
older individuals looked up to by the younger ones. These could be school
leaders, church group leaders, gang leaders, or community sports icons.
- Social Network Theory: This
theory posits that it is critical to understand one’s broader social
network and particularly those who serve as “reference people” and who
sanction behavior. Social norms are best dealt with at the level of social
networks. “Bridge populations” were addressed utilizing this theoretical
framework in Thailand (Morris, 1997).
- Theory of Gender and Power:
This theory helps guide the development of interventions for women in
heterosexual relationships taking into consideration how a woman’s
commitment to a relationship and lack of power can influence her risk
reduction choices (DiClemente, 1995).
“…let’s choose to unite the
powers of markets with the authority of universal ideals. Let us choose to reconcile the creative
forces of private entrepreneurship with the needs of the disadvantaged and the
requirements of the future generations…”
Kofi Anan
Each
professional discipline naturally thinks of their respective planning process
as the one best suited for obtaining the results needed in their “line of
business.” Health Promotion is a line of
business assumed by local health posts, Municipal and State Departments of
Health, National Ministers of Health, and Global Health Promotion and Social
Development institutions. If we
translate the jargon of any discipline’s strategic planning process to everyday
language, we would most likely arrive at the same set of activities, such as
those that follow, with additional wording that is specific to the current
effort:
§
investigating to
clearly understand the current situation – listen, observe, analyze and
identify key [behavioral] influencers and relevant stakeholders.
§
planning to
intervene to put things more in line with one’s objectives, in consultation
with stakeholders
§
taking action to
effect change – organize and implement the strategy, maintaining a common focus
in all activities
§
reviewing what was
done, to identify “best practices” or “lessons learned” utilizing behavior
and biological indicators in the evaluation process
§
applying the newly
acquired knowledge and repeating the aforementioned process or proclaiming that
what has been done is a “benchmark” that all others should aspire to in the
respective discipline and try to maintain the successful level of performance.
When a process that was put in place by predecessors of
an organization’s current leadership is required for one reason or another, it
is increasingly difficult for new leadership to consider new possibilities even
when new issues emerge that need special consideration. Corporate or Institutional culture, and
Administrative Heritage are some of the labels assigned to this phenomenon,
which has been documented in a number of Management texts. For change to occur in organizations,
commitment has to come from the top and must be supported all the way through
the organization (public, private, or social), whatever the process of change
is called.
A new approach is needed to make a difference in HIV/AIDS
Prevention Programming.
What process of change seems to work everywhere in the
world? “…the creative forces of private
entrepreneurship…” and “the powers of markets with the authority of universal
ideals…” are phrases which bring to mind the processes which have converted
populations around the globe to Coca Cola, trendy fashions (torn jeans),
Tabasco sauce, and many other products.
Marketing is a strategic planning process/model that is rarely explored
to its fullest potential, especially when it comes to not-for-profit
ideals.
Social Marketing is nothing more than utilizing private
sector commercial marketing practices on behalf of a social cause. It is [optimally] free of deceit and immoral
practices often associated with over-zealous salespersons and advertisers. It is, like Marketing, a motivating system of
presentations that stimulates the adoption of new behaviors – If done well, it
can be a process of changing behaviors without detailed cognitive processes
involved. Typical [product] social marketing practices include things like:
1.
labeling, packaging,
branding a product or service for easy identification
2.
determining pricing
that corresponds to the low-income consumer’s willingness to pay
3.
promoting/
advocating taking ownership of the cause or social benefit or personal health
improvement mandate, and
4.
selecting the most
appropriate population group(s) and where/how to expose them to your cause,
good, or more specifically, to the desired behavior
The steps above are pretty much standard fare. With its motivating principles founded in the
commercial marketplace, the Marketing strategic planning process goes much
further in analysis of a situation to include many more factors which might
either positively or negatively influence the population focus [target]
adopting the desired behavior. Steps 3
and 4 above, when carried out strategically and with great forethought carry
much greater weight/influence than passing out condoms during Spring Break or
Carnival. For example a cigar smoked by a famous actor in a popular movie could
conceivably start a national trend. The “trend” dies after a time when it isn’t
reinforced periodically. Some people feel that marketing practices are
manipulative and one would have to agree, given that marketers manipulate
emotions, cognitively and subliminally, to stimulate consumers to adopt new
behaviors. Subliminal presentations often have stronger suggestive power than
direct messages. Brazil has experienced this process on behalf of the social
sector previously, in their televovelas, as mentioned
elsewhere in this document.
