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Marketing HIV/AIDS prevention: challenges to implementation and sustainability Gill, Jaspal 1998

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Marketing HIV/AIDS Prevention: Challenges to Implementation and Sustainability by Jaspal Gil l B.A. , University of Victoria, 1996 A Thesis Submitted in Partial Fulfilment of The Requirements of the Degree of Master of Arts in The Faculty of Graduate Studies School of Community and Regional Planning We accept this thesis as conforming to the required standard THE UNIVERSITY OF BRITISH C O L U M B I A September, 1998 ©Jaspal Gi l l , 1998 In presenting this thesis in partial fulfilment of the requirements for an advanced degree at the University of British Columbia, I agree that the Library shall make it freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. It is understood that copying or publication of this thesis for financial gain shall not be allowed without my writ ten permission. Department of Cn rY) m U/lUij f)V) Oi /UOjl/TyiaJ P/dV)^1!^ The University of British Columbia Vancouver, Canada Date DE-6 (2/88) Abstract In North America, statistics indicate an increasing incidence of HIV in youth and young adults. As there is still no cure, disease prevention remains the only option, emphasising the on-going need for effective HIV/AIDS prevention programs and policy. Social marketing offers one approach to influence individuals to protect themselves and others from HIV. Social marketing applies commercial marketing techniques to promote social causes, ideas, and practices with the ultimate objective to voluntarily change human behaviour. The success of social marketing to effect social behaviour change has inspired its application to HIV/AIDS prevention. This thesis seeks to broaden and deepen the understanding of social marketing and its application to HIV/AIDS prevention. The research is two-fold, the first comprises an analysis of the social marketing approach and the second examines the approach in practice. To evaluate social marketing's practical application to HIV/AIDS prevention two case studies are examined, Condomania in Vancouver, B.C. and Project Action in Portland, Oregon. The study aims to identify 1) the impact of the specific social marketing strategies on the target population; 2) common challenges in the implementation process and; 3) barriers to sustaining AIDS prevention programs over the long-term. Using interviews and evaluation studies, the above questions were addressed. The findings indicate positive impacts on behaviours and attitudes regarding condom use, at least in the short-term in Project Action and among females in Condomania. However, no direct cause-effect correlation is possible of the interventions and behaviour change. The case study analysis did highlight impact enhancing attributes that include incorporating a peer-to-peer workshop, continuous and repetitive programming, and emphasising a message to challenge sexual norms among main and long-term partners. With respect to implementation both HIV/AIDS prevention programs faced the following challenges: program opposition from conservative groups, community apprehension, difficulty in reaching ethnic communities, obtaining and collecting representative data, and limited funding. Lesson learned from the analysis include: 1) the importance of community mobilisation to foster support and diffuse opposition; 2) the significance of target population involvement in message design, content, and distribution; and 3) the need for detailed attention to monitoring and evaluation to obtain representative and relevant data necessary in the program implementation process. T A B L E OF C O N T E N T S A B S T R A C T ii T A B L E O F C O N T E N T S iv L I S T O F T A B L E S vi L I S T O F F I G U R E S vii A C K N O W L E D G E M E N T S vi i i 1. C H A P T E R O N E : I N T R O D U C T I O N 1 1.1 BACKGROUND 1 1.2 PROBLEM STATEMENT 2 1.3 METHODOLOGY 3 1.4 RESEARCH LIMITATIONS 4 1.5 OVERVIEW OF CHAPTERS 5 2. C H A P T E R II: L I T E R A T U R E R E V I E W 7 2.1 PART I: SOCIAL MARKETING: THEORETICAL FOUNDATIONS, CONCEPTS AND CONTEXT: 8 2.1.1 History of Social Marketing 9 2.1.2 Marketing Theory 10 2.1.3 Alternative Approaches to Social Change and Heath Promotion 16 2.2 PART II: T H E SOCIAL MARKETING PROCESS AND A I D S PREVENTION 21 2.2.1 The Social Marketing Process: 22 2.3 PART III: SOCIAL MARKETING: A CRITICAL ANALYSIS, CHALLENGES AND WEAKNESSES 28 2.4 CONCLUSION 33 3. C H A P T E R 3: C A S E S T U D Y : P R O J E C T A C T I O N & C O N D O M A N I A P R O G R A M D E S C R I P T I O N 36 3.1 INTRODUCTION 36 3.2 PROGRAM DESCRIPTION : 37 3.3 PROJECT ACTION 37 3.3.1 Target Audience 38 3.3.2 Project Action Objectives 38 3.3.3 Program Components 39 3.4 CONDOMANIA 40 3.4.1 Target A udience 41 3.4.2 Program Objectives 41 3.4.3 Program Components 42 4. C H A P T E R F O U R : R E S E A R C H R E S U L T S 47 4.1 EVALUATION CRITERIA 47 4.2 PART I: MARKETING STRATEGY: PROGRAM IMPACT 48 4.3 PROJECT ACTION 48 4.4 RESULTS 50 4.4.1 Behaviour 51 4.4.2 Attitude 55 4.4.3 Reach and A wareness 57 4.5 CONDOMANIA 58 4.6 RESULTS 59 4.6.1 Behaviour 59 4.6.2 Attitude 60 4.6.3 Reach and Awareness 64 i v 4.7 S U M M A T I V E I M P A C T E V A L U A T I O N OF C O N D O M A N I A A N D PROJECT A C T I O N 64 4.7.1 Impact: Behaviour, Attitudes and Awareness 64 4.7.2 Impressions of Program Impact 66 4.7.3 Program Effectiveness 68 4.8 P A R T II: B A R R I E R S A N D C H A L L E N G E S TO I M P L E M E N T A T I O N 71 4.8.1 Defining the Target Audience 71 4.8.2 Campaign Design and Promotional Challenges 72 4.8.3 Program Opposition 74 4.8.4 Corporate/Private Sector Barriers 75 4.8.5 Competition and Community Support Building 76 4.8.6 Outreach in Ethnic Communities 78 4.8.7 Monitoring and Evaluations 79 4.9 P A R T III: B A R R I E R S TO SUSTAINABILITY 81 4.9.1 Funding 81 4.9.2 Government/Political Barriers 82 4.9.3 Campaign Approach and Audience Relationship 83 4.9.4 Inslitutionalisation 83 4 . 1 0 F U T U R E OF T H E P R O G R A M S : 84 4.10.1 Project Action 84 4.10.2 Condomania 84 5. CHAPTER 5: SOCIAL MARKETING AND AIDS PREVENTION: LESSONS LEARNED AND RECOMMENDATIONS 86 5.1 INTRODUCTION 86 5.2 I M P A C T OF M A R K E T I N G S T R A T E G Y : IMPLICATIONS TO P R A C T I C E 86 5.2.1 Peer-to-Peer Approach 87 5.2.2 Repetitive/Continuous Message 88 5.2.3 Selective A wareness 89 5.3 C O M M O N I M P L E M E N T A T I O N A N D SUSTAINABILITY BARRIERS L E S S O N L E A R N E D - IMPLICATIONS FOR P O L I C Y , P R A C T I C E A N D R E S E A R C H 89 5.3.1 Community Mobilisation 90 5.3.2 Campaign Relevance/Design 92 5.3.3 Outreach in Ethnic Communities 93 5.3.4 Monitoring and Evaluation 93 5.3.5 Competing Behaviours and Organisations 94 5.3.6 Funding 95 5.3.7 Inslitutionalisation 96 5.4 S O C I A L M A R K E T I N G T H E O R Y TO P R A C T I C E : A F I N A L C O M M E N T 98 6. REFERENCES: 101 A P P E N D I X A P P E N D I X 1: B E H A V I O U R A L THEORIES 106 A P P E N D I X 2: S U R V E Y QUESTIONS 110 A P P E N D I X 3: PROJECT A C T I O N M E D I A C A M P A I G N . . .113 A P P E N D I X 4: C O N D O M A N I A M E D I A C A M P A I G N 117 V LIST OF T A B L E S T A B L E 1: S O C I A L M A R K E T I N G V E R S U S C O M M U N I T Y PARTICIPATION 3 2 T A B L E 2: C O N D O M A N I A ' S C A M P A I G N 43 T A B L E 3: C A M P A I G N T H E M E S 4 4 T A B L E 4: C O N D O M U S E 51 T A B L E 5: H I V P R E V E N T I O N IN T H E PAST M O N T H 53 T A B L E 6: H I V / A I D S P R E V E N T I O N - A C T I O N S T A K E N 52 T A B L E 7: L O C A T I O N S W H E R E C O N D O M S W E R E O B T A I N E D 53 T A B L E 8: C O N D O M ACQUISITION 54 T A B L E 9: E X P O S U R E TO A C T I O N M E D I A A N D C O N D O M U S E A T L A S T INTERCOURSE 54 T A B L E 10: S E L F E F F I C A C Y A N D C O N D O M U S E 56 T A B L E 11: I M P O R T A N C E OF C O N D O M U S E 5 9 T A B L E 12: C O N D O M U S E A N D P U R C H A S E 61 T A B L E 13: S O C I A L A C C E P T A B I L I T Y OF C O N D O M S 62 T A B L E 14: M O T I V A T I O N A N D C O N D O M U S E 63 v i LIST OF F I G U R E S FIGURE 1: E X C H A N G E M O D E L 13 F IGURE 2 : S E V E N C H A R A C T E R I S T I C S OF SOCIAL M A R K E T I N G 2 0 FIGURE 3: S O C I A L M A R K E T I N G PROCESS 2 2 F IGURE 4: B E H A V I O U R C H A N G E C O N T I N U U M M O D E L 2 5 v i i ACKNOWLEDGEMENTS I would like to thank the following individuals who helped develop my initial ideas and guided my research: Darren Dahl - Assistant Professor, Faculty of Management, University of Manitoba Penelope Gurstein - Associate, Community and Regional Planning, University of British Columbia Wayne Greene - Director, Health Safety and Environment, University of British Columbia Chuck Weinberg - Chair Marketing Division, Commerce and Business Administration, University of British Columbia Case Study Research: Project Action in Portland, Oregon Condomania in Vancouver, British Columbia Research Support: Sohail Agha - Population Services International, Washington, D. C. Mark Alstead - HIV/STD Education Programme International - Seattle-King County Department of Public Health Gary Goldbaum - HIV/STD Education Programme International - Seattle-King County Department of Public Health v i i i Marketing HIV/AIDS Prevention: Challenges to Implementation and Sustainability 1. Chapter One: Introduction 1.1 Background Social marketing is the application of commercial marketing techniques to promote social causes, ideas, and practices with the ultimate objective to change human behaviour. For the purposes of this research, social marketing is defined by Andreason (1995) as the "application of commercial marketing technologies to the analysis, planning, execution, and evaluation of programs designed to influence the voluntary behaviour of the target audience in order to improve their welfare and that of society." Social issues to which the approach has been applied include environmental protection, family planning, and nutritional programs. Social marketing has been particularly successful in health promotion. The emphasis of the following research is the application of social marketing to AIDS (Acquired Immune Deficiency Syndrome) prevention. There are notable examples of AIDS prevention programs both internationally and domestically. For the purpose of this research case studies will be drawn from Canada and the United States. UNAIDS global reporting indicates an alarming spread of the HIV/AIDS. In April 1997, Executive Director, Dr. Peter Piot of the Joint United Nations Program on HIV/AIDS l (UNAIDS), drew attention to the major challenges and obstacles facing the international community in its efforts to combat the epidemic. In April 1996, there were approximately 3.1 million new infections and HIV/AIDS-associated illnesses causing the death of an estimated 1.5 million people, including 350,000 children.1 In North America the incidence of HIV/AIDS continues to grow. Initially the disease was linked to homosexuals and intravenous drug users. By the late 1980's the disease began to grow in the heterosexual population (Hill, 1989). As the epidemic evolves, more infections are occurring in younger people. From 1975 to 1990, the median age of HIV/AIDS infection fell from 29.6 years to 24.5 years (Health Canada, 1997). The growing incidence of AIDS world-wide and the absence of an effective cure or vaccine leaves few options except disease prevention. The increasing occurrence of HIV/AIDS in younger populations has alarmed health advocates, government agencies, and the public. The epidemic has prompted efforts to develop effective strategies aimed at youths and young adults. 1.2 Problem Statement The above statistics speak to the need for policy and planning for effective HIV/AIDS prevention programs. Successes in the application of social marketing to bring about changes in social behaviour change, such as contraceptive promotion in developed countries, inspired government and NGOs to apply the same principles to HIV/AIDS prevention. The disease's spread, Though decreases of new infections have been noted in some countries, the disease is presently spreading rapidly throughout Asia and countries of Central and Eastern Europe. Given under-diagnosis, incomplete reporting, and reporting delay, UNAIDS estimate that over 7.7 million AIDS cases have occurred worldwide since the pandemic began. 2 particularly among younger people, and the increasing use of social marketing to address the problem has prompted this research. The specific objectives of the research are two-fold. The first consists of a literature review that will discuss the theoretical framework of the social marketing approach, the social marketing process, and its application to AIDS prevention. This will close with a critical analysis of social marketing theory and practice. The second objective will analyse specific case studies that have applied a social marketing approach in their HIV/AIDS prevention efforts to: 1) identify the impact of the marketing strategies employed on the target population; 2) identify common barriers and challenges in the implementation process; 3) identify barriers to sustaining HIV/AIDS prevention programs in the long-term. The rationale behind this research is to further the effectiveness of HIV/AIDS prevention programs that employ a social marketing approach. The intent is to gain a better understanding of the application of social marketing in order to plan more effective strategies and interventions in the future. If more is known of the range of variables to overcome in the implementation process foreseeable challenges are avoided. 1.3 Methodology This study will compare and contrast the efforts of two communities that implemented AIDS prevention programs using a social marketing approach. The programs are Condomania in Vancouver, B.C. and Project Action in Portland, Oregon, aimed at young adults and adolescents 3 respectively. The case study analysis has three research objectives. The first is to identify the impact and effectiveness of the marketing strategies. The analysis of the marketing strategies is based on evaluation studies conducted by Farrell Research Group, under contract for Condomania, and Kaiser Permanente Centre for Heath Research, under sub-contract by the Oregon State Health Division which was contracted by Project Action. The second objective is to identify challenges and barriers in the implementation process common to both programs. In-depth interviews were held with members of the project implementation teams from the respective programs. The qualitative information gathered from the interviews were coupled with information collected from research reports. A similar methodology is applied to answer the third research objective, to identify the future sustainability of the programs. The insights from project managers and individuals involved in the program implementation, coupled with evaluation, will bring to bear the challenges of program design, implementation, and sustainability in the long-term. 1.4 Research Limitations The research limits its scope to two case studies. The case studies are not directly comparable as the target groups are young adults (ages 19-25) in Condomania and adolescents in Project Action (ages 12-21). Other research considerations and limitations are the social and political differences of the two project locations, Condomania in Vancouver, B.C. (Canada) and Project Action, in Portland, Oregon (United States). These differences imply variations in the institutional agencies involved, their political and economic structures, and social systems. Such differences may impact conclusions and findings in a manner that is not clearly tangible. 4 Findings and conclusions are based on die research of Farrell Research Group and Kaiser Permanente Centre. Farrell Research Group's evaluation was a post-intervention telephone survey. A pre-intervention baseline was not established. Meanwhile, the Project Action's evaluation sought input and advice from young people associated with the social service agencies involved in the AIDS prevention programs. As a result, many of these youths were receiving support and assistance from these agencies. The influence of social service agencies on youths in the program design and evaluation may have influenced results in such ways that are not entirely clear, such as a higher than average condom use (Blair, 1995:15). Both studies were conducted on a contractual basis for Condomania and Project Action. Despite the above limitations the thesis research has proceeded. The stated program evaluation reports coupled with one-to-one interviews, are the primary information sources for project description, impact evaluation, and identifying challenges to implementation and sustainability. 1.5 Overview of Chapters Chapter 1 (Introduction) provides a brief overview of the rationale for researching social marketing and its application to AIDS prevention. Discussed are the problem statement, specific research objectives, methodology, and research limitations. Chapter 2 comprises the literature review, an in-depth analysis of the social marketing approach. This chapter is divided into three parts. The first part, covers the background, definition, and principle concepts of social marketing. The second describes the social marketing process with specific application to AIDS 5 prevention. The third is a critical analysis of social marketing. In closing, the problem statement is redefined. Chapter 3 describes the case studies providing a brief overview of the program components and objectives of the two AIDS prevention programs, Condomania in Vancouver, British Columbia and Project Action in Portland, Oregon. Chapter 4 comprises the case study analysis and outlines the research results of the two respective programs. Discussed are the findings pertinent to the three research objectives articulated in Section 1.2. Chapter 5 discusses the research conclusions and their implications to future practice and research. Recommendations applicable to future AIDS prevention programs are derived from the analysis, specifically for programs employing social marketing in their AIDS prevention efforts aimed at adolescents and young adults. 6 2. Chapter II: Literature Review Innovative solutions are required as HIV/AIDS spreads in the developed and developing world. To date, prevention through safer sex practices remains the only viable option to curb the growth of the disease. Experienced health professionals working in the HIV/AIDS field are finding that health communication and promotion strategies alone are inadequate to achieve the necessary behaviour change (Helquist and MacDonald, 1993). Research indicates that AIDS prevention involves a complex set of factors that influence individual behaviour. Beliefs, attitudes, and skills associated with HIV prevention, the availability of services and incentives interact to inhibit or promote safer behaviours (Helquist and MacDonald, 1993). The documented success of social marketing in the health field has prompted academics and practitioners to turn to this approach to address the HIV/AIDS challenge. The following comprises a literature review regarding the application of social marketing in health promotion and disease prevention. The discussion is comprised of three parts. Part I is a discussion of the theoretical foundations and concepts of social marketing and its context in relation to alternative approaches to social behaviour change, specifically education and law. Social behaviour change is defined as attempts to change public attitudes and behaviours. This change is often forwarded via social change campaigns, "organised efforts conducted by one group (the change agent) which intends to persuade others (the target adopters) to accept, modify, or abandon certain ideas, attitudes, practices, and behaviour" (Kotler and Roberto, 1989:6). Part II describes the social marketing process as applied to AIDS prevention and 7 discusses the impacts regarding sexual behaviour. Part III comprises a critical analysis of social marketing. This section reviews literature assessing the strengths and weaknesses of social marketing in theory and practice. 2.1 Part I: Social Marketing: Theoretical Foundations, Concepts and Context: Social marketing is the application of marketing techniques and methods developed in the commercial sector to solve social problems. For the purposes of this research, social marketing is defined by Andreason (1995) as the "application of commercial marketing technologies to the analysis, planning, execution, and evaluation of programs designed to influence the voluntary behaviour of the target audience in order to improve their welfare and that of society." The target audience consists of individuals or groups whose behaviour the marketer is trying to influence. There is some debate over the definition and domain of social marketing. Academics and practitioners maintain diverse views regarding applicability of social marketing beyond the traditional economic domain (Kotler and Andreason, 1991). For the purposes of this research, Andreasen's (1995) previously cited definition is used as it encompasses three key components of the social marketing approach. First, unlike the commercial sector, social marketing seeks to influence social behaviour to benefit the individual and general society; not the marketer. Second, there is an emphasis on behaviour change rather than on awareness or attitude change. Third, the target audience plays a central role in the social marketing process (Lefebvre and Rochlin, 1997). 8 2.1.1 History of Social Marketing Social marketing in theory and practice has been developing over the last thirty years. Kotler and Andreason (1991) highlight three key factors in social marketing's growing application. First, rising costs and limited funds that require many social and public programs to assert their legitimacy. Such constraints acted to change the expectations of public and non-profit organisations. The second, an increasing recognition of the success of social marketing in the public sector. Particularly, the application of social marketing in developing countries which made available cost-effective and efficient family planning services and products. Lastly, the sharp decline in traditional sources of funding from benefactors, government subsidies and grants, to donations by the private sector. The decline of these funding sources increased pressure for obtaining moneys from a limited pool of funds. Managers, in light of these changing attitudes, economics, and political realities sought innovative solutions. The private sector, considered to be more creative, efficient, and flexible, was approached for viable alternatives. Accordingly, private sector management concepts applied to non-profits and public agencies was thought to enhance service delivery, management, and promotion. Social marketing was an outgrowth of this process. The concept of applying marketing techniques to bring about social change began to emerge in the late 60's and 70's. A quote reflecting this untapped potential was articulated by M L . Rothchild (1979) in his article "Marketing Communication in Non-Business Situations or Why Its So Hard to Sell Brotherhood Like Soap." Given the influence of commercial marketing on consumer behaviour, academics 9 and practitioners asserted that these same principles could be applied to improve individual and societal aims (Manoff, 1985, Fine, 1981). Since its inception, social marketing has been avidly applied in the health field from family planning, physical fitness programs, to anti-smoking efforts (Novelli, 1990, Mackenzie-Mohr, 1997, Cassidy and Ramah, 1992, Agha and Davies, 1998, Meekers et al, 1997). Significant impacts of the approach are demonstrated, such as: contraceptive social marketing campaigns resulting in a 21% decrease in the birth rate in Bangladesh between 1970 and 1991 (Kotler and Andreason, 1996); increasing use of oral rehydration therapy in the developing world (Kotler and Andreason, 1991); and AIDS prevention programs that sold over 100 million condoms in sub-Saharan Africa (Harvey, 1997). 2.1.2 Marketing Theory Social marketing applies concepts and techniques developed in the commercial sector for the public good. Social marketing falls into the category of non-profit/public marketing management. Often marketing is incorrectly associated with selling or advertising of products and services -social advertising, rather than a comprehensive management function. The following highlights, concepts, and techniques drawn from traditional marketing that form the foundation of social marketing. Consumer Behaviour Theories of consumer behaviour form the primary base of marketing. Marketing is concerned with the process "by which people adopt, maintain, or discard patterns of behaviour" or the acceptance of ideas and beliefs that precede a behaviour (Lovelock and Weinberg, 1989:10). These theories draw on social and behavioural science, anthropology, and economics (Novelli, 1990). In commercial marketing the study of consumer behaviour and patterns allows the marketer to understand the complex factors influencing customer purchase and use of specific goods and items and reduce them to basic ideas (Novelli, 1990). This understanding enables the marketer to develop a system, methodology, and offer a product which to influence consumer buying behaviour and patterns. Marketing Concepts Marketing seeks to link the objectives of the "internal environment" of an organisation with the "external environment". The external environment consists of constituents (target group) that an organisation seeks to serve or influence as well as those it hopes to influence. Sound management strategy develops a marketing plan to facilitate the relationship between the internal and external environment. The plan functions to develop attractive programs for people and/or organisations that will lead to the desired behaviour change among the target group(s). The marketing planning process, more commonly known as the marketing strategy, has four concepts at its core: exchange, market segmentation, the marketing mix, and competition (Dahl, et al., 1997). These principles underlie the marketing process and guide the techniques and technologies used to influence positive behaviour change, (summarised from Dahl, et al, 1997). 1) Exchange Exchange is a central concept in marketing to describe transaction between parties. Marketing is i i concerned with mutually advantageous transactions between parties. As Kotler and Andreason (1991) assert exchange is the "most useful way to conceptualise the relationship between marketers and their target consumers" (Kotler and Andreason, 1991: 123). Behavioural theory deems a rational individual will behave in a way that is advantageous to them. Every action has perceived costs and benefits, and an individual's behaviours is a reflection of the ratio of benefits to cost. The costs are defined as the sacrifices made to receive the benefits (Andreason and Kotler, 1991). An exchange also involves a degree of involvement. Involvement is defined as the degree of importance or level of concern generated by a product or behaviour (Lovelock and Weinberg, 1989). Market researchers have distinguished between low-involvement and high-involvement exchanges. High involvement exchange, as defined by Andreason and Kotler (1991), reflect a consumer's self-image, present high economic or personal costs for behaving incorrectly, carry a perception of high personal or social risk of a "wrong" decision; and 4) compete with social pressures of an alternative behaviour. When applied to social marketing exchange becomes even more complex. Unlike profit organisations, public and non-profits goals do not always have clear exchange. Many times the exchange involves intangible benefits and costs. Often the marketing efforts aim to influence high involvement behaviours, such as, changing eating habits and practising safe sex. Research into the nature of the exchange allows the social marketer to understand the costs and benefits from the perspective of the consumer, and develop a strategy to minimise those costs. Figure 1: 12 describes the exchange relationship between the marketer and consumer regarding condom usage (Cassidy and Ramah, 1993:91). F i g u r e 1: E x c h a n g e M o d e l Benefits • Prospect o f Healthier Life/ Costs • Money • Effort • Inconvenience • Embarrassment • Fear Arousal • Social Disapproval • Decreased Pleasure Longer Li fe • Sense o f Control • Reduced Anxiety • Protection o f Loved Ones • Achievement • Self Worth Source: modified from Ramah, M. and Cassidy, C M . (1992). Social Marketing and the Prevention of AIDS. Washington, D.C: AIDSCOM, Academy for Educational Development. 2) Market Segmentation Market segmentation is the process of dividing a total market into one or more parts based on distinctive characteristics and attributes. Segmentation is a key organising principle of marketing. Once the unique aspects of a target group are identified, a social marketer can better plan the product and promotion to meet specific needs, desires, and wants. Though the ideal would be to change the behaviour of an entire population, target groups allow a marketing effort to be concentrated, efficient, and achieve more significant results. 3) Competition In the private sector competition refers to the other products and services vying for consumer buying power. In the non-profit sector competition presents itself in various forms. Competition in its most passive form is from the existing attitudes and behaviours that form the status quo that 13 oppose the social marketer's efforts. Often the target audience is reluctant to change behaviours that comprise existing societal norms. The social marketer also competes with other alternative behaviours seeking to better the human condition and that of society, for example alternative transportation and anti-smoking efforts. In its most active form competition presents itself as direct opposition to the behaviour change forwarded by the social marketer. A family planning program may face inhibiting opposition from a pro-life group. Non-profits and publics also compete among each other for a limited pool of funds, program control and management, and organisational territory or "turf. 4) Marketing Mix The last component of the marketing strategy is the marketing mix. There are four broad areas in the marketing mix that work together to promote the desired consumer behaviour. The 4 P's are the essential ingredients of the marketing program. These four variables are interdependent. A change or failure of one can potentially influence the success or failure of a marketing effort. The 4 P's are summarised by Lovelock and Weinberg (1987) with respect to publics and non-profits: 1) Product: Goods, services, and social behaviours offered in the marketplace; 2) Price: Benefits and costs of a proposed action. Extend beyond monetary costs, to costs such as geographic distance, deviations from the social norm, or the loss or change of an activity. 3) Place (Distribution): Place/distribution is concerned with where, when, and how the product is to be delivered to the customer. Distribution connotes the process of disseminating a product. The concept of place takes into consideration the preferences and practices of the target population, which will ultimately impact the accessibility of messages, products and services to 14 the target audience (Lefebvre, 1992). 4) Promotion (Communication): Involves the where, how and what of the message to be directed at prospective customers. It influences the organisation and its products. Novelli (1990) defines promotion narrowly to refer to marketing devices that include coupons, premiums, and cash incentives and communication to refer to the advertising, public relations, and direct marketing (e.g. telemarketing, mail-outs) efforts. The above comprise the marketing strategy which enables an organisation to reach its goals. The strategic process helps to define an organisation's mission, to set objectives and goals, formulate a strategy, and specify tactics (Pornpitakpan and Weinberg, 1997). A marketing strategy offers a disciplined approach to recognising the factors and variables that affect an organisation's relationship with its constituents (customers). Social marketing draws from traditional marketing an understanding of the factors and variables influencing exchange, market segmentation, competition and the market mix (4 P's). But, it does face many distinct challenges which include: non-existent or negative demand: competition with rigid cultural norms and behaviours; high involvement exchanges that involve an individual to consider his/her identity, personal benefits and costs, social/group pressures and cultural norms; benefits which are "invisible" in the exchange where nothing happens or where benefits are transferred to larger society; and limited funding and financial support primarily from benefactors and governments making programs party to public scrutiny, accountability and political whims. Such variables and others pose unique challenges to the social marketing effort. 1 5 2.1.3 Alternative Approaches to Social Change and Heath Promotion A variety of approaches have been developed to influence social behavioural change. Andreason (1995) identified 4 alternative approaches that include, education, persuasion, behaviour-modification, and social influence. Kotler and Roberto (1989) identified four approaches: technological, economic, political/legal, and educational. The following discussion will draw largely from Michael Rothchild's, "Carrots, Sticks and Promises" that identified three broad approaches; education, marketing, and law to manage social behaviour change. A l l three are viewed as strategic tools applicable to public health and social issues. The suitability of one approach over another is dependent on recognising the complexity of the behaviour change involved. Drawing primarily from the work of William G. Ouchi (1980) education was considered appropriate to conditions where information alone will result in voluntary change in behaviour. Such an instance occurs when there is low involvement and if the externalities or (impacts on general society) are low. The force of law is deemed to be appropriate when the impacts on society are high and behaviour change is difficult to achieve. Marketing offers a middle ground for motivating desired behaviours voluntarily. Education Educational approaches assume that the target adopter will make rational decisions. Rothchild (1997:3) defines education as "messages of any type that attempt to inform and/or persuade a target to voluntarily behave in a particular manner, but do not, on their own provide immediate rewards or punishments. Messages that fall into this category include "Just Say No" to drugs campaigns or the health conscious "Just Do It" campaigns by Nike. The education approach begins with the primary assumption that individuals will do the right thing i f they understand the problem or issue and know how to change it. The role of the educator is it to bring facts to the target audience. But as Rothchild states, "education can teach and create awareness about existing benefits, but cannot deliver them, even though the resultant knowledge may have value for long run behaviour in the pursuit of benefits" (Rothchild, 1997:3). Education delivers the message, but it does not offer or deliver an explicit exchange. Rothchild views persuasion, behavioural solutions, and health communications to fall under education approaches. Persuasion ranges from social control and propaganda found in totalitarian systems to the free competition of ideas in democracies to motivate behaviour change. Health communications is defined by Rasmuson, Seidel, Smith, and Booth (1988) as the development and diffusion of messages specific to an audience in order to influence knowledge, attitudes and beliefs in favour of healthy behavioural choice (Rothchild, 1997:3). The educational approach underlies the Health Belief Model used extensively in the health care field. This model views behaviour as a reflection of an individual's perception of the health problem, the severity of the problem, and the cost and benefits involved in the desired action (Andreason, 1995). Though the educational approach has been successful in certain instances, it is criticised by behaviour change strategists in that it does not concentrate on behaviour change. It assumes that an individual will make rational choices that will enhance his/her livelihood. The complexities of social pressures and cultural norms and or environmental restraints are not a part of this model, bringing into question its efficiency and effectiveness. Marketing and law both incorporate aspects of education in their behaviour change strategy. Messages used to inform and persuade are used to support the marketing effort or the enforcement of law. However, ideally education is only one aspect of a marketing or law enforcing strategy. Law Rothchild (1997:4) defines law "as the use of coercion to achieve behaviour in a non-voluntary manner, or to threaten with punishment for non-compliance or inappropriate behaviour". Political and legal measures involve developing public policy and law interventions to bring about desired behaviour change. Intervention can take the form of restricting the production, sale, and use of given items, for example, the sale of cocaine and crack is prohibited. Law can also entail an economic dimension, for example, a carbon tax aimed at reducing vehicle carbon dioxide emissions by impacting the demand on oil, gas, and vehicles. Law is used in instances when education and marketing cannot achieve the desired change. Law is best utilised when a change is desirable to the target audience, but, may not be viable economically or when there is a competing behavioural standard. Marketing Marketing falls in-between the definition of education and law. Kotler and Roberto (1989) define social marketing as a "program planning process that promotes the voluntary behaviour of target audience by offering benefits they want, reducing barriers they are concerned about, and using persuasion to motivate their participation in program activity" (in Rothchild, 1997:4). Marketing departs from education for it offers and brings a direct and timely exchange for a desired behaviour to the audience. Marketing adds choices and shows the costs versus the benefits to the environment while education merely informs the target of available choices. Marketing differs from law in that the behaviour change is completely voluntary, based on free choice and rewards. Under law, behaviour is a coerced exchange and non-compliance is penalised (Rothchild, 1997). The above three categories define the role and need for marketing to forward social ideas, beliefs, and practices. As Rothchild asserts education raises awareness and law coerces in the effort to instil behaviour change. However, awareness does not necessarily translate into behaviour change and law is not always desirable nor ensure effectiveness. Within the realm of liberal democracy marketing offers a tool for social change to influence voluntary behaviour change to benefit the target audience and or the general public. Social marketing is a distinct approach to behaviour management that aims to benefit the individual and society at large. Drawing from commercial marketing concepts and techniques, the social marketing approach is used to analyse, plan, execute, and evaluate programs that are designed to influence voluntary behaviour of a target audience to improve their welfare and of general society according to its current norms and conventions. Andreason (1995) identifies seven key features characteristic of a social marketing approach: Figure 2: Seven Characteristics of Social Marketing 1. Consumer behaviour is bottom line: Behaviour change is a measure of a program's success. 