Many social sector organizations perform only a partial
role in the Marketing strategic process with the assumption that donors, MOH or
NACP officers have performed the prerequisite detailed planning exercise. These “partial role” organizations refer to
themselves as Social Marketing Organizations (SMO) when they would be more accurate
to call themselves one or more of the following:
§
Social sales
organizations
§
Social advertising
organizations
§
Social
communications/education organizations
It is past time to show reliable and verifiable results
in the struggle against AIDS. Condom
sales levels may be appropriate indicators for social sales organizations while
knowledge and attitude indicators may suffice for social communications
programs. However, a fully implemented
strategic marketing intervention on a national or regional/trade bloc scale can
be evaluated using biological and behavioral indicators (STD reduction, decline
of HIV incidence, delayed sexual initiation, reduction of sexual partners,
strict condom usage).
Saturating the market with condoms doesn’t let us know if
they are being used in the situations when they are most needed. There are two ways to proceed. We have to
learn why they aren’t used each and every time a sexual risk behavior
occurs. Or, we have to popularize
condom use so that non-use is stigmatized as irresponsible, uncaring, and
unacceptable behavior. Based upon my observations, male condom use
is generally associated with wanton behavior, distrust, a lack of intimacy and
therefore the sex act is perceived as abusive rather than personal and loving.
How do popular products become so widely acceptable and
consumed? They are perceived to be “in”
or “cool” and other benefits are only secondary to how we believe our friends
and acquaintances perceive us when we obtain and utilize products that are
“popular.” “Everyone is doing it…” Even the argument
that [sensitivity is lost] will disappear when the usage behavior is accepted
as desirable and normal (“popular”). There are bountiful examples of this in
all of society. And, many of contemporary fashions are far from comfortable.
The process of popularizing a product comes from
strategic placement of a message, concept, or product in telenovelas,
cinematic presentations, magazine articles, paperback novels, comic books, news
programming and other venues via the Key Influencer, either in the form of an
admired actor or story character, respected politician, sports figure, or media
personality. This is achieved at the same time that a mass media advertising
campaign is carried out with public relations and promotion activity too. It is
a coordinated and planned subliminal and cognitive presentation of the desired
behaviors by influential members of communities and society at large. This
process is carried out every day in the commercial marketplace.
A. Recommendations
- Given the scope of what
needs to be done regarding behavior change in Brazil, I propose that an
entity be put in place to facilitate maintaining the necessary focus over
all USAID funded NGO/PVO participation in HIV/AIDS prevention efforts regarding
behavior change via the use of [social] marketing practices. In the past,
efforts have been scattered over many implementers, each with their own
separate agenda that has sometimes diffused the energies of the USAID
funded activities. The focus should be on sexual behavior change with
evaluation indicators reflecting that focus. Although projects claim that
behavior change is at the core of what they are about, it has not been a
part of their strategic process and rarely has behavior change been evaluated
using baseline and follow up studies.
As part of the entity’s SOW, they could sponsor workshops to help
standardize the strategic planning process. The perception is that planning
protocols are already in place yet the epidemic continues and the “institutional
culture” of most government bureaucracies and PVOs/NGOs
continues with well-meaning but ineffective/incomplete strategies.
- Using commercial marketing tactics, I propose that this
behavior change marketing entity bring all of the stakeholders together to
guide them through the process of strategic involvement. They must feel
that they have had a part in the strategic development before they can
assume “ownership” of the effort which is necessary to elicit their full
support. The currently operating NGO’s comparative advantage to address
one or more of the components of the behavior change marketing strategy
could be identified in this process, if not already known, and performance
based contracts could follow, once consensus is reached on the important
aspects of the initiative. Behavioral baseline studies should commence as
soon as possible and efforts monitored closely and collaboratively with
the stakeholders.