2. Programs must be cost-effective: Social marketers are entrusted with limited resources to influence a desired behaviour change. Strategies employed must be cost-effective and efficient. 3. A l l strategies begin with the customer: Social marketers take a customer-centred approach in their strategies and tactics. Strategies begin with understanding of the customer's needs, wants, values and perceptions. 4.Interventions involve the Four P's: Product, Price, Place and Promotion: these principles comprise the marketing mix and are considered interdependently when developing interventions. 5. Market research to design, pre-test and evaluate intervention programs: Research is the cornerstone of a marketing strategy. Social marketer's take considerable time to conduct formative research and pre-testing. 6. Market Segmentation: Social marketing involves targeting specific groups for strategic purposes. "Marketing recognises that a message cannot be targeted to the individual (which is costly) or the masses (which is ineffective), but must be targeted at a carefully chosen market segment" (Andreason, 1995). 7. Recognition of Competition: Social marketers' recognise the implications of competition on a target group's decision making and behaviour change. Source: modified from Andreason, Alan. (1995). Marketing for Social Change. San Francisco: Jossey-Bass Publishers. In summary, social marketing is a valuable tool to influence social behaviour change to the betterment of individual and/or society. Unlike other approaches to social behaviour change, social marketing is distinct in its ultimate objective to affect voluntary behaviour change. With 20 respect to AIDS prevention, educational programmes comprising of pamphlet and poster development and distribution, and informational programs do raise awareness. But, studies indicate that increased knowledge does not translate directly into behaviour change (Wagman, 1993). The force of law is not a option in the context of liberal democracy (e.g. mandatory testing and control measure for those HIV positive). Social marketing offers a middle ground to both education and law in AIDS prevention. The target audience defines the methods used in the social marketing approach which may involve raising education levels, changing attitudes, and beliefs. The end objective of these efforts is behaviour change. 2.2 Part II: The Social Marketing Process and AIDS Prevention Social marketing utilises a systematic framework and process (Kotler, 1989). This process incorporates strategic marketing concepts discussed above such as exchange, market mix, target group research, and testing in an applicable framework. Part II discusses the social marketing process as it relates to HIV/AIDS prevention. The social marketing process acknowledges internal and external factors acting on an individual to either promote or inhibit behaviour change. Social marketers involved in AIDS prevention draw heavily on health behaviour theory (Fishbein et al, 1997). In practice, AIDS prevention efforts may apply a combination of health behaviour theoretical approaches to form the foundation for the intervention. A few of the common underlying theories include the Health Belief Model (Rosenstock, 1994), Social Cognitive Theory (Bandura, 1994), the Theory of Reasoned Action (Fishbein et al, 1994) and the Transtheoritical Model of Behaviour Change (Prochaska, DiClemente, and Norcross, 1992 in Fishbein et al, 1997). Given the scope of this research a selective review of behaviour theories applicable to AIDS prevention is articulated in Appendix 1. References are noted for additional reading. 2.2.1 Th e Social Marketing Process: Social marketing offers a step-by-step, researched-based problem-solving process. Marketer's have successfully applied the social marketing process to AIDS prevention efforts aimed at reducing high-risk sexual behaviour. The following discusses major steps involved in a social marketing strategy. There are slight variations to this model, but the key elements consist of formative analysis, planning an effective strategy based on research, and a process of continuous monitoring and evaluation to ensure the program is reaching its objectives. Figure 3, from Novelli (1990), illustrates the major steps in social marketing process: Figure 3: Social Market ing Process Source: modified from Lefebvre C. (1992). "Social Marketing and Health Promotion", in R. Bunton and G. MacDonald (eds.) Health Promotion: Disciplines and Diversity. London: Routledge. Refining Plan Elements 4) Implementation 5 ) Monitoring and Evaluation 6) Feedback to First Stage Formative Research 2) Planning 3) Development, Testing, and 1) Analysis -Market research/ 22 A) Analysis: Formative Research Analysis is the first stage of a social marketing process. This initial stage involves understanding the target's needs and their environment (Novelli, 1990, Andreason, 1995, Manoff, 1985). This includes understanding a potential target group's knowledge, attitudes, and beliefs, resistance points, and behavioural stage. Formative research is used to develop the marketing strategy in order that media, distribution, and marketing efforts can be planned effectively and efficiently. As Ramah and Cassidy (1992) stress, an effective message speaks in a language and content that relates to the target group. Market research identifies a baseline of existing knowledge, attitudes, practices, and behaviours (KAPB) of the potential customers. The formative research along with the " K A P B " identify concerns, resistance points, and appropriate distribution channels for the marketing effort (Ramah and Cassidy, 1992). In the case of HIV/AIDS prevention the research can take place in the street, bars, or drug shooting galleries. Tactics for research include in-depth interviews, focus groups, and ethnographic research. Market research reveals the complexity of the consumer decision process. For example, an individual's decision to use condoms involves the interaction of a range of social and environmental factors (e.g. previous experience with condoms, the impact of social perception of condom use, and the perceived risks). Intention, does not necessarily guarantee behaviour change (Ramah and Cassidy, 1992). The accuracy of a knowledge, attitude, practice and behaviour analysis has direct bearing on the 23 effectiveness of a communication strategy. An AIDS social marketing project in Tijuana, Mexico illustrates the importance of assessing a target group's K A P B when developing message content. The project aimed to increase condom use among female sex trade workers. The research revealed that rather than appeals for a longer life, the women were more concerned about providing for their families. The message was then designed to instil in these women the importance of staying alive so they could provide for their children. Messages are developed around the question: "If something happens to you, what will happen to your child?" A small comic book was designed and distributed inside a two-condom pack restating this message (Andreason, 1996). Formative research also reveals market subtleties. A study of older gay men involved in long-term relationships responded more favourably to a message that emphasised responsibility, "Both of us are responsible for preventing AIDS. That's why we use a condom". While young gay men involved with multiple partners and more erotic lifestyles preferred a direct message of, "Use A Condom!" (Ramah and Cassidy, 1992). Market research also reveals sources of resistance. AIDS is invariably associated with sex workers, homosexuals and intravenous drug users as the highest concentrations are found in these populations. This association raises apprehension among conservative groups and members in a given community. AIDS prevention programs have been a point of contention in many communities. The placement of vending machines in public schools and venues have spurred much debate, as witnessed by the Condomania in Vancouver, British Columbia and Project Action in Portland, Oregon discussed in Chapters 3 and 4. 2 4 Lastly, market research identifies the target's stage of behaviour change. Drawing from the Transtheoritical Model referred in Appendix 1, Figure 4: illustrates the Behaviour Change Continuum Model. Interventions are developed according to the stage of the target audience. The aim of the intervention is to move consumers from "unawareness of the need or opportunity to the adoption of a beneficial behaviour". The K A B P data identifies the stage of behaviour change of the target audience. To an unaware target group the marketing strategy would involve raising knowledge levels. To an aware target group the marketer would first determine barriers to action and then proceed to form a strategy to overcome them. For example, among teenagers knowledge of HIV/AIDS may be high, but, cultural norms make the discussion and purchase of condoms embarrassing. In this instance the marketer may concentrate efforts to popularise condom use among teenagers. Figure 4: Behaviour Change Continuum Model Unaware Aware Concerned Knowledgeable Motivated to Change Ready to Try Try New Behaviour Assess Sustained Adoption Preparation Threshold Stages Goal Source: modified from Ramah, M. and Cassidy, C M . (1992). Social Marketing and the Prevention of AIDS. Washington, D.C.: A1DSCOM, Academy for Educational Development. B) Planning After the information has been collected (e.g. about the target audience, competitors, government/political groups, and social-economic aspects as well), the second stage is 25 developing the marketing strategy or the planning stage. The marketing strategy outlines the mission statement, goals, objectives, and scope how these goals and objectives will be achieved (Andreason and Pornpitakpan, 1997). Details of the product, access to product, affordability, promotion, and communication components are defined. C) Development, Testing, and Refining Plan Elements Stage three establishes the organisational structure to carry out the program. This involves establishing an organisational framework to do the marketing effectively and efficiently. Social marketing efforts often function on limited resources and find that forming alliances within a community help to achieve program objectives. Pre-testing is conducted of the product on the target group. It is the customer who ultimately decides the success or failure of a program. Pre-testing can save a program from being completely misdirected or failure. It also allows a program to be fine-tuned or to evaluate alternative strategies and tactics. Pre-testing does not only apply to the communication strategy of a program, but, the entire marketing strategy (e.g. price, the distribution channels, product). D) Implementation, Monitoring and Evaluation and Feedback Stages 4, 5 and 6 involve implementing, monitoring, and evaluation of the marketing program. Andreason (1995) views implementation to be a matter of a clear delegation of responsibility, duties, and projects, and agreed upon time-line to complete projects, detailed planning, and follow-up measures to ensure what is planned is carried out. Monitoring and evaluation are key elements of the social marketing process. Monitoring and 26 evaluation through such methods as focus groups, interviews on the street, and one-to-one interviews allow the marketer to ensure a program's objectives are being met and assess impacts of the program. Monitoring is an ongoing process running the duration of the program. Evaluations are used in formative research to assess a baseline, process evaluations are conducted during the program to ensure effective implementation, and summative evaluation occur at the end of the program to address broad questions of program effectiveness. In social marketing monitoring and evaluation allows the marketing process to be continuous, iterative, and evolving. The feedback identifies gaps in order that appropriate modifications can be made to the marketing program. Indicators to measure effectiveness in AIDS prevention campaigns include: condom sales, falling incidence rates of sexually transmitted diseases, and attitudinal changes (Ramah and Cassidy). In conclusion, social marketing offers a disciplined, systematic approach that is actively being applied in HIV/AIDS prevention efforts. Social marketing grounded in behaviour theory, managed with a sound marketing strategy, a disciplined process, coupled with the application of innovative and creative techniques has proven to be a useful approach in HIV/AIDS prevention efforts targeted at youth and young adults. Though based on a systems approach, social marketing maintains flexibility for the process is cyclical and iterative. Monitoring, evaluation, and feedback in the implementation process allows necessary changes to be incorporated over the program intervention. 27 2.3 Part III: Social Marketing: A Critical Analysis, Challenges and Weaknesses Social Marketing Challenges and Weaknesses Social marketing draws from traditional marketing an understanding of the factors and variables influencing exchange, market segmentation, competition, and the market mix (4 P's). But, it does face distinct challenges which include: non-existent or negative demand of a desired behaviour; competition with rigid cultural norms and behaviours and alternative behaviours; high involvement exchanges that involve an individual to consider his/her identity, personal benefits and costs, social/group pressure and cultural norms; "invisible" benefits where nothing happens or where benefits are transferred to larger society; and limited funding and financial support primarily from benefactors and governments making programs party to public scrutiny, accountability, and political whims. Such characteristics serve as a point of contention among social marketing critics. Theoretical and Ethical Challenges: Criticism has marked social marketing since its earliest inception. Luck (1969) debates the application of marketing concepts and principles outside the conventional boundaries believing such action will confuse its definition and threaten the discipline's identity. Similar opposition was articulated by Carmen (1973) and Bartel (1976). Conservatives of the marketing tradition view the discipline to be grounded in the transaction of goods and services. From this perspective, social marketing does not have a clear "quid pro quo" or exchange, for often there is a one-way transfer of resources, and customer and marketer incentives are unclear. Hastings and Haywood (1994) in response express the need to expand the definition of profit to include 28 indicators such as a "better quality of life" and other non-monetary terms which still translate into benefits and the self-interest of the target audience ( Buchanan et al. 1994, Hastings and Haywood, 1994). Buchanan, et al (1994) express concern about the growing application of social marketing in the health field. They critically consider the application of social marketing as a tool for promoting health, challenging the transferability of marketing principles that typically promote "high-risk behaviour, sugar-fat loaded foods and violence" to the "selling" of good health or the public good. The approach has been regarded apprehensively, particularly the use of advertising to achieve public ends (Wallack, 1990). Hastings and Harwood (1994) on the first point clarify that social marketing is not directly comparable to the profit-focused, private sector marketing. They assert no harm in harnessing commercial marketing concepts and techniques to increase personal and societal welfare and assert that social marketing is not social advertising. Advertising, communication, and promotion comprise only a part of the entire marketing strategy. Countless research studies have correlated poor health to political administration, social and economic ills, and environmental conditions. Social marketing has been criticised for not addressing the core source of such problems (Wallack, 1990). Similarly, social marketing has been criticised for being victim-blaming. Marketing functions on the condition of individual behaviour change which leads to the assumption that the individual is responsible for the solutions to the problem. But, the individual may have little or no control over the root of the problems such as economic status, working conditions, public policies, and laws (Ling et al, 1992). Solutions to such core problems involve fundamental shifts in society. Social marketers work with the recognition that such fundamental transformations may not be obtainable in the near future and seek to understand the psychological, social and environmental constraints that effect and determine behaviour and plan accordingly. Hastings and Harwood (1994) assert a social marketing approach may not resolve the root cause of the problems, but it does attempt to improve conditions in the interim (Hastings and Harwood, 1994). A program emphasis on marketing and sales has raised apprehension on the ability of social marketing to meet end user needs. A sales emphasis can result in a misdirected target group focus and campaign design. As Luthra (1988) points out, in Bangladesh mass media channels such as television and the press are primarily accessible by men and the urban elite (in Ling et al, 1992). She argues that a literacy rate of 16% among women makes public health instructional billboards and newspapers useless to most mothers and others of low socio-economic status. Social marketing is also viewed to be disempowering, particularly when communities become dependant on "outside" products or services. For example, the delivery of oral rehydration package do save lives; but, the target audience is not made aware of readily available self-sufficient techniques. Scepticism is expressed of the customer-centred approach of social marketing. Rather it is believed the emphasis should be on changing community norms and collective behaviours, deemed to be more cost-effective in reaching individuals and families. Referred to as the social 30 influence approach that emphasises changing social norms through campaigns that target the entire community. Social marketers do recognise this approach. Andreason (1995) expressed this approach is more effective in situations where social issues and norms are well understood and expected, pressures to conform are extremely strong, and behaviour to be influenced is socially important and visible. The social influence approach is more effective where there are strong community ties such as rural communities in Africa and India. This approach is difficult to apply in societies based on ideas of individualism where diverse lifestyles, subcultures, and attitudes co-exist such as, North America (Andreason, 1995). A broad-based approach to HIV/AIDS prevention in Western society is helpful in raising awareness. But, many times it can be disregarded by populations practising high-risk behaviours for no relationship is drawn between the health promotion message and their individual lifestyle. Social marketing works on the principle of market segmentation and targeting the marketing effort that best relates to the target audience (Andreason, 1995). Social marketing often is criticised for its top-down approach in program implementation. The hierarchical approach stems from social marketing's underpinnings in business management principles. More recently, there has been a move toward community based social-marketing. Community mobilisation defined by Middlestadt (1997) is the "process of empowering individuals to find their own solutions, whether or not the problems are solved". Community participation does require the social marketer to give up authority and control and may slow down the process. Differing expectations may lead to conflicts over planning and resource allocation. As well, suspicion between the social marketers and community participants may 31 result. The following delineates the differences in the two approaches (from Middlestadt 1997). Table 1: Social Marketing Versus Community Participation Issue Social Marketing Community Participation Definition of Problem/ Expectation Whose behaviour do we need to influence and how? How should we, as community members, address this issue given the overall context of our community? Decision-making Assumes ultimate decision-making authority. Consultation with the target audience, but primary decisions are made from professional analysis and interpretation. Believe control resides with those most directly effected and assume involvement and control of the process. Target Focus Focus primarily on the individual and individual behaviour change View intervention as an opportunity to change the community context in support of behaviour change. Program Development Practitioners may emphasise methodology not necessarily the people involved. Emphasis of community values and perspective to guide program development and acceptability. Formative Research Rely heavily on data to establish measurable behavioural objectives. Rely on intuitive knowledge of their communities, (allows formative research, process to be truncated and cut directly to program). End Product Practitioners have traditionally focused more on program outcomes. Long term sustainability is an important element. View community ownership as essential, to deal with problems long after experts leave. Domestic and international experience demonstrate that programs can be "enriched when social marketers" work in partnership with community-based organisations" (Middlestadt et al., 1997:307). The success is evidenced in programs such as, AIDS Communication Support Project and A I D S C O M . The application of community participation and ownership implies a greater acceptability of programs introduced by social marketers. Manoff (1985) stresses the importance of having community co-operation which can spell the success or failure of a AIDS Communication Support Project (a program providing technical support service to the Centre for Disease Control projects throughout the United States to enable national, state, and local organizations to use health communication, behavior science, and social marketing in HIV prevention efforts) and AIDSCOM (a program that has helped local health planners in over 2 0 countries in Africa, Latin America and Asia devise prevention interventions targeted at populations engaging in high-risk behavior). 