3.
Enhance the
information gathered in monitoring and evaluation protocols by adopting
behavioral and biological indicators such as:
§
STI exposure in the
past 6 months
§
condom use in last
anal sexual encounter
§
condom use in last
vaginal sexual encounter
§
non-condom use in
last 4 sexual encounters
§
proximity to
affordable condom vendor
§
number of casual
partners in past 3 months (6 months?)
§
Frequency of
exposure to Icon/Key Influencer support for safe sexual practices
§
Condom use when
“High” (Drug/Alcohol use)
4.
Since these
indicators are intended to evaluate the effectiveness of the behavior change
marketing efforts, the current SMOs could continue to utilize sales and
distribution statistics as indicators of their effectiveness in doing what they
do. The claim by DKT is that they can not survey the populace near where their
condoms are sold because their distributors won’t tell them where they sell
them. Distributors respond in this way because they fear competition from the
importer themselves.
5.
Promote quality as
the main feature of social marketing condoms and utilize the Key Influencer(s)
to modify the social norm relevant to condom use.
- Future Directions
Messages
can be conveyed through the marketing activities that will impact, in addition
to condom use, the delayed onset of sexual initiation, fidelity, personal
responsibility and respect for others. The marketing process includes the
training and sensitizing of TV/ Radio/ Cinema/ Newspaper and Magazine writers,
editors, producers, directors, and executives. Cultural icons should be brought
in to the network and nurtured to be supportive of the overall effort of
behavior change. Public figures of all kinds should be brought into the network
of “key influencers” for the desired behavior change. Telenovelas
could be encouraged to adopt programming that features the desired behaviors exhibited
by a favored “star.” A new concept for a telenovela
or “reality” show could be collaboratively produced with committed and
concerned persons from the media industry, such as “Sex in the City” or “Queer
as Folk” (Cable network programs in US and EU) that feature sexual issues as
their primary focus. The main thrust is to keep your message
alive through the Key Influencers of society and present it following
recognized behavior change models/theory.
This
approach of behavior change [social] marketing addresses the needs of many
audiences. Conservative and liberal thinking agendas both can be addressed
without infringement on the other point of view. Differences of opinion often
deal with nuances rather than the big picture. Once agreement can be reached on
the broad strokes, the various mechanisms at the detail level can be worked
through. The identification of Key Influencers must be done through research
not by anecdote or political pressure. Also, rarely can social norms be changed
in a few years via small groups. It may be important for other reasons to keep
small groups funded, but large scale impact must have large scale input. In all
project activity, we must remember that education does not necessarily mean
influence, that knowledge does not often enough translate into behavior change,
and low prices and easy access do not necessarily make one a committed condom
user.
It is envisioned that the BCM (Behavior Change Marketing)
approach will take off once a person(s) is in place at USAID to coordinate the
activities. The first step would probably entail significant research to
identify relevant “motivators” for vulnerable populations and groups at
increased risk, and Key Influencers (KI) that are influential at a national
level regarding the behaviors and specific group(s) in question. Consumer
psychologists, advertisers, and social sector behaviorists should collaborate
early on to detail the ensuing campaign and prepare culturally relevant
background material. A workshop for writers, journalists and those KI that have
been identified should then be brought together for a stakeholders’
meeting/workshop, sponsored by USAID and the CN, to elicit wide support for the
principles of the BCM model.
Each NGO community would be guided through the process of
developing their own implementation plan of nurturing Key Influencer (KI)
support favorable to their primary audience. National level KIs
would be developed by the CN and the USAID coordinator. The establishment of a
new “social norm” will be the objective by each NGO and the national level
effort. One NGO might have fidelity as their desired social norm, while another
might have strict condom use as their desired norm. The national effort would
focus on a mass media advertising campaign with reinforced messaging presented
with subtlety via telenovelas and the cinema, while
other presentations might focus on product quality and accessibility. The
workshops would sensitize and educate KI writers and journalists, politicians,
business leaders, etc. and should be held on a periodic basis to reinforce the
messages and continued support. KI
support and active participation from all areas of society influential to the
vulnerable populations and groups at increased risk is important. And yet other
workshops could be designed to facilitate the development of NGO relationships
with global donor and grant-making organizations for purposes of long term
sustainable programming.
Jontex virtually controls the São Paulo market, which is an
important venue for AIDS prevention and social marketing condoms. Eventually,
J&J’s disinterest in providing a product accessible by the working poor,
for the prevention of AIDS, will reach investors and board members of their
international HQ. International “goodwill” will require that they take action
and either participate in the CN’s social marketing
effort by placing a low cost product on the shelves themselves or they will be
forced to allow their product to compete head to head with the social marketing
brands of Prosex (BEMFAM) and Prudence (DKT), and
perhaps others. It could prove interesting if either Prosex
or Prudence initiated dialogue with J&J to partner with them so that
J&J could avoid devaluation of their condom brand while still meeting the
social requests of the government.
Thus
far, we haven’t come close to fully analyzing the situation and determining
many of the possible angles of attacking the problem. This document presents a strategy that, if
followed, will lead to more complete planning and should lead to greater
success in local AIDS prevention programming, especially to those related to
Social Marketing and behavior change. Too often a budget is established to
pursue an objective prior to determining what needs to be done to accomplish
the objective. This is true for public,
private and social sector endeavors. The private sector can retreat from a
market when failure is eminent and seek easier [more profitable] targets. The social sector can focus on niche symptoms
and never curtail the advance of the problem on society. The public sector is ultimately responsible
and can not retreat. While politics play a role in everything that
is done, dogma and rhetoric present challenges which have to be taken into
account. There are many ways of addressing important issues and all of them
deserve consideration.
Possible new Intermediate Result:
IR3:
Expanded Social Marketing through Behavior Change [Social] Marketing
Communications
3.1 Increased exposure
to Key Influencers with HIV/AIDS prevention messages
3.2 Reduced STI
prevalence in focus areas
3.3
Increased condom use in anal and vaginal
sexual encounters
3.4
Increased proximity to affordable condom
retailer
3.5
Increased perception that Social Marketing
condoms are of high quality and suitable for all sexual activity
Implementation
Options:
1.
Continue the current social marketing of condom activities with BEMFAM and DKT
with increased levels of funding to expand their operations and strengthen
their chances for financial sustainability. Work with the CN to promote condom
use via mass media in São Paulo with special consideration given to social
marketing brands. This may break open the São Paulo market and increase
sustainability efforts of both condom social marketing organizations. Encourage
an expansion of their distribution networks in non-traditional outlets, via the
Aliança Luz model in Ceará, to areas of increased
infection rates in the South. Utilize Centro Corcini
and their Hotline to expand the knowledge of sexual behaviors nationwide.
Introduce a condom that will be perceived to be especially effective in anal
sex practices. Overall, strengthen the perception of quality of the social
marketing brands.
2.
Concentrate efforts in collaboration with the CN. Facilitate in what ever way
possible their efforts to create a nationwide reduction in the costs and
increased availability of condoms. Assist in the funding of mass media
advertising and encourage the policy changes that are necessary to reduce
import taxes on condoms and raw materials for the manufacture of condoms.
Continue activities with those organizations that can demonstrate behavioral
impact. This is the least costly option.
3.
Develop the behavior change [social] marketing strategy that is the thrust of
this document. This will benefit all NGOs involved with AIDS prevention and
particularly encourage the reduction of risk through multiple behavior change
options. Continue collaboration with the CN and enhance programming through
current, effective AIDS prevention partners. Work with private sector and
social sector scientists to develop an effective behavior change strategy,
taking advantage of KIs throughout society, which
will result in the establishment of a set of social norms that will reduce
one’s risk of exposure to HIV/AIDS. Put in place an entity that can facilitate
a focus on behavior change, network with and develop KI support, develop
strategically timed workshops and seminars to strengthen all levels of KI
support and enhanced participation in the effort to affect a new societal norm.
This option is somewhat more costly than option one and potentially the most
effective option available.