32 project. He viewed community involvement not only to be operationally sound, but a political necessity (Manoff, 1985). Practical Weaknesses Practitioners have highlighted distinct weaknesses in applying the social marketing approach. Noted are the time, money, and human resources required to implement an approach which involves elements such as communication development, message distribution, and monitoring and evaluation. The costs incurred with the delivery of a media message, products and services can place a strain on public and non-profits working with limited budgets. Bloom and Novelli (1981) documented a series of practical challenges involved in implementing the social marketing approach. Their concerns included obtaining relevant consumer and behavioural research and data, discerning the relative influence of behaviour determinants, classifying target group segments, designing product concepts, choosing channels and design; "pretesting methods and materials; implementing long-term positioning strategies, and ignoring segments most vulnerable and often most negatively oriented to the message" (Ling et al, 1992:345). Organisational problems include poor understanding of marketing activities and the role of the marketing strategy (Ling et al, 1992). 2.4 Conclusion Social marketing is a theoretical approach to social behaviour change. It draws upon commercial marketing principles and techniques to bring about voluntary changes in behaviour to the benefit of individuals and/or general society. It is a flexible approach drawing upon a range of disciplines and theories of human behaviour to guide its research, development, 33 implementation, and evaluation of its programs. Social marketing sharpens the focus on the public as its central tenet is customer orientation. The customer focus coupled with a systematic, disciplined process has proven to be effective in program design, delivery and public reception (Lefebvre and Rochlin, 1997). It is an innovative tool that has been successfully applied to AIDS prevention programs both internationally and abroad. Social marketing does face many challenges. Often, it attempts to influence a negative demand, high involvement decisions, and changing behaviours rooted in entrenched attitudes, beliefs, and culture (Andreason, 1995). It is by no means perfect. Criticisms speak to the need for further research of social marketing theory and application. Some programs that have applied the social marketing approach have not reached their goals (Weinberg and Pornpitakpan, 1997). "Success is neither universal nor easily achieved" given the implications of competing forces and extensiveness of the social problems (Weinberg and Pornpitakpan, 1997:1). In this respect social marketing in theory and practice is an evolving process. Its iterative process is characteristic of its practical application, where lessons learned are used to improve future programs. Given the increasing application of social marketing in AIDS prevention, it is timely to identify specific challenges and barriers faced by these social marketing efforts. The goal of AIDS prevention programs is to instil behaviour change in the population, that will curb the spread of the disease. The sensitivity surrounding HIV/AIDS poses unique challenges to the social marketer. The research case studies, Condomania and Project Action, illustrate the application 3 4 of social marketing to AIDS prevention. Three research objectives are outlined, to: 1) identify the impact of the marketing strategy employed; 2) identify barriers to implementation; 3) identify barriers to sustainability Specifically, the research will add to the body of literature that researches the application of social marketing to AIDS prevention efforts targeted at youths and young adults in North American communities. Such research is of use to practitioners, academics, and community workers interested in the utility of social marketing in AIDS prevention. It is hoped the lessons learned from past social marketing efforts can be used to augment future development and implementation of HIV/AIDS prevention efforts. 35 3. Chapter 3: Case Study: Project Action & Condomania Program Description 3.1 Introduction The earliest AIDS prevention efforts focused on raising awareness (Debus and Jimerson, 1993). As the World Health Organisation concluded in 1988 these efforts did improve awareness, however, they did not necessarily translate into behaviour change (Debus and Jimerson, 1993). Surveys conducted between 1988 and 1990 in countries world-wide confirmed a universal awareness and fear of AIDS; yet, misinformation of the disease's transmission still existed and few people were taking necessary precautions (Debus and Jimerson, 1993). Acknowledging the weaknesses of past efforts to influence safer sexual behaviour, health professionals searched for alternative approaches to HIV/AIDS prevention. Studies of the social marketing approach indicate a positive correlation to health behaviour change (Kotler and Roberto, 1989). In particular, its successful application to contraceptive marketing programs provided impetus for its application to HIV/AIDS prevention (Debus and Jimerson, 1993; Andreason, 1996; Kotler and Roberto, 1989). The research examines two AIDS prevention programs that have used a social marketing approach Condomania; based in Vancouver, B.C. and Project Action in Portland, Oregon. The two social marketing campaigns in the respective communities are unique in terms of program design, components, and implementation. The research will comprise an analysis of the first six Condomania campaigns as the time period of the intervention corresponds to Project Action in Portland, Oregon. After the sixth campaign, the Vancouver/Richmond Health Department turned to radio and transit "continuous" advertising. Chapter 3 will describe the program objectives and elements of Project Action and Condomania in turn. 3.2 Program Description Project Action and Condomania are both geographically located on the north-western border of North America. Condomania in Vancouver, B.C. and Project Action in Portland, Oregon. Both programs had similar objectives to influence safer sexual behaviour in a young cohort population; youths and young adults. They differ in their institutional framework, specific target population, marketing strategy with respect to the product, price, promotion, and place, and their approach to community participation. 3.3 Project Action Project Action is a demonstration social marketing teen HIV/AIDS risk reduction project carried out in Portland, Oregon from July 1992-December 1994. Project Action was developed by Population Services International (PSI), an international non-profit organisation based in Washington, D.C. PSI specialises in developing social marketing and communication strategies to promote healthy behaviour and health products. The following description is a summary from PSI's Project Action Impact on Teen Risk Reduction report (Blair, 1995). Project Action was PSI's first domestic social marketing initiative. It was a demonstration project, as nothing of its kind to date had been implemented in the United States. The primary 37 objective was to demonstrate the effectiveness of using social marketing to achieve teen HIV/AIDS risk reduction. Funding for the project was by: Henry J. Kaiser Family Foundation/California, Public Welfare Foundation, The Moriah Fund, The Ford Foundation, Stuart Foundation, The David Geffen Foundation, and The Greenville Foundation (Blair, 1995). When Project Action was implemented AIDS had been in existence in the US for 10 years (Blair, 1995). In Portland, there already existed a strong community commitment to prevention demonstrated by state, national, and community AIDS programs and organisations. But, no programs in the Portland area had used mass media or marketing interventions to influence safer sexual behaviour. Over the intervention period support for the teen HIV/AIDS program grew, evidenced by increased condom availability at social service agencies, youth organisations, and school health clinics in Portland's school district (Blair, 1995). 3.3.1 Target Audience Project Action targeted sexually active young people between the ages of 12-21 considered at high-risk of infection based on their behaviour, environments, and life situations. Characteristics to define high-risk teens were homelessness, drug addiction, teen parents, teenagers questioning their sexuality, previous contraction of a sexually transmitted disease (STD), or involvement with the juvenile justice system (Blair, 1995). 3.3.2 Project Action Objectives Project Action outlined the following objectives for its program activities: • to increase condom use among sexually active youth; 38 • to increase condom use among sexually active youth, without encouraging an increase in the level of sexual activity; • to improve access to affordable condoms among the target population; • to generate positive peer norms concerning condom use; • to generate positive attitudes towards condoms and condom use; • to strengthen and reinforce feelings of self-efficacy for obtaining and using condoms; • to increase awareness of Project Action risk reduction message through broadcast and environmental media. 3.3.3 Program Components Project Action identified the need to focus efforts on the individual to change risky sexual behaviour. Coupled with support structures in the community (e.g. social services and systems) to sustain the behaviour. Similar to PSI's international project the program comprised of the following 5 components: Community Mobilisation: An outreach campaign for the purposes of building community support for the project; specifically the education of HIV/AIDS among teens, collaborate with existing community organisations, build allies in the community, and diffuse opposition. Over 100 presentations were made in the community, included the Chamber of Commerce, neighbourhood and business associations, community coalitions, civic groups, elected officials, school officials, church groups, community leaders, and health and social service agencies. Safer Sex/Motivational Campaign: An 18-month media campaign promoting safer sexual behaviour running from January 1993 to April 1994. The campaign involved both broadcast and environmental media. With the help of local teens and an advertising firm, three Public Service Announcement (PSA's) were developed. Project Action secured a total of 2,800 minutes of free 39 broadcast time from five television network affiliates and two cable stations in Portland. Three television PSA's were developed and aired on local Fox affiliate and Paragon Cable and made available for video distribution. Environmental media consisted of poster, pocket cards listing condom vending sites, key chains, and T-shirts. (See Appendix 3: Project Action Media) Condom Vending Operation: The project installed 230 vending machines over the duration of the project. The machines sold latex condoms for 25 cents each. Locations were identified by local teens, (e.g. all age night clubs, pizza parlours, fast food restaurants, clothing and record stores, community recreation centres, public libraries, pool halls, and bowling alleys). Decals were posted where Project Action vending machines were located. Peer-Skills Building: One year into the implementation, Project Action developed a curriculum to implement teen-facilitated skills building workshops to help teens identifying sexual boundaries, improve decision-making, and develop communication and negotiation skills for safer sex. Project Action recruited and trained teens. Research, Monitoring, and Evaluation: Evaluations using both qualitative and quantitative research were conducted during the design and implementation of the project, e.g. focus groups, pre-testing of PSA's and print media, point-of-purchase surveys, and market research. An outcome evaluation to assess the behavioural impacts of the project was conducted by Oregon Health Division and Kaiser Centre for Health Research. 3.4 Condomania Condomania has been an "ongoing effort by the Vancouver/Richmond Health Department to reduce the spread of sexually transmitted diseases, including HIV, among young heterosexual 40 people in Vancouver by popularising condoms and their use" (Eason, 1994:1). Formerly, Condomania was the Vancouver Condom Awareness Campaign and came about as a result of informal discussions between the Vancouver Health Department and the now defunct Women and AIDS Project (Wagman, 1993). In the 1990's health agencies noted an increasing incidence of HIV among heterosexual women. Alarmingly, many of these women had contracted the disease through vaginal intercourse, rather than IV drug use as seen in the US. Lack of public awareness of HIV was also a factor. A formal broad-based public education program targeted at women was developed by May 1990. The Positive Women's Network was invited to join the development process. In December 1990, funds were secured from the City of Vancouver for the first campaign. The provincial Ministry of Health has funded all other programs to an amount approximating $50,000 per campaign (Eason, 1994). 3.4.1 Target Audience Statistics and seroprevelance studies indicated women in their early child bearing years (e.g. 19-30 years) were the most likely group to become infected with HIV (Wagman, 1993). This information led young adult women to be the primary target group. This group was not being targeted by other AIDS service or community organisations. Since the initial Condomania campaign the target group has changed according to research and evaluation (e.g. female, males, both sexes, and different age cohorts) (Eason, 1994). 3.4.2 Program Objectives The broad objective of Condomania was to popularise condom use among males and females 19-24 year olds to reduce the incidence of all STD's including HIV. The campaigns focused on raising awareness of the potential risks of disease contraction and providing a preventable option (condoms). The first campaign targeted women at risk who engage in unprotected vaginal sex and provide condoms to them for disease prevention. Social marketing went beyond education, to understand the target audience's values and beliefs to develop a relevant message. Outlined objectives of Condomania's campaign messages sought to reinforce, (Vancouver Health Board, 1994:4): • partner communication re: sexual relationships • shared responsibility (between the sexes for condom use) • social acceptability of condoms • self-esteem (to request and maintain condom use) 3.4.3 Program Components Condomania consisted of six key elements (Wagman, 1993): 1. Design and production of campaign material 2. Public Promotion-advertising 3. Focused community education 4. Volunteer recruitment and training 5. Media relations 6. Program evaluation A three year program was developed consisting of two, two-month campaigns each year. After the first campaign, the communication mix of the campaigns consisted of interior/exterior advertising in buses and community education involving information and condom distribution at public venues by volunteers modelling comfort and ease with condoms. 42 Design and Production of Campaign Materials Condomania's message was intended to be informative, attractive, and provocative - abstinence and fear messages were excluded. V R H B following the example of America Responds to AIDS, implemented a time limited, multi-media campaign, accessible, repetitive, and replicable campaign (Wagman, 1993). The six campaigns were fundamentally the same, however, over time with ongoing monitoring and evaluation the target populations have changed from women only, to both sexes, and males only (Eason, 1994). As well, the communication strategy has changed over time. Table 3: summarises the comparative statistics of six campaigns. Table 2: Condomania's Campaign Campaign 1 2 3 4 5 6 Date March 1991 Nov. 1991 Nov. 1992 May 1993 Sept. 1993 May 1994 Funding $50K $50K $50K $50K $110K carried over Target Market-Gender Women Women Men Both Both Women Target Market -Age 19-30 19-30 19-30 19-24 19-24 19-24 Peer-Approach Volunteers 22 26 37 21 37 16 Safe Sex Packages 13,000 12,000 13,200 15,000 24,000 14,700 Bar/Clubs Participating 9 15 18 17 13 3 Other Location for Safe-Sex Packages Distribution Universities Universities Fitness Clubs Beaches Pharmacies Sports Bus Posters 7 billboards 10 shelters 500 interiors 50 exteriors 414 interior 39 exteriors 240 interior 59 exteriors 240 interior 59 exteriors 240 interior 59 exteriors 240 interior Other Posters 3,000 1,000 2,800 200 500 large 700 small 59 exterior 240 interior Bar Coaster 2,000 0 0 20,000 50,000 -Other Advertising Radio PSA Source: Eason, Angus. (1994) "Condomania Marketing Audit." -Appendix I -Public and Non-Profit Marketing. University of British Columbia. Initially, design and production was contracted out and public communication and advertising was done in house. In the second campaign, design, communication, and advertising was contracted out, proving to be more cost-efficient and effective (Wagman, 1993. The popularising of condoms became the campaign focus. Formative research revealed a light fun message was more relevant to the target audience. The design chosen best popularised condoms and was well received when tested among the focus group (Wagman, 1993). Table 3 summarises the characteristics of the six different Condomania campaigns. Table 3: Campaign Themes Campaign Theme l "Condoms keep your love alive." "Enjoy your love life", Public health style poster 2 "Remember, if he really cares he wears" Comic style, one women talking to another women "* j "Boys will be boys, but men will wear condoms...Every time! Comic style two women talking 4 -"The longer you use condoms...the longer you last". Comic style, man and women talking -Due to unacceptability to BC Transit and community health nurses, the above format was only used in bars. A second design was used for buses and high schools: -"Will she call me a jerk if I don't wear a condom?...She probably won't call you at all." Comic style, 2 men talking 5 "In the heat of passion...It's cool to wear a condom" 6 "You're the most important reason for wearing a condom" Comic style, woman only with information about other STD's Source: Eason, Angus. (1994) "Condomania Marketing Audit."