C. Strategy Design
A Private
Sector Approach
If you were a global commercial enterprise trying to
enter a new market, you might elect to plan your strategy utilizing the
following guideline. It’s presented here with a social slant and founded on the
behavior theory mentioned previously.
1. Observe and document – Those things which
currently exist within the following “environments”
- Demographics &
Economics of populace: Understand every aspect of the population and
include rates of infection, who is currently infected, migration of
infections between age groups, economic groups, lifestyle groups and
especially “bridge populations,” religious groups.
- Political attitudes,
knowledge, practices and legal obstacles (media restrictions, essential
commodities [medicines], taxation, etc): Is the political leadership sympathetic
to the health crisis? Are any KI in this group willing to stand up and
speak out for condom use as was done in Uganda? Can any be positively
influenced? How? Are there tax structures which interfere
with carrying out the intervention? What would it take to make all systems
complimentary? (Ministry of Health, Ministry of Finance/Economy/Fazenda,
Ministry of Foreign Trade/Affairs)
- Physical/geographical/technological
constraints which could impact delivery of the product or message: Will the diversity of the country affect
the approach or behavior change messaging? Or, is travel difficult from
one area to another? What is the
current flow of goods and services?
Are there other situations made difficult due to these types of
environmental issues?
- Culture [religion, ethnic
tradition, language(s)]: Is the area of one major belief system or many?
How do they interact? Are all
active? Which? What is their desire for society? Have they come together
for any issue? What? Why? When? How? What positive role can they play?
What are the behavior patterns which facilitate transmission?
2. Identify those in the society who can
positively or negatively influence the outcome of your efforts?
- Key Individuals or things
in society that influence the behaviors and attitudes of your targeted
population(s): Who are these Key Influencers (KI) and what motivates them
to act? Are they aware of their
influential role? Have they refused to participate or have they been
asked? Do they, will they collaborate with others?
- Middlemen for all levels of
operations, including distributors of product and messages, and possibly
state and municipal leaders, educators, parents, ministers, traditional
leaders, and anyone you must go through to connect with “targeted” segment(s)
of the population: How are they influenced? Individually and collectively?
Do they or have they ever collaborated successfully?
- Suppliers of commodities,
and supplies necessary for fulfilling your mission: What are their motives and objectives,
concerns? How do they operate? Who are their leaders? How are they influenced?
- Competition for product,
service, time, energy, interest, attention of target(s): What currently exists within the society
or marketplace that distracts one from listening to messages, learning new
things, adapting desired behaviors?
3. Focus or “target” your efforts. Identify what you want
to accomplish [behavior change] and then identify what subsets of the
population will maximize your efforts (based upon risk factors – see below) and
leverage your inputs. You will want to
influence everyone to reduce their risk and be responsible in their actions
toward others while concentrating efforts [focusing] on highest risk behavior
patterns. Reducing one’s risk can include many approaches from abstinence, to
monogamy, to strict condom usage. Not all risks are equal. The following
information was taken from the World Bank site on Confronting AIDS.
- … the average chance that an infected male will sexually transmit
HIV to an uninfected female partner by unprotected vaginal sex is
estimated at between 1 and 2 per 1,000 exposures (in industrialized
countries). The risk of transmission from an infected female to an
uninfected male partner through unprotected vaginal sex is one-third to
one-half as great (Haverkos and Battjes 1992)... Anal sex carries
the highest risk, especially for the receptive partner - between 5 and 30
per 1,000 exposures for the receptive partner.
§
Risk may be highest soon after
infection. Studies of homosexual men suggest that an individual
faces a 10 to 30 percent chance of becoming infected during a single act of
unprotected receptive anal intercourse if his partner is at the early, acute
stage of the infection (Jacquez and others 1994).
4. Determine the correct product(s) or service(s) to
accomplish your objective, specifically with the subsets of the population
(segmented by behaviors rather than demographics) that you have identified and
are focusing on. Example: Fund the development of a condom brand appropriate
for anal sex practices; sponsor workshops for teaching/sensitizing TV writers
and other journalists; network with producers and directors and other power
brokers in the media industry.
5. Determine what the working poor are willing to pay for
condoms to maximize affordability and cost recovery. Perform a WTP
(willingness-to-pay) survey as has been reported on by Foreit
and Foreit (Population Council/Frontiers and The
Futures Group/DC).
6. Identify where to situate your product and/or service
so that you obtain the coverage necessary to both:
- remain relevant to the
targeted cultural patterns and behaviors, and
- build a sustainable
distribution network
7. Promote and advertise - Keep message in front of
target and utilize Key Influencers when and where possible. Maintain an active profile – keep positive
and let the negative consequences of failing to adopt the desired behavior(s)
be known as a matter of fact. Arrange to
have support materials available when and where needed in the language or
format needed to maximize understanding and correct behavior patterns. Assure the public that the desired set of
behaviors are the “new” social norm through creative placement of your product
or desired behavior into public view through key influencers via telenovelas, cinema, print material, and other forms of
media.
8. Plan for sustainability - Prepare a budget for all
“marketing” activities and compare with available budget resources allowed
either by the national political process or global donor community. Once
the difference is established, utilize the same strategic process to resolve
the problem of under-funding, if such exists.
Proposals to charitable foundations and international donor
organizations would be a first option for obtaining necessary funding to
implement your program. Downsizing your efforts will contaminate the entire
strategic approach and should be avoided.
Alternative approaches to accomplishing your objectives should be
considered prior to eliminating them. In The
Mind of the Strategist, Kenichi Ohmae tells us
that we need to pay more attention to the customer than to profitability and
that once customers are satisfied, profits will follow, e.g. sustainability.
-----------------------
VI.
Source/Literature Cited
Books:
1. Avaliação das Ações de
Prevenção ás DST/AIDS e Uso Indevido de Drogas nas
Escolas de Ensino Fundamental e Médio em Capitais Brasileiras, by Maria das Graças Rua and
Miriam Abramovay (Evaluation
of STI/AIDS Prevention Activities and Drug Abuse in Primary and Middle Schools
in Brazilian State Capitals)
2.
The Brazilian
Response to HIV/AIDS: Best Practices. (National Coordination for STD and AIDS.
Brasilia: Ministry of Health, 2000.) UNAIDS
3.
Creating Demand:
Powerful tips and tactics for marketing your product or service, by Richard Ott
4. Marketing Social Revisitado: Novos Paradigmas do Mercado Social, by Miguel Fontes
5.
The Mind of the
Strategist: The art of Japanese Business, by Kenichi Ohmae
6.
The Portuguese
Dictionary, by William Collins Sons & Company
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Contraceptive Use Among Adolescent Women in Northeast Brazil, Studies in
Family Planning 2000; 31[3]:228-238
- Harvey, P.D. – The impact of condom prices on sales in social
marketing programs. Studies in Family Planning, Vol. 25, No. 1, 1994, p.
52-58
- Hearst, N., et al – Reducing AIDS risk among port workers in
Santos, Brazil, American Journal of Public Health 1999, Jan;89(1):76-78
- Jimenez, A.L. – Prevention of sexually transmitted diseases in
women: association with socio-economic and demographic variables, Cadernos de Saúde Pública
2001 Jan-Feb;17(1):55-62
- Luppi, C.G. – Late diagnosis of HIV
infection in women seeking counseling and testing services in São Paulo,
Brazil, AIDS Patient Care STDS 2001 Jul;15(7):391-7
- Sepkowitz, Kent A. – AIDS, the First
20 Years, New England Journal of Medicine, Vol. 344, No. 23 June 7, 2001
- Vieira, E.M. – Key aspects of sexual behavior and safer sex
practice among men in the city of São Paulo, Cadernos
de Saúde Pública 2000 Oct-Dec;16(4):997-1009
Documents:
1.
Acceptability of the
Female Condom after a Social Marketing Campaign in Campinas,
Brazil July 31, 2001 by Galvão, et al.
2.
AIDS: The Brazilian
Experience, Ministry of Health, Brasilia 2001
3.
AIDSMARK Annual
Report, PSI/DKT October ’00 – September ‘01
4. Aliança Luz Relatório
de Atividades, 1997-2001
5.
An Expansion of
Public Policy to Increase access and use of male and female condoms as a
strategy of AIDS prevention in Brazil by Maria Eugênia
Fernandes
6. Aspectos de epidemia
de AIDS na Região Sul do Brasil, 1987-98: evidências de crescimento
diferenciado by Célia Landmann
Szwarcwald for Fundação Oswaldo Cruz
7. Boletim Epidemiológico
AIDS Ano XIV No 02 – 14th – 26th Semanas Epidemiológicas
–abril a junho de 2001
8.
Brazil: Activity
Data Sheet, USAID CBJ FY2002
9. Centro Corcini TeleAIDS Relatório Annual SAC/DKT 2001
10. Condom Social Marketing: Selected Case Studies, UNAIDS
11. Conference Report: Nonprofit Marketing Summit Conference,
Tampa, FL March 16-17 2000
12. Estrutura do Varejo Brasileiro
(Structure of the Brazilian Retail Market) Census 2000, ACNielsen
company
13. Expanded Response Indicators and Performance Measures,
Draft 10-26-01
14. O Que é Barong – Project
description of Barong theatrical group
15. Quick Reference Guide: Indicators & Instruments for
Monitoring & Evaluation of USAID/UNAIDS/WHO HIV Prevention/AIDS Care/STI
Control Programs November 2000
16. Illustrative menu of partnership options in Brazil, USAID
2002
17. Instituto PROMUNDO,
Projeto de Jovem para Jovem
18. Integrated Marketing Communication for Behavioral Results
in Health and Social Development by Everold N. Hosein 2000
19. Integrated Plan of the UNAIDS Theme Group to support the
National Response on STD/HIV/AIDS, Brazil June 2001
20. Mid-Term Evaluation of IMPACT/FHI, IMPACT/MSH, Pathfinder
do Brsil and DKT do Brasil, USAID/Brazil May 2001New
Breakthroughs in Social Marketing: DKTInternational
1996-97 Progress Report
21. Política de
Preservativo na Prevenção ao HIV/AIDS e DST no
Brasil, MOH Brazil 2001
22. Preservativos: Hábitos
e Atitudes, by Sinal Pesquisa, November
2001
23. Proposta Nacionalo Para Ampliação do Mercado do Preservativo,
Ministério da Saúde, Coordenação Nacional de DST e AIDSRevised
Results Framework, SO3 – Brazil 2002
24. Sexual Behavioral Change for HIV: Where have theories
taken us? June, 1999 by Rachel King
25. Social Marketing: An effective tool in the global
response to HIV/AIDS UNAIDS/98.26
26. Social Marketing and the New Technology: Proceedings of a
Washington Roundtable, Academy for Educational Development
27. Summary Booklet of Best Practices, Issue 2 2000, UNAIDS
28. Sustainability, Sustainable Development and the Health
Sector, USAID Center for Development Information and Evaluation, October 1994
29. USAID: Support for Family Planning & Reproductive
Health Programs in Brazil, 11/2000
30. USAID Support for Family Planning/Reproductive Health in
Brazil Summary Report, June 2000 by Merrick, Liljestrand,
and Pielemeier, a POPTECH report.