-Appendix II -Public and Non-Profit Marketing. University of British Columbia. Public Promotion-Advertising The first promotion consisted of seven billboards, 500 bus interior cards and ten bus shelters. Billboards were used only in the first campaign (Wagman, 1993, V H B , 1994)). The outcome evaluation deemed that for the amount of exposure, billboards were too expensive. The transit campaign was supported by transportation research which revealed women rode buses more than they drove cars. For the second campaign advertising was purchased on the outside of 50 local buses and the transit company donated 414 inside spaces (Wagman, 1993). For the remainder of the campaigns transit and a peer-to-peer approach were identified as the main modes of communication. (See Appendix 4: Condomania campaign visuals) Focused Community Education Bars and night-clubs were solicited to circulate the safer sex message. Initially, it was necessary to educate the bar managers of the strategy. The first campaign enlisted nine bars and the second campaign fifteen (Wagman, 1993). For the second campaign, more direct interaction with bars developed activities such as, contests and relays to blow up condoms, tossing condoms through hoops, and free condom hand-outs with special drink orders (VHB, 1994). Over time other public venues were used such as sports events, fitness centres, pharmacies, and universities. Volunteer, Recruitment, Training: Distribution of condom packages was done by volunteers. The volunteers were a crucial element of the community education approach in bars and other public venues. A peer-oriented approach was deemed to have more success than health care professionals. Sources for volunteers included local AIDS service organisations, university and community colleges, and the volunteer program of the health department. It was extremely difficult to find volunteers for the first campaign. In the second and subsequent campaigns volunteer recruitment was not a problem. Volunteers were appreciated with campaign-end 'get-togethers' (Wagman, 1993). Media Relations: For each campaign press kits were prepared. In order to attract attention, press kits varied for each campaign. During the first campaign there was extensive media exposure with all major stations and newspapers picking up the story (Wagman, 1993). By the second campaign there was less coverage as expected. Research, Monitoring, and Evaluation: Over time, the campaigns developed a evaluation and monitoring process. Formative, process, and summative evaluations served as sources of internal and external review for each of the campaigns. These evaluations were used to revise the upcoming campaigns. Formative evaluations consisted of focus groups and in-depth interviews that enabled the program implementation team to become more effective in the design and direction of the campaigns. Formative evaluation also consisted of ad hoc community meetings. Process evaluations consisted of in-house bi-monthly meetings to ensure activities were progressing as planned and allowed for implementation issues to be addressed. Summative evaluations consisted of both formal and informal evaluations. A formal evaluation was contracted out to Farrell Research Group (FRG) to discern the impact of the campaign on the target population. The informal evaluations consisted of anecdotal reporting by those involved in the peer-approach and community education campaign. Volunteers and bar managers/staff were surveyed using a questionnaire addressing issues such as bar coverage, target group, timing and frequency of distribution, training, reaction to message and approach, and volunteer benefits (Eason, 1994). 46 4 . Chapter Four: Research Results The following compares and contrasts Project Action and Condomania, specifically to address the three stated research objectives: 1) to identify the impact on behaviour, attitudes, and, awareness of the social marketing programs; 2) to identify common implementation challenges faced in the social marketing process; and 3) to identify challenges in sustaining and institutionalising the respective programs. 4.1 Evaluation Criteria Evaluation of program impacts is a key component of the social marketing process. The first research question will compare and contrast the impact of the two AIDS prevention programs. Impact is the extent to which the programs were instilled attitude and behaviour change in the target audience to practice safe sex. For the purpose of this research, program effectiveness is based not only on the analysis of the impact evaluation studies, but also upon the qualitative impressions disclosed in the one-to-one in-depth interviews with members of the project implementation team and community groups. The in-depth interviews of the project implementation team form the primary source of information to address the second and third research objectives that concentrate on implementation barriers and challenges to program sustainability. Both programs had small program implementation teams. Two persons co-ordinated the implementation activities in Project Action, aided by youths, community advisory board members, volunteers, and 47 consultants. Three persons co-ordinated the activities of Condomania aided by volunteers and consultants. As well discussions were held with representatives of community AIDS prevention organisations from the respective communities. These interviews will reflect individual involvement and bias of the respective organisations. For confidentiality purposes, those interviewed will not be referred to by name, but as Participant A , B, etc. Initially, the research intended to analyse the individual components of the respective campaigns and assess their impact and effectiveness. Further study revealed that this was inappropriate when evaluating the social marketing approach. The basis of the approach relies on several elements working together synergistically to effect behaviour change. Mindful of the approach, the summative evaluation of the respective programs evaluate the program as a whole and the individual components as they relate to each other with respect to program impact and overall effectiveness. Effectiveness will be based on the quantitative impact studies and qualitative impressions disclosed in the interviews. As both of the projects have taken different approaches to instil behaviour change, the analysis will look at each program individually and close with a discussion comparing the impact and effectiveness of both programs. 4.2 Part I: Marketing Strategy: Program Impact 4.3 Project Action Oregon State Health Division was contracted by PSI which sub-contracted with Kaiser Permanente Centre for Health Research to conduct an outcome evaluation. The evaluations 48 aimed to assess the impact of Project Action on teen sexual behaviour specifically condom use, attitudes, and awareness. The outcome evaluation used a "rolling cross sectional" design comprising of baseline data and a different sample of teens interviewed each week (Blair, 1995:5). The survey worked with fourteen organisations from the following six types of agencies; "juvenile justice, alternative education, multiple counselling services, shelters for runaway and homeless youth, counselling for chemical dependency, and services for gang-involved youth" (Blair, 1995:6). The sample aimed to represent the target population, high-risk youth between the ages of 12-21 affiliated with the above mentioned agencies. (Polen, 1995; Blair, 1995). The survey involved 508 baseline interviews conducted from November 1992 to January 1993 and 1704 interviews during the intervention period from January 22, 1993 to November 1994. A total of 2,212 were conducted all were voluntary, anonymous, thirty minutes in length. A l l respondents received $10.00 for their participation. The following describes the surveys conducted during the intervention summarised from PSI/Project Action: Impact on Teen Risk Reduction (1995). Point-of-Purchase Survey: Conducted to gather individual perceptions of the vending machines and whether vending machines influenced condom purchase and/or use. Two surveys were conducted the first in the "summer of 1993 with pro-bono support from the Department of Anthropology and Sociology at Lewis and Clark College in Portland, Oregon. The second was in the summer of 1994 with pro-bono support from Business and Economic Department at Western Oregon State College" (Blair, 1995:6). Business managers/owners and employees were surveyed in the first round to assess levels of comfort and support for the vending machines. Customer Intercept Survey: A local market research firm (Griggs-Andreson Research) was contracted to conduct a survey at a local Burger King to assess customer attitudes regarding the vending machines in the restaurant. A total of 190, five-minute interviews were randomly conducted; Equal numbers of men and women were interviewed. Monitoring: Comprised of process data of the program components, which included press media coverage, broadcast logs for PSA's, condom vending sales, and peer-to-peer workshop participant information (Blair, 1995). 4.4 Results Project Actions impact findings and statistical observations breakdown into three categories behaviour, attitude, and awareness summarised from the more detailed PSI/Project Action: Impact on Teen Risk Reduction (1995). The baseline is the reference period, and post period refers to the intervention. The statistical analysis was collapsed into eight quarterly clusters, which included the baseline sample over the two-year period. For significant outcomes the research group used linear regression for (dichotomous outcomes) and multiple linear regression (for continuous outcomes) (Polen, 1995). In the study "Main or steady partner" is defined as a spouse or partner that the respondent had been with for awhile, like a boyfriend or girlfriend and "other partner" as not a main or steady partner and someone the respondent had not been with for awhile (Polen, 1995:9) 5 0 4.4.1 Behaviour I. Condom Use Among sexually active members at last intercourse with other partners, the study indicated a rise in condom use with casual or new partners that coincided with project interventions. Survey responses indicated that condom use among those sexually experienced at last intercourse with "other" partners rose from 72% at baseline to 90% in the first quarter of the study where it remained until the last quarter when it dropped to 74% (Blair, 1995:8). Among sexually experienced main partner teens, about 60 percent of the teens used a condom at last intercourse which did not rise from this baseline level. Table 4: Condom Use Sexually Active Teens Question Baseline 11/92-01/93 Feb/Apr 1993 May-Jul 1993 Aug-Oct 1993 Nov.93-Jan.94 Feb-Apr 1994 May-Jul 1994 Aug-Nov 1994 Used condom with last intercourse 72% 90% 88% 88% 89% 91% 89% 74% Had intercourse in the last month 77% 89% 87% 88% 92% 94% 94% 71% Main Partner Used condom with last intercourse 60% 60% 62% 70% 50% 55% 58% 48% Had intercourse in the last month 56% 60% 60% 71% 48% 58% 55% 46% Polen, Micheal. (1995). Outcome Evaluation of Project Action - Final Report. Table 9. Kaiser Permanente Centre for Health Research, Portland, Oregon. II. HIV/AIDS Prevention Youth respondents displayed little change in their attitudes and behaviours to reduce their chances of contracting HIV/AIDS. At baseline 60% of the respondents reported that they had 5 1 done something in the past month to reduce their chances of getting HIV/AIDS. This percentage did not vary considerably during the intervention period (Blair, 1996:9). Of those teens reporting a behaviour change to decrease their chances of contracting HIV/AIDS, at baseline 2% said they consistently used condoms, which rose to a high of 16% in the second to last quarter of the first year dropping to 11% in the last quarter, in August and November 1994 (Blair, 1995:9). Among teens stating they had done something in the past month to decrease their chances of contracting the AIDS virus, at baseline 18% said they had stopped having sexual intercourse which rose to 39% to the last quarter. Other survey questions indicated little or no positive change in behaviours or attitudes and are summarised in Table 6. Table 5: HIV/AIDS Prevention - Actions Taken Action taken in the past month to decrease Baseline Feb/A May- Aug- Nov. 93 Feb- May- Aug-chances of getting HIV/AIDS 11/92- pr Jul Oct - Jan.94 Apr Jul Nov 01/93 1993 1993 1993 1994 1994 1994 Increased use of condoms 20% 15% 24% 16% 16% 13% 10% 6% Started using condoms 11% 0% 3% 1% 3% 1% 0% 2% Consistently used condoms 2% 12% 5% 11% 6% 13% 16% 11% Stopped having sexual intercourse 18% 30% 26% 30% 32% 35% 39% 39% Decreased number of sexual partners 16% 8% 14% 8% 9% 1% 1% 4% Chose sexual partner more carefully 11% 6% 8% 10% 2% 1% 2% . 1% Decreased frequency of sexual intercourse 7% 5% 5% 6% 9% 5% 2% 6% Abstained—postponed sexual intercourse 5% 15% 10% 12% 6% 11% 10% 17% Stayed with one sexual partner 3% 1% 1% 1% 9% 12% 13% 11% Other 8% 8% 4% 6% 8% 6% 6% 4% Polen, Micheal. (1995). Outcome Evaluation of Project Action - Final Report. Table 19. Kaiser Permanente Centre for Health Research, Portland, Oregon. 5 2 Table 6: H I V Prevention in the Past Month Question Baseline 11/92 -01/93 Feb/A pr 1993 May-Jul 1993 Aug-Oct 1993 Nov. 93 - Jan.94 Feb-Apr 1994 May-Jul 1994 Aug-Nov 1994 Have you done anything in past month to decrease your chances of getting HIV/AIDS -Yes Responses 60% 58% 58% 56% 57% 58% 59% 55% Polen, Micheal. (1995). Outcome Evaluation of Project Action - Final Report. Table 19. Kaiser Permanente Centre for Health Research, Portland, Oregon. III. Improved Accessibility to Condoms Over 50% of sampled teens reported condom vending machines as an "easy source" for condoms. This figure peaked at 79% in the first quarter, after which it remained over 70% until the last quarter when it dropped to 63%. Only 1-2% of the surveyed teen respondents mentioned vending machines as a condom source in the past month, during the program period (Blair, 1995:10). Overall the actual number of teens that obtained condoms in the past did range far from 65%. Table 7: Locations Where Condoms Were Obtained Location Baseline 11/92 -01/93 Feb/Apr 1993 May-Jul 1993 Aug-Oct 1993 Nov. 93 -Jan.94 Feb-Apr 1994 May-Jul 1994 Aug-Nov 1994 Vending Machines 0% 2% 2% 1% 0% 1% 1% 1% Drug Stores 5% 8% 8% 14% 9% 10% 12% 10% Supermarkets 10% 5% 3% 10% 7% 7% 4% 3% Health Clinics in Schools 9% 0% 3% 5% 6% 8% 9% 3% Heath Services 17% 14% 20% 18% 13% 24% 21% 19% Social Service Agencies 18% 2% 5% 9% 20% 10% 4% 10% Friends 21% 49% 32% 29% 25% 24% 23% 25% Family Members 15% 14% 18% 9% 16% 10% 18% 19% Convenience Stores 2% 4% 5% 2% 4% 3% 6% 7% Other 2% 2% 3% 2% 0% 2% 1% 1% Polen, Micheal. (1995). Outcome Evaluation of Project Action - Final Report. Table 8. Kaiser Permanente Centre for Health Research, Portland, Oregon. 53 Table 8: Condom Acquisition Question Baseline Feb/Apr May-Jul Aug-Oct Nov. 93 - Feb-Apr May-Jul Aug-11/92- 1993 1993 1993 Jan.94 1994 1994 Nov 01/93 1994 Got condoms, past month 66% 51% 61% 72% 65% 59% 57% 60% Polen, Micheal. (1995). Outcome Evaluation of Project Action - Final Report, table 8. Kaiser Permanente Centre for Health Research, Portland, Oregon. IV. Project Logo and Condom Use No significant correlation was found between Project Action media, specifically the Project Action logo and/or PSA's, and increased condom use. "Among teens who had seen the Project Action logo, 55% percent used a condom with a main partners and 86% used a condom with other partners. Among teens who had not been exposed to Action media, the results were similar, 58% and 86% respectively" (Polen, 1995: 17). Table 9 : Exposure to Action Media and Condom Use At Last Intercourse Question Saw Action Logo Saw Action PSA Action Exposure Index No Yes No Yes 0 1 j Used condom at last intercourse With Main Partner Yes 58% 55% 56% 58% 61% 50% 61% No 42% 45% 44% 42% 39% 50% 39% With Other Partner Yes 86% 86% 86% 86% 86% 86% 87% No 14% 14% 14% 14% 14% 14% 14% Polen, Micheal. (1995). Outcome Evaluation of Project Action - Final Report. Table 12. Kaiser Permanente Centre for Health Research, Portland, Oregon. 54 4.4.2 Attitude I. Self-Efficacy: Defined as "the conviction that one can successfully execute the behaviour required to produce the outcomes" (Bandura, 1977a:77). Respondents indicated little trouble in obtaining condoms and using condoms. A measure of questions inquiring the respondents "commitment, confidence in their ability, to get condoms and negotiate their use" was conducted (Blair 1995:12). Sixteen different questions were asked to discern self-efficacy. The evaluation indicated that there was no increase in self-efficacy to buy condoms among the respondents, but, the self-efficacy to obtain free condoms was higher in the post-period intervals than the baseline. This last figure rose from 72% to a high of 89%), and dropping to 77% in the last quarter (Blair 12, 1995). Overall self-efficacy rose for condom use during the intervention. Self-efficacy was high at baseline and maintained throughout the intervention. At baseline 78%> of the sexually active respondents stated that they "could use a condom with their next partner" (Blair, 1995:10). In the first quarter this rose to 95%, then hovered around 81 -93% for the duration of the intervention period. Peer norms around the open discussion of condom use did not show increase and sometimes indicated a decline. Other data related to self-efficacy and condom use is summarised in Table 10. 55 Table 10: Self Efficacy and Condom Use Questions Baseline 11/92-01/93 Feb/Apr 993 May-Jul 1993 Aug-Oct 1993 Nov. 93 -Jan.94 Feb-Apr 1994 May-Jul 1994 Aug-Nov 1994 Responds "very sure" to statement "I can buy condoms if I need to" 72% 68% 66% 66% 61% 65% 67% 68% get free condoms if I need to" 72% 86% 73% 78% 83% 89% 81% 77% use a condom every time I have sex" 59% 74% 68% 74% 56% 57% 41% 50% use a condom with the next new partner I have" 78% 95% 82% 86% 87% 93% 84% 81% always keep a condom with me when I go out" 52% 30% 52% 58% 53% 47% 46% 48% use a condom correctly" 82% 82% 86% 85% 88% 83% 78% 85% convince my next new partner that we should" 53% 81% 53% 48% 51%> 50% 41%) 54% talk openly to my friends about using condoms" 65% 54% 47% 58% 43% 38% 33% 48% put a condom on myself/my partner, even during the heat of passion" 56% 69% 63% 44% 34% 39% 34% 36% convince a friend that he/she should use condoms" 38% 30% 29% 32% 24% 22% 20% 27% tell others in a social conversation that 1 use condoms" 54% 29% 31% 30% 28% 41% 39% 39% talk to my next partner about using a condom even if I don't know his/her feelings about condoms" 53% 82% 64% 76% 66% 84% 76% 66% put a condom on myself/my partner, and enjoy the experience" 42% 70% 62% 41% 32% 38% 36% 41% insist that my next new partner and 1 use a condom before I agree to have sex with him/her" 66% 86% 66% 74% 73% 84% 75% 75% refuse to have sex with any new partner if he/she won't use a condom" 59% 68% 70% 64% 71% 87% 84% 80% use a condom even if I've been drinking or using drugs" 46% 55% 53% 63% 62% 74% 62% 59% Polen, Micheal. (1995). Outcome Evaluation of Project Action - Final Report. Table 17. Kaiser Permanente Centre for Health Research, Portland, Oregon. II. Social Acceptability of Condom Use Teen comfort with condoms rose during the early periods of the implementation. At baseline, 22% related positive experiences with condom use. In the first quarter this positive attitude rose to 40%, remaining at 20-28% until July 1994 (Blair, 1995:11). Respondents confirmed vending machines were a positive reinforcement to safer sexual behaviour indicated in the Point of Purchase Surveys. III. Peer Norms Social Influence behaviour theory views peer norms to have a strong impact on adolescent behaviour. The survey indicated no change in peer norms. There existed a strong and consistent peer support for condom use among new/casual partners. Survey results indicated 94% believed that most of their friends should use condoms with new/casual partners which remained at 97% and above for the remainder of the intervention. The survey maintained weaker support of condom use with main/steady partners (Blair, 199511). At baseline 69%> respondents believed that there friends think the respondent should use condoms with main/steady partners. This figure rose to 78%) in the first quarter declining gradually to baseline levels by the last quarter. 4.4.3 Reach and Awareness Recall of Project Action's risk reduction messages via PSA's, logo, environmental media, and condom vending machines was high. A high of 40%> recalled Project Action's PSA's by the end of the first year. Over half of the respondents recalled the Project Action logo and understood the significance of its message (Blair, 1995:13). Table 5 summarises the recall of Project Action media. Table 5: Media Forms and Recall Media Form Recall - (Highpoints) PSA 40% Project Action Logo 59.8% Promotional Materials 31.98% Environmental Media 25%) Project Action Posters 43%> Project Action T-Shirts Condom Vending Machines 43.8% Source: Source: Blair, J. (1995). PSI/Project Action: Impact on Teen Risk Reduction. Prepared for Population Services International: 13. 57 4.5 Condomania After three years of Condomania campaigns, the Vancouver/Richmond Health Department contracted Farrell Research Group (FRG) to conduct a cumulative evaluation of the project. The following summarises key research findings from the report, Lower Mainland Young Adults and Condomania (1994). The survey method consisted of a randomised pre and post telephone surveys and a series of in-depth interviews with bar patrons. Telephone interviews aimed to obtain a representative sample of Lower Mainland young adults between the ages of 19-24. The interview period was between the period of June 8 to July 11, 1994. The telephone interviews were differentiated into two groups, members of Test Group - included those individuals of the target population that recalled 2 of the 5 Condomania posters. The Control Group - were those members that did not recall any Condomania posters. To ensure reliability those interviewed that recalled one of the five posters were not included in the sample population (FRG, 1994). In order to ensure an accurate representation of young adults a random sample of 22,000 was pulled from the Lower Mainland telephone directory. A l l members were called a minimum of three times to determine i f someone 19-24 lived in the household. The research was designed to include 200 respondents in the Test and Control Groups. But, only 3% of the total interviewed population between the ages of 19-24 had not seen Condomania. As a result, the final sample consisted of 201 interviews in the Test Group, and 152 interviews in the Control Group. The sample was from a diverse range of cultural and socio-economic backgrounds. Two-thirds of the respondents were pursuing post-58 secondary education, with almost half-enrolled in or completed university. The sample was also representative of Lower Mainland's immigrant population (FRG, 1994). 4.6 Results. 4.6.1 Behaviour I. Condom Use: Respondents were asked a series of statements and asked to choose one out of four possibilities that a best friend would use to describe him or herself. Survey results revealed females were more likely to claim condom use to protect themselves from STDs over their male counterparts (FRG, 1994:16). Sixty-seven percent of females unexposed to the campaign used a condom with a new partner, which rose to 79% among those having campaign exposure. A different set of factors motivated condom use among males. Half of the males respondents were motivated by protecting themselves against STD's while others felt an obligation to their partner. Males associated condom use with "loss of sensation and one-night stands" (FRG, 1994:20). Table 11: Importance of Condom Use Females Males Seen Condomania Have Not Seen Condomania Seen Condomania Have Not Seen Condomania Agree strongly that: Today, condoms are a must 90% 86% 73% 69% Agree strongly that: 1 always use condoms the first time I have sex with a new partner 79% 67% 65% 72% Do not agree at all that: A condom gets in the way of good sex 54% 40% 27% 26% Do not agree at all that: A pill keeps people from getting STD's 89% 81% 86% 75% Agree strongly that: Condoms are still necessary when you use the pill 71% 63% 54% 61% Source: Farrell Research Group Ltd. (1994) Lower Mainland Young Adults and Condomania. Table 5b. Prepared for Vancouver Health Department. July. 5 9 Condom usage declined in long term relationships. Long term defined as that based on love, caring, support, sharing, trust, honesty, and friendship. Often described as monogamous and serious marriage-type commitments. The survey defined the duration of such a relationship as ranging anywhere from six months to two years. Of the group one-third claimed condom use all the time in long-term relationships. Condom use was more likely to be used for pregnancy prevention than STD's. A decline in condom use appeared to be dependent on relationship duration, partner-testing, and partner trust. A prevailing perception among "monogamous partners is that such relationships (albeit short-lived) negate the need for a condom" (FRG, 1994:21). The F R G study did reveal a small correlation between increasing condom use in long-term relationships among those females and males that had recalled Condomania (FRG, 1994). The six campaigns made more of an impact on the female target population than male. The importance of condom use was high among females irrespective of whether or not they had been exposed to Condomania. Females exposed to the advertising were more inclined to endorse the importance of condom use the "first time they have sex with a new partner" - 79% of females compared to 65% of males - (FRG 1994: 24). Social acceptability of condoms and comfort levels rose slightly, but did not translate into greater condom use (FRG 1994:25). 4.6.2 Attitude I. Self-Efficacy - Responsibility for Condom Use and Purchase While young adult females essentially believe that condom use and purchase is the responsibility 60 of both partners. Males are less likely than females to agree that condom usage is the responsibility of both sexes (FRG 1994: 18). It was noted that males, that had recalled Condomania, were likely to view condom use a responsibility of both partners and not just men alone (FRG 1994, 25). Females appear to be more comfortable with condom purchase. Interestingly, males are the more likely to be the primary purchasers of condoms. Of females, 36% stated their partner usually buys the condoms and 58% of males stated themselves to be the primary purchaser (FRG, Table7b). Table 12 summarises the research findings. Table 12: Condom Use and Purchase Females Males Seen Condomania Have Not Seen Condomania Seen Condomania Have Not Seen Condomania Do not agree at all that: Condom usage is the responsibility of men 58% 49% 27% 15% Do not agree at all that: Condom usage is the responsibility of women 56% 47% 28% 25% Agree strongly that: Condom usage is the responsibility of both partners 95% 88% 84% 69% - Who usually buys condoms: Partner 36% 44% 9% 3% Respondent Themselves 6% 12% 58% 71% Do not buy them at all 5% 7% 2% N/A Both 54% 33% 28% 21% Refused 5% 3% 5% - Who should buy condoms: Both partners 94% 83% 82% 85% Male 6% 16% 16% 15% Female 2% n/a n/a n/a Source: Farrell Research Group Ltd. (1994) Lower Mainland Young Adults and Condomania. Table 7a and 7b. Prepared for Vancouver Health Department. July. II. Social Acceptability and Condoms "Overall, social acceptability of condoms is lower than perceived level of the importance and 61 actual usage. This suggests usage is a function of internalisation of personal risk involved rather than a level of social affirmation" (FRG 1994:19). Only one half of the young adults indicated that they would feel comfortable discussing condom use with friends and this did not vary considerably among respondents that had been exposed to Condomania. Similarly, comfort with direct discussion about condom use with their partner ranged at 80% among those that seen and not seen Condomania. (FRG, 1994). Table 13: Social Acceptability of Condoms Females Males Seen Condomania Have Not Seen Condomania Seen Condomania Have Not Seen Condomania Agree strongly that: It is easy for me to talk about condoms with my friends 60% 60% 52% 41% Agree strongly that: I feel comfortable talking with my partner about using a condom (among those in relationship). 84% 85% 81% 75% Do not agree at all that: I would be embarrassed to buy condoms ' 52% 57% 66% 51%o Source: Farrell Research Group Ltd. (1994) Lower Mainland Young Adults and Condomania. Table 8b. Prepared for Vancouver Health Department. July. III. Motivations and Condom Use Table 14 summarises research results of respondents describing the likely response of their best friend. There is marked difference between males and females regarding condom use among someone that they care about. Of interest is the unease among women who have seen Condomania and condom use on a one-night stand. Respondents noted the difficulty of maintaining condom use with the influence of alcohol intake. Among males the survey noted a 6 2 higher level of discontent with condoms use for the reasons of pleasure and spontaneity. "Females who have seen the advertising are more likely to discount the notion that condoms inhibit good sex" (FRG 1994, 24). "Females exposed to Condomania are more likely to indicate that when water-based lubricants are used with a condom this increases sexual pleasure" (rather than preventing STDs). Disqualifying the notion that condoms get in the way of good sex (FRG, 1994:25). Table 14: Motivation and Condom Use Seen Condomania Have Not Seen Condomania Seen Condomania Have Not Seen Condomania I find it easy to use condoms when... I'm with someone I care about 61% 50% 36% 30% I don't know the person very well 22% 22% 27% 31% On a one-night stand 8% 16% 28% 26% I've had something to drink 3% 3% 3% 8% Don't know 6% 9% 6% 5% When I consider using condoms... I want to protect myself from STD's 74% 64% 49% 62% I feel caring towards my girlfriend's/boyfriend's request 19% 21% 31% 25% I want to satisfy my girlfriend's/boyfriend's request n/a 10% 11% 10% I feel resentful, I'm expected to use them 5% 2% 5% 2% Don't know 2% 4% 4% 2% I prefer not to use condoms because... It doesn't feel as good 17% 25% 37% 41% I can't be spontaneous with lovemaking 24% 23% 29% 15% I feel embarrassed 12% 15% 5% 3% It means I don't trust my boyfriend/girlfriend 8% 3% 9% 18% My girlfriend/boyfriend doesn't trust me 12% 8% 3% 8% Don't know/no reason 28% 26% 17% 15% When i use a water-based lubricant with condoms... I increase my feelings of pleasure 33% 17% 32% 30% I help stop the condom from breaking 25% 20% 23% 31% I protect us from getting pregnant 21 20% 9% 21% I help prevent STDs 7% 23% 17% 8% Don't know 15% 21% 19% 10% Source: Farrell Research Group Ltd. (1994) Lower Mainland Young Adults and Condomania. Table 9b. Prepared for Vancouver Health Department. July. 6 3 4.6.3 Reach and Awareness The survey indicated a high level of awareness of the importance of condom use given the prevalence of AIDS and STDs. Awareness and recall of Condomania was strong. "Over, half the sample claim to have seen condoms or safer sex advertising on public transit or the backs buses in the past two years (FRG, 1994:22). Of significance is two-thirds of this sample spontaneously recalled the Condomania campaign. "The cartoon/animated format is played back by one third of the sample and almost one quarter recall the neon colours" (FRG, 1994:22). The respondents were able to "spontaneously" reiterate the "Get it on" caption and describe the various Condomania posters" (FRG, 1994:22). Given Condomania media emphasis on transit, bars, and universities reach was largely among young adults living in the City of Vancouver and university students (FRG, 1994:23). Of those that had seen Condomania 75% mother tongue was English, compared to 10% Chinese, and 15% Other. 4.7 Summative Impact Evaluation of Condomania and Project Action 4.7.1 Impact: Behaviour, Attitudes and Awareness A. Significant Impacts Both impact evaluations of Condomania and Project Action indicate positive changes regarding condom use among youths and young adolescents that correspond to program interventions. In Project Action at baseline, 72% of high-risk teens used condoms with other partners which rose to 90% in the first quarter of the intervention period. 6 4 Condomania's six campaigns were successful in reaching its female audience. Females were more likely to have a greater understanding of the importance of condoms use in ensuring safe sex, particularly when having sex with a new partner, and that condoms were a shared responsibility. Of females, 67% of the sample who had not seen the campaign used a condom the first time they had sex with a new partner compared to 79% among those who had been exposed. Program impact can also be discerned by the number of females who discounted the notion that condoms inhibit good sex. Of females who had been exposed to Condomania, 33% agreed that water-based lubricant increased feelings of sexual pleasure compared to, 17% who had not been exposed to the campaign (FRG, Table 9b). Condomania's safe sex packages specifically included a condom, a sample packet of lubricant, and a comic strip instruction insert. The marketing strategy of both campaigns were successful in reaching their target audience. High levels of recall were prevalent in both project sites with over half of the respondents indicating recollection. For Condomania, the free distribution of condoms in bars, universities, and public venues by peers proved conducive to raising awareness of HIV/AIDS and affecting behaviour change. In Project Action the vending machines were not a source of condoms for the sampled youth, but they did play an important role as environmental media and normalising social and community norms regarding teens, condoms, and HIV/AIDS prevention (Participant A, C and D, 1998). B. Limited Impacts Condomania effected limited impacts on the male target audience. Slight increases were noted in social acceptability and comfort with condom use. In Condomania, males were more likely to view condoms as a matter of obligation to their partner than self-protection. In Project Action youth respondents displayed little change in their attitude and behaviour to reduce their chances of contracting HIV/AIDS. At baseline 60% of the respondents reported that they had done something in the past month to reduce their chances of getting HIV/AIDS. This percentage did not vary considerably during the intervention period (Blair, 1996:9). Project Action's survey indicated no increase in self-efficacy to buy condoms among the teen respondents, but the self-efficacy to obtain free condoms was higher in the post-period intervals than the baseline. This last figure rose from 72% to a high of 89%, and dropping to 77% in the last quarter (Blair 12, 1995). The vending operation was successful in selling condoms. However, of the youths surveyed throughout the intervention only 1-2% actually purchased condoms from the vending machines. *Project Action actually found itself to have a surplus of machines (Participant D, 1998). In both project sites the respective studies indicated low condom usage among main or "long-term" partners. Involvement with a long-term partners led many of the respondents to feel as though condoms were not a necessity as issues of trust entered the relationship (FRG, 1994). 4.7.2 Impressions of Program Impact Statistics of target population behaviour and attitudinal change are coupled with impressions of project implementation staff and members Project Actions advisory board. As Participant A, the program director of Project Action, revealed, "You know that you have been effective when past efforts are taken for granted." Initial response to Project Action's vending machine program was extremely tentative, concerns included the possibility of community outcry and machine vandalism (Participant B, 1998). Today newly turned 14 and 15 year olds take the vending machines for granted. With comments such as "Haven't these machines always been here?" or "Is this new?" (Participant A, 1998). These comments are indicators of a change in social norms and the acceptance of vending machines as integrated elements of community services and products. As Participant A stated, "It set the norm within the community around condom dispensing and condom use. It changed the perspective of business owners, parents, and kids within the community around condom use and accessibility". Community acceptance, as pointed out by Participant C, Project Action Outreach Specialist, also measures program impact and effectiveness for community support allowed for the continued implementation of the program (Participant C, 1998). Participant D, a representative of the Oregon-Hispanic AIDS Prevention Project, and Participant F, a member of Cascade AIDS Project, were also interviewed. Both sat on Project Action's advisory board comprised of community representatives. The interviews accounted positive impressions of Project Action's impact and work in the community. Participant D believed Project Action did a remarkable job in mobilising the community, youth involvement, and increasing youth access to condoms for a subsidised price of 25 cents (Participant D, 1998). Participant F, stressed the discontinuation of the program as the only drawback of the project (Participant F, 1998). A repetitive media message was viewed as crucial to AIDS prevention efforts. (Noted: Project Action was delivered as a two-year, stand-alone, demonstration project and not as an institutionalised program in the community). The personal interviews revealed the success of the peer-to-peer workshops in motivating sexual behaviour change. In hindsight, Project Action's outreach specialist recommended incorporating the peer skills building component early-on in the social marketing campaign. "For the highest risk youth that component was most valuable. You could give them all the tools at their disposal. You can put the condoms in their hands. You can give them the message. But, i f they cannot negotiate at 11:00 at night with their partner about using condoms. You haven't finished your job" (Participant C, 1998) 4.7.3 Program Effectiveness Monitoring and evaluation allows program implementors to assess program impact on the target population. To assess program effectiveness program and process objectives are compared with program outcomes. In conclusion no direct cause-and-effect relationship of the intervention and resulting behaviour change can be made of Condomania or Project Action. When comparing the program objectives to program outcomes, both programs were partially effective. Monitoring and evaluation serves as tool to assess impact, but is by no means an unbiased indicator. The evaluation studies are limited by the research methodology and techniques employed. The . monitoring and evaluation of Project Action indicated short-term impacts on the target population and in Condomania attitude and behaviour changes among the female target group. 68 Project Action aimed to increase condom use among sexually active youth without encouraging an increase in the level of sexual activity; to improve access to affordable condoms among the target population; to generate positive peer norms concerning condom use; to generate positive attitudes towards condoms and condom use; to strengthen and reinforce feelings of self-efficacy for obtaining and using condoms; and increase awareness of Project Action risk reduction message through broadcast and environmental media. The program was effective in effecting short term impacts on behaviours and attitudes among the target group without increasing the proportion of teens that were sexually active. However, the evaluation indicated high baseline levels of condom use and self-efficacy. This cast doubt on the appropriateness of the HIV/AIDS prevention programs targeted at "high-risk" youth . The assessment of program impact is limited to surveyed high-risk youth associated with the previously mentioned social service agencies. Impacts on youth not associated with above mentioned agencies is unknown. In addition, the evaluation was not able to discern an observable link between the Project Action vending machines and acquisition of condoms by the surveyed target population. An evaluation of process effectiveness is also a measure of program effectiveness. Project Action successfully implemented its individual program components. Measured in quantifiable minutes of Public Service Announcements, the organisation of a community advisory board, program support from a wide variety of institutions in the Portland area, a condom vending 6 9 machine operation (installation of 240 condom vending machines in locations recommended by youths), and over 85,000 sold during evaluation period (Polen, 1995). The peer-to-peer component was brought in later in the campaign its impact was not assessed Condomania broad objective over the six campaigns was to popularise condom use among young adults. Specific objectives included increasing partner communication regarding sexual relationships; shared responsibility (between the sexes for condom use); social acceptability of condoms, and self-esteem (to request and maintain condom use). Condomania's evaluation indicates the program interventions have been successful in reaching and popularising condom use among its female target population. With respect to increased partner communication no change was noted between those that had seen versus not seen Condomania (for example increased ability to talk about condoms). Females having seen Condomania were more likely to respond that condom use and purchase was the responsibility of both partners. The study indicated no significant changes in the social acceptability of condoms among females having seen and not seen Condomania. But, did notice a decline in embarrassment levels and an increase in comfort levels discussing condom use with partners among males. Females having seen Condomania were more likely to strongly agree that they always use condoms the first time they have sex with the new partner and less likely to agree that a condom gets in the way of good sex. Condomania process evaluation is measured by its deliverables. Condomania successfully carried out six transit campaigns. Recalled by a majority of the survey respondents. In addition , 70 they extended their community education and distribution of safe sex packages beyond bars to other public venues. The radio campaign trail on the sixth campaign indicated the need to purchase air time to insure broadcasting of PSA's. 4.8 Part II: Barriers and Challenges to Implementation The social marketing process outlined in Chapter II describes an implementation program from formative research, to design and planning, implementation, monitoring and evaluation, and feedback. This process forms the basis for the social marketing approach employed by both Project Action and Condomania. The purpose of this research question is to highlight the barriers and challenges faced in designing and implementing a social marketing campaign specific to HIV/AIDS prevention programs. The source of information for the following is largely based on one-to-one interviews with project implementation staff and evaluation reports. 4.8.1 Defining the Target Audience Conservative opposition affected access to the target population. In Condomania the ideal positioning for the target included pre-adolescents. Access to this group was restricted by conservative opposition and 'red tape' (Participant B, 1998, Participant C, 1998, Eason, 1994:5) In Project Action high-risk teens were accessed largely through select agencies serving youths between the ages of 12-21. Part of the program design was to survey the target population in highschools for baseline evaluation purposes via self-administered questionnaires at the school health clinics. Administrative approval could not be obtained from Portland's Public School 71 District to conduct these surveys during the baseline period and the highschool survey was abandoned (Blair, 1995). 4.8.2 Campaign Design and Promotional Challenges Both programs had their design and messages scrutinised by their media hosts. Condomania had various negative experiences with the transit advertising company, Seaboard. Interior and exterior bus posters were recommended by public promotion experts as the most effective means to communicate the message city-wide with existing funding constraints (Participant B and E 1998). But, the sexual nature of the message often led to censorship. Frustrating program staff, especially when focus groups had approved the lines thought to best reach their peer group. This was a problem in both the transit campaigns and later the radio advertising done by Condomania. Posters were also distributed in the secondary schools. But, whether they were displayed was dependent on the public health nurse's discretion (Eason, 1994). During the fifth campaign a 30-second PSA was developed to be played on the local radio stations. Positive comments were received of the scripts. Fourteen stations said that they would play the tape. In the end only three stations used the tape - all at university campuses. Depending on free air time proved to be unreliable. Both Condomania (transit and radio) and Project Action (PSA's and vending machines) incorporated design and message modifications to those more tolerated and appropriate to the media hosts. Discussion with Condomania's program director revealed a significant number of challenges in developing the campaign design. Many of the advertising and design houses did not have 72 experience in developing messages with an educational component regarding sexual behaviour change. Many designs were not relevant to the target population (Participant B, 1998). Discussions with Participant A, C, and D affiliated with Project Action revealed the importance of community mobilisation in the program design process. The project implementation team worked strategically with media representatives in Portland in the development of the media campaigns, including television stations, and public relations and ad firms. This collaboration proved to be particularly fruitful with respect to PSA broadcasting. Media gatekeeper involvement was incorporated in the PSA development. Project staff met personally with community relations managers at each of the network-affiliates and cable television stations to educate them of the risks posed to Portland teens (Participant A, 1998). Project Action and the ad firm developed the PSAs and then invited the television community-relations managers to a review and comment. Suggestions were incorporated from the networks, but the basic condom promotion message was maintained. The involvement did not guarantee network commitment to airing the PSAs. On the planned day of the broadcast, Project Action held a press conference to launch the PSAs which all local T.V. news teams attended. As a result of the press event, Portland's networks and cable television stations agreed to broadcast the PSA's over a 15-month campaign (Participant A, 1998). In total Project Action was able to secure 2,800 minutes of free air time with five television network affiliates and two cable stations (Blair, 1995). Media gatekeepers concerns of public outcry did not transpire. 4.8.3 Program Opposition Participants A and B revealed that both programs expected more opposition from conservative groups than what actually transpired. As Participant A stated, Project Action never became a "foci of conflict" (Participant A, 1998). Rather the threat of opposition was used as an excuse by business and individuals to decline participation in the program. Potential opposition was identified early-on in the Project Action design and implementation stage. Possible sources included opposition from a minority of citizens against condom distribution in highschools; the Oregon Citizen Alliance, other conservative right-wing organisations, and concerned members in the African American and Hispanic community over condom promotion. The condom vending operation a was key element of the Project Action campaign. When the program was well underway, the City of Portland allowed Project Action to place vending machines in the Parks and Recreation Centres once consent was received by the community. Project Action went to the individual communities and obtained endorsement for placing the vending machines in the recreation centres. Opposition arose at one of the centres from a right-wing Christian group. This group home-schooled their children and used the community centre for their children's recreation during the day. When this group discovered condom vending machines at the recreation centre they threatened boycott, public protest, and negative media attention. Fortunately, discussions with the group and meetings diffused this conflict (Participant A, 1998). Condomania also faced some disconcerting opposition from right-wing groups. The most troubling followed after a free condom distribution at a local baseball game. The campaign planned to attend three baseball games at Nat Bailey Stadium. Attendance at the first game was viewed as a success. Unfortunately, the stadium received a letter from an anti-abortion/ anti-condom group threatening harassment of sports fans and Condomania volunteers if they continued of these events (Participant B, 1998). Condomania was not prepared for this type of opposition, remaining stadium campaigns were discontinued (VHD, 1994). 4.8.4 Corporate/Private Sector Barriers Roughly one out of four businesses were open to hosting a Project Action condom vending machine (Participant A, 1998). The businesses were approached to place a vending machine on their premises as an act of public service. Project Action agreed to provide the machine, cover all liability, service the machine monthly, and provide free educational brochures. Many businesses declined for reasons of possible negative customer reaction, policies against vending, moral or religious objections, or existing business of selling or distributing condoms (PSI, 1994). Examples of corporate and business barriers are discussed. Project Action, with support of Oregon's health department, approached the private sector for their vending machine. Among the sites were fast-food restaurants that were local hang-outs for many teens. Initially, the downtown Burger King accepted a pair of vending machines in March 1993. Project Action, then approached the franchise owner to place vending machines at its other restaurants. The President of the Oregon franchise approached the Regional Corporate 75 Vice President upon the second request by Project Action. The Regional Vice President denied the request and ordered the removal of the existing vending machines. Project Action appealed to Burger King's national office and was able reinstall the vending machines and obtained support in a second Burger King outlet (PSI, 1994). Other chains such as MacDonalds, Taco Bell, Wendy's and Pizza Hut were not interested in any participation or dialogue with Project Action. Similar response was met by a local movie theatre chain (PSI, 1994). In addition to the transit promotion, Condomania implemented a community-education component. Condomania, in its initial campaigns approached bars and night-clubs to conduct the peer-to-peer free condom distribution by volunteers. This peer-approach was met with apprehension. The heavy message of HIV/AIDS was considered at odds with the light-hearted and fun atmosphere fostered in bars and night-clubs. But, with education bar managers became open to the idea (Participant B, 1998). Between 3 and 18 bars participated over the three year period. The condom distribution actually became a source of entertainment, with condom hand-outs, special drink orders, and contests. (Eason, 1994). Pharmacists were also solicited to distribute condoms with the pill. Pharmacies had to be educated to the idea of coupling pill prescription with condoms. Every year the dropout rate was extremely high for this initiative (Participant B, 1998). 4.8.5 Competition and Community Support Building Project Action undertook an extensive community mobilisation effort to gain support for the 76 work it intended to conduct in Portland. Part of this process involved building support allies in the community. Discussions with Project Action staff revealed that building such support was a challenge for an organisation "outside" the community. Project Action had to prove itself within the community and bring potential competitors onside. Formative research and community work 6 months prior to commencing the two year project helped to dampen potential conflicts, duplication of services, and "turf wars. Project Action over the intervention period proved itself in the community and established a committed support network. Discussion revealed that community mobilisation was key. As Participant C (1998) stated, "Without the community mobilisation, nothing else would have happened." Putting the time into community mobilisation got the vending operation off the ground and into the community (Participant D, 1998). From the outset Project Action acknowledged the need for political support of its program in the City of Portland. As Participant A stated, "AIDS prevention is political work for you are changing a culture" (Participant A, 1998). Project Action's, project director, expressed uncertainty of the lasting impacts of the community mobilisation work. Participant C, the outreach specialist, believed the effort paved the way for other organisations to approach the community with their specific initiatives and co-ordinate the health and human sector in the Portland area (Participant C, 1998). Discussion with members that sat on the advisory board revealed positive impressions of the community mobilisation effort and the program implementor's style used to gather community support (Participant D and F, 1998). Community organisations were acutely aware of Project Action's impact on promoting safe sex in the community (Participant D and F, 1998). 77 Condomania did not incorporate a community mobilisation component in its marketing strategy. It has been criticised for its lack of community participation in the development and implementation of its campaigns (Participant F and G, 1998). The program manager cited with respect to other AIDS organisations the "community was not happy with what we were doing" (Participant B, 1998). Often Condomania was believed to be encroaching on the work of other AIDS organisations (Participant B and G, 1998). Limited resources were cited for the lack of community participation efforts. Campaign feedback from the community was obtained from evaluations and anecdotal comments from volunteers working in the peer-to-peer condom distribution, bar staff, focus groups, and collected data. Condomania's presence at "raves" (all-night dance parties) was largely a result of volunteer feedback and has been well received. 4.8.6 Outreach in Ethnic Communities In both programs, evaluations and interviews with project implementation members revealed access to ethnic groups to be an on-going challenge. Portland found it difficult to maintain ethnic representation in their peer-to-peer workshop (Participant A and D, 1998). Participant A believed the challenge of maintaining ethnic representation was a factor of "connection" or affinity to the dominant values of a group (Participant A, 1998). With respect to Portland's Latino population a separate peer-to-peer group was formed to deal with issues reflecting Latino youth interests. This approach proved to be more successful in Project Action's community outreach. For future programs it was suggested that ethnic groups be more represented in the PSA's and environmental media (Participant D, 1998). Participant B, from Condomania, revealed similar concerns of its reach in the ethnic population of young adults. In the evaluation following Condomania's sixth campaign a distinction was noted of the sampled population whose mother tongue was not English. The sample indicated that ESL young adults were less likely to agree with almost all the statements relating to the importance of condoms than young adults whose mother tongue was English (FRG, 1995). Representation of diverse cultures was also minimal in the volunteer recruitment (Participant B, 1998). 4.8.7 Monitoring and Evaluations Monitoring and evaluation are key elements of the social marketing process which aims to identify the program and process effectiveness. However, in both instances the project members mentioned a less than favourable account of the evaluation process. In Project Action, measurement of the number of condoms sold to discern program impact on Portland's teens was viewed as inadequate. Project Action was a comprehensive HIV/AIDS prevention campaigns with components involving broad-based media outreach to skill development in individual teens regarding condom use and sexual health. Participant A and C commented on the shortcoming of the monitoring and evaluation system to capture the breadth of the social and psychological impact on Portland youth and the community (Participant A and C, 1998). Participant A of Project Action, noted a high-level of condom use among high-risk teens at baseline, a surprise to Project staff. At program start general population statistics indicated 50% 79 of teenagers used condoms all or most of the time. When high-risk teenagers were interviewed it revealed that approximately 80% used condoms most or all of the time. Existing data made it difficult to ascertain if the baseline was indicative of actual use or if the culture of high-risk teens prompted this response. Many of the high-risk teens had contact with agencies promoting safe sex and HIV/AIDS awareness. Participant A and C of Project Action also noted other weaknesses in the monitoring and evaluation. "The outcome evaluation was successful in capturing the views of high-risk youth that were consumers of social service agencies experienced with Project Action, we missed entirely the "bulls-eye" the highest risk youth, those practising unsafe behaviours on a regular basis and were not getting help from anywhere" (Participant C, 1998). It was stated that formative research had accessed this population for the focus groups, but the contracted evaluation had missed them entirely. Similarly, the impact on youth not at high-risk was not evaluated. The outcome evaluation also assessed failure when the intervention outcomes returned to baseline levels. The Project staff viewed this as an indicator of program success. That the interventions worked to instil behaviour change and rather there was a need for a continuous and repetitive message to sustain the behaviour. Project implementation members from Condomania also expressed concerns of the monitoring and evaluations. Participant E believed the sampled population to be an inaccurate representation of the target population. The sample at times bore a higher representation from middle and upper classes (for example, university students), possibly skewing the sample results. 80 Participant B, the program director of Condomania, commented that "there were times the questions we wanted did not get asked or were not asked in the way we intended" (Participant B, 1998). Inexperience of the contracting agent with the nature of the topic was mentioned as a possible reason (Participant D, 1998). Difficulties of ethnic representation, outreach to ethnic communities, and limited resources were other points of concern. 4.9 Part III: Barriers to Sustainability 4.9.1 Funding Funding was cited as the most significant overarching barrier for Condomania and Project Action (Participant A , B, C, D, 1998). Public service and non-profits often work with minimal funds to accomplish the most grandiose of tasks. Participant A, of Project Action, maintained fund-raising as an overarching barrier and extremely time-consuming throughout the program (Participant A, 1998). Condomania's funding was negotiated on a campaign per campaign basis (Participant B and E, 1998). Fortunately, though minimal, Condomania has been able to secure funding for all its campaigns. Limited funding and uncertainty has restrained campaign potential, impacted timelines, and event scheduling. Interviews with Condomania's project implementation team indicated the desire to use television to reach the young adult target population (Participant B and E). Resources have restrained the first six campaigns to a transit promotion and free air time of the PSA's at a local radio proved to be unreliable. Limited funding also makes the projects 81 dependent on volunteer support. The co-ordination of volunteer support required a significant allocation of time and energy by the project co-ordinators (Participant B, 1998). Project Action worked with limited resources for the two-year period and obtained a significant amount of pro-bono support from local-affiliated network stations, ad companies, and newspapers (Participant A, 1998). Participant F, a member of Cascade AIDS Project in Portland, revealed the need for a continued and sustained marketing effort to promote safe sexual behaviour and condom use. Of course a sustained marketing effort requires additional resources. In contrast to Condomania, Project Action was a stand alone, two-year demonstration campaign. There was no intention to sustain the program, beyond the two years. Two components of the Project were sustained to the communities benefit, the condom vending machine operation is an ongoing, self-sustaining, privately managed operation and the peer-to-peer approach was taken over by a local community organisation, Cascade AIDS Project. 4.9.2 Government/Political Barriers Discussion with project implementation members revealed the impact of the political environment on prevention programs. Funding often is dependent on the political environment. When Project Action was initiated youth AIDS prevention was a new, highly political topic and many organisations were competing for a limited pool of money. Today, funding for AIDS projects is even more competitive as it no longer captures the needed media and political attention. 82 4.9.3 Campaign Approach and Audience Relationship The two projects illustrated the challenge of maintaining campaigns that are fresh, new, and relevant. Condomania noted a lack of interest by bar managers with each subsequent campaign. By the fifth campaign bars and night-clubs had become saturated and bar managers did not wish to extend activities and patrons took the campaigns for granted (VHB, 1995). Participant B acknowledged that with campaigns "everything has a lifespan to it." Highlighted was the importance of being aware of the target population needs and wants and incorporating timely changes. Project Action, overall was successful in their design of the Project Action logo and messages. Described as "hip" and youth oriented (Participant F, 1998). Participant C mentioned in retrospect the desire to develop more environmental media, such as T-shirts and posters, and distinct themes for each PSA rather than one overarching theme. 4.9.4 Institutionalisation Condomania is managed by a public health organisation and government funded. The program has been sustained since 1991. This suggests that sustainability may be achieved if such programs are incorporated into existing institutional administrative frameworks of a community. But, discussions with Project Action staff revealed that many of their accomplishments were dependent on their being a non-profit organisation with no affiliations and ties with existing organisations. As Participant C commented, "There was no way we could have done what we had done had we been a public institution. There was no way we could have got the ads on T.V. or the condom vending machines up. It just wouldn't have happened. Being an independent non-profit was very helpful" (Participant A, 1998). Project Action undertook an extensive 8 3 community mobilisation effort to build a relationship of trust with the community, existing organisations, businesses, publics, and non-profits. The replication projects support this perspective. Implementation of such public health projects in existing institutions have involved challenges such as dealing with hierarchical administration, red-tape, "turf-wars", government regulation, and clashing personalities. 4.10 Future of the Programs: 4.10.1 Project Action Project Action is still located in Portland, Oregon. It is no longer involved in HIV/AIDS reduction in Portland, Oregon. Instead, it serves as an informational source for replication projects in Seattle, Washington and San Jose, California and any other communities initiating similar project. Modification was recommended of the component parts, that would first emphasise community mobilisation, followed by youth involvement (peer-to-peer), media, and a condom vending operation. This sequence was considered to be a more appropriate layering of the components and more efficient use of limited time and resources. Though the projects applied component elements developed in Portland they are both unique to their community and face their own distinct challenges. 4.10.2 Condomania After the sixth campaign, Condomania incorporated continuous advertising in its condom promotions. Upon FRG's evaluation, Lower Mainland Young Adults and Condomania (July 84 1994) Vancouver/Richmond Health Board refocused it efforts. The evaluations indicated that successful attitude and behaviour changes had been achieved in the female target population. Males, however remained resistant to change. As of 1995, funding was secured for four more campaigns. A new design house was approached to reach the male target population and medium for the advertising changed. Radio though more expensive was chosen for it had a far greater reach than transit alone. For the first campaign three advertisements were commissioned and two flights of advertising time were purchased (VHB. 1995). The last three campaigns comprise continuous advertising component coupled with promotions on bus shelters, and interior and exterior transit advertising. The radio advertising again faced issues of censorship and funding issues. Evaluations of these campaigns indicate positive behaviour change associated with the interventions in targeted male population. The challenge of using condoms in long-term relationships still remain. The evaluations also indicated the continued difficulty in reaching respondents whose first language was not English. The last Condomania campaign was held in fall of 1996. Presently, the Vancouver Health Department is re-focusing its efforts and future resources to reach pre-adolescents and adolescents. 85 5. Chapter 5: Social Marketing and AIDS Prevention: Lessons Learned and Recommendations 5.1 Introduction HIV/AIDS presents a complex biological and social dilemma to societies world-wide. Social marketing offers a tool to health managers to promote safer sexual behaviour. The theoretical approach which draws largely from marketing principles sets out a strategy to proactively change human behaviour. Its application to HIV/AIDS prevention aims to influence safer sexual behaviour, largely through the increased use of condoms. Illustrated in this research is the impact of social marketing campaigns on safe sex behaviour and the implementation challenges that the theoretical approach faces in practice. The three research questions re-stated from the introduction aimed to: 1) identify the impact of the respective marketing strategies on the target population; 2) identify barriers and challenges in the implementation process; 3) identify barriers to future sustainability of the discussed AIDS prevention efforts. The research questions aim to learn from past experience in order that more effective HIV prevention programs targeted at youths and young adults may be developed in the future. By comparing and contrasting the above mentioned programs strengths and weaknesses are noted. The following is a summary of the lessons learned from which recommendations are drawn. 5.2 Impact of Market ing Strategy: Implications to Practice The case study analysis indicates both marketing campaigns to have a positive impact on behaviours and attitudes regarding condom use, at least in the short-term in Project Action and among females in Condomania. The impact evaluation is an indicator of the campaign on the 8 6 target population. The evaluations indicated behaviour and attitude change that corresponded to intervention intensity (Project Action) and awareness of the campaign (Condomania). However, in both instances no direct cause-effect correlation could be made between the interventions and the increased condom use. Evidence from formal and informal research suggest interventions have invoked behaviour and attitude change in the target populations. The evaluations also highlighted points of resistance in the target population regarding attitude and behaviour change. As in Project Action, youth respondents did not vary considerably from the baseline - 60 percent - in actual behaviours to reduce their chance of contracting HIV/AIDS. In Condomania three out of six campaigns were targeted at males or both sexes. But, male responses indicated only a minimal shifts in behaviour and attitude change regarding condom use. However, the limitations of the evaluation should be acknowledged before interpretation is made of the results. These limitations are discussed in the introduction and in-depth in sections 4.9.7. and 5.3.4. 5.2.1 Peer-to-Peer Approach Though awareness and recall of Project Action was high, the challenge of behaviour change remained. Discussion with Project Action staff and YouthCo (a Vancouver community organisation serving the needs of HIV positive and negative youth) highlighted the need for youth and young adults to develop skills to negotiate condom use. Project Action's social marketing campaign incorporated such an element during its intervention, the peer-to-peer workshops. This program was developed and managed by teens and transferred to Cascades 87 AIDS project when Project Action terminated. The objective of the peer-to-peer workshop was to help youths develop skills to better negotiate their sexual health. The workshops were not in the initial program approach, but monitoring and feedback identified this need in the community, Participant C, Project Actions Outreach Specialist, recommended that this component be fully integrated and initiated early on in the social marketing campaign. As Participant C stated, the peer-to-peer component was most valuable to the highest risk youth. 5.2.2 Repetitive/Continuous Message The most significant sexual behaviour change among the target population was an increase in condom use among other/new partners in both social marketing campaigns. Project Action's evaluation revealed the behaviour change was not sustained, dropping-to baseline levels with the intervention's termination. Possibly implying the need for a continuous and repetitive message to sustain the desired behaviour (Hornik, 1997). Messages promoting sexual behaviour change are characteristically high involvement decisions requiring individuals to negotiate a range of social and cultural influences. Significant changes in individual behaviour are likely to occur over an indeterminate period of time as the individual moves from awareness to action. Campaigns ideally should be planned over the long-term and incorporate a comprehensive monitoring and evaluation system to feedback into future campaign design and planning. Condomania's campaign has been ongoing since 1991, and has incorporated a successful monitoring process to identify target needs and information gaps. This knowledge is then used to refine and develop the upcoming campaign. 5.2.3 Selective A wareness Both campaigns set out to increase condom use among main/steady partners. The case studies reveal the prevalence of strong socio-cultural values that resist condom use among main or "long-term" partners. Pre-existing sexual beliefs and values compete with campaigns promoting safe sex. In both programs condom use among main/steady partners did not vary considerably. Considering the definition of main or long-term relationship (from months to years) and the number of such relationships an individual may encounter over a lifetime makes the lack of condom use highly problematic. This information assesses the need for future campaigns to emphasise the implications of multiple sexual partners and disease prevention. No solution is offered regarding message design and program development to overcome socio-cultural obstacles, except acknowledgement of this challenging task. 5.3 Common Implementation and Sustainability Barriers Lesson Learned - Implications for Policy, Practice and Research The social marketing approach outlines a process to conduct a campaign resultant in behavioural changes. The key elements of which are formative research, design and planning, implementation, monitoring and evaluation, and feedback. Discussed are lessons learned with respect to overcoming implementation and sustainability challenges, where feasible recommendations are provided. Issues offering no practical solutions serve as indicators of areas requiring additional research. 5.3.1 Community Mobilisation Community mobilisation played a crucial role in the successful implementation of Project Action's component elements. The community mobilisation effort had specific objectives that included: • creating support, coalitions, building trust; • working closely with the community to posit its goals and developing a niche in the community for its HIV/AIDS prevention efforts and avoid duplication of services; • to define the target population - affirmed through youth focus groups, input from state health departments and community focus groups; • diffusing controversy and preparing for conservative opposition; • gaining support of corporations and businesses who were approached to join in the AIDS prevention effort by supplying condoms or housing the condom vending machines. (Many businesses expressed apprehension with the vending machine operation, and campaign design, promotion, and distribution.) • gaining support of the media gatekeepers who in the end aired the PSA on a partially pro-bono basis. PSI initiated the community mobilisation effort 6 months prior to launching the program. Outreach involved presentations, discussions with groups and organisations and media coverage. Community mobilisation methods such as presentations and media were helpful in building support, allies, and community ownership of the program components, while at the same time 9 0 diffusing program opposition. This proved a fruitful exercise for Project Action and initial efforts laid the groundwork for successful implementation of the program (PSI, 1996). Vancouver/Richmond Health Board's Condomania program has been in existence since 1991. The program took a more ad hoc approach to community participation inviting schools, public health nurses, and other agencies serving the HIV/AIDS sector to meetings when developing their campaigns. Interviews with community groups, specifically AIDS Vancouver and YouthCo have stated the need for organised community participation with respect to STD and HIV/AIDS prevention in the Vancouver area. Interviews with the program director revealed many setbacks and communication breakdowns, potentially reduced or entirely avoided had there been more community involvement. To date, limited funding has constrained organised community participation to ad hoc meetings. It is recommended to take a more organised community participation approach. Possibly, future government funding requests could specify the need to develop a 'round-table' where various groups (e.g. youth clinics, heath services, HIV/AIDS community services) working in the field of sexual health could advise and collaborate among each another. Such an effort could help guide the strategic direction, possibly co-ordinate action, and share existing resources (Eason, 1994). A less formal community participation could also be initiated. Resources to develop community participation frameworks are available at the School of Community and Regional Planning. The school's internship program could be utilised to develop a participatory planning framework and process on sexual health or specifically HIV/AIDS prevention on a pro-bono basis or at a reduced costs. 9 1 5.3.2 Campaign Relevance/Design Condomania and Project Action found maintaining campaign inertia and freshness an ongoing challenge. Project Action found youth involvement an effective strategy. Studies indicate target audience involvement in the design and implementation process makes social marketing programs much more successful. In Project Action all program components included a youth element. It is youth that decided the message content and design; vending machine locations, and direction of the peer-to-peer workshops. Project Action's design was characterised as "hip" in discussion with Participant F, a member of Cascade AIDS projects. It was youth that included the abstinence message in Project Action (Participant D, 1998). This authorised youth to have ownership of the program and was a reflection of their social and physical environment. This involvement translates into greater ownership, better communication, and increases the likelihood of sustaining interest, reflection, and behaviour change. For future reference, Project Action did learn from its experience to develop a media approach with a longer life span. For example, rather than developing one theme and three PSA's under that theme (Condoms falling out of sky in different circumstances), to develop three distinct themes to maintain freshness, attention, and extend the broadcasting period. Condomania used formative research, peer-to-peer community education, and focus group testing as channels to tap into the ideas and perceptions of young adults. After the fifth campaign the program implementation team noted a change was necessary in their media campaign. Funding largely impacted design, message development, and distribution in both programs. 92 5.3.3 Outreach in Ethnic Communities Both programs experienced problems reaching ethnic groups in the target audience. In Project Action's peer-to-peer workshop, maintaining ethnic representation reflective of Portland's population proved to be an ongoing challenge. Condomania noted a distinction in the sampled population whose mother tongue was not English. ESL young adults were less likely to agree with nearly all the statements relating to the importance of condoms than young adults whose mother tongue was English (FRG, 1995). Identifying the barriers to ethnic communities would foster more effective communication and co-operation. Studies indicate culture and language create social distance between campaigns and the target community (Flora et al., 1997). The case studies indicate the need for programs to develop mechanisms to more effectively reach ethnic communities. Until modifications to message content, design, and distribution are implemented, groups within the target population will be entirely missed. 5.3.4 Monitoring and Evaluation The social marketing approach relies heavily on research, monitoring, and evaluation. The case studies revealed the