Websites:
- www.Social-Marketing.com – Research in the Social Marketing
Process by Nedra Kline Weinreich
- www.aids.gov.br/final/inferior_nova.asp - Coordenação Nacional de DST
e AIDS – Brazil’s national
AIDS control program
- www.cdc.gov/nchstp/od/gap/countries/brazil.htm
- Center for Disease Control, Global AIDS Program: Brazil
- www.cia.gov/cia/publications/factbook/geos/br.html
- CIA, The World Factbook – Brazil
- www.dkt.com.br/html/est_007.html - DKT do Brasil Estudos &
Pesquisas
- www.fhi.org/en/cntr/lac/brazil/brazilofc.html
- Family Health International, Brazil
- www.ippfwhr.org/profiles/init2_braziil.html
- Condom Social Marketing (Prosex)
- www.jhuccp.org/pr/h9/h9figs.stm - Condoms
Sold Through Social Marketing ’91-’97 and Condom Use and Sexually
Transmitted Infections, Thailand, ’89-‘93
- www.prb.org/Template.cfm?Section=PRB&te...?ContentDisplay.cfm&ContentID=357 –
Population Reference Bureau 2001 World Population Data Sheet
- www.usaid.gov/pop_health/aids/Countries/lac/brazil.html
- Global Health, Brazil Situation Analysis
- www.usaid.embaixadaamericana.org.br –
USAID Brazil
- www.social-marketing.org/sm.html - Social
Marketing Institute
- www.StevenMobley.com
– Consultant web site
Contacts/Interviews:
BEMFAM:
- Ney Francisco
Pinto Costa, Executive Director
– ncosta@bemfam.org.br
- Marcelo Mendoça, Social Marketing
Coordinator – marcelo@prosex.com.br
- Márcio T. Thomé,
Finance Manager – mthome@bemfam.org.br
Coordenação Nacional de
DST/AIDS, Ministry of Health
- Jhoney Barcarolo,
External Cooperation Technical Coordinator – Jhoney@aids.gov.br
- Alexendre Grangeiro, Deputy
Coordinator – grangeiro@aids.gov.br
- Raldo Benefacio,
Deputy Coordinator – raldo@aids.gov.br
- Rosemeire Munhoz,
External Cooperation Coordinator – rosemeire@aids.gov.br
- Denise Doneda, Prevention Coordinator
– ddoneda@aids.gov.br
- Cristina Camara, NGO Technical Consultant – ccamara@aids.gov.br
DKT do Brasil:
- Craig Darden, DKT Country Director, - cdarden@dkt.com.br
- Marcio Rodavalho
Clemente, Marketing Manager - mclemente@dkt.com.br
- Simone Martins, Manager of Institutional Relations – smartins@dkt.com.br
- Mark
Drew Crosland
Guimarães, Professor Adjunto de Epidemiologia, UFMG, Belo Horizonte drew@medicina.ufmg.br
JSI/Brazil and Instituto PROMUNDO
- Miguel Fontes,
JSI/Brazil Country Director
– m.fontes@johnsnow.com.br
- Cecilia Stodart, JSI/Brazil Deputy
Director – c.studart@johnsnow.com.br
- Bebhinn Ni Dhonaill –
Instituto PROMUNDO - b.dhnoaill@promundo.org.br
Population Council/Brasil:
- Juan Diaz, Brazil Representative – jdiaz@popcouncil.org.br
- Sheri Lippman, Population Fellow – slippman@popcouncil.org.br
USAID:
- Janice Weber, USAID/Brazil Director
- Lawrence [Doc] Odle, USAID Health
Officer – Lodle@usaid.gov
- Jaime Rojas, USAID AIDS Senior Technical Advisor - jrojas@usaid.gov
- Glenn Sessions, USAID HIV/AIDS Technical Advisor – gsessions@usaid.gov
Others:
- José Conçalves Araújo,
Commercial Director, INAL condom manufacturer – iga@olla.com.br
- Maria Eugênia Fernandez, Family
Health Association
- Marco Martinez, Commercial Director, Blowtex condom
manufacturer – martinez@blowtex.com.br
- Cristina
Pimenta, Former Rio de Janeiro representative for FHI/AIDSCAP
- Sandra Aparecida Sozio,
ACNielsen Company Account Manager – Sandra.sozio@acnielsen.com
Annexes
Relative Risk Table from World Bank document Confronting AIDS
BEHAVIOR CHANGE
MARKETING ENTITY Workshops Seminars Technical Assistance BCM via KI BCM via KI BCM via KI Focus Behavior
Group Focus Behavior
Group Focus Behavior Group Product/Service Promotion Campaign w/KI NGO Community NGO Community NGO Community BCM Mass Media Campaign w/KI Marketing Consultants Consumer Psychologists Social Sector Behaviorists Media Network Research Organizations DKT do BEMFAM/Prosex GOB/MOH/CN USAID/BRAZIL
Possible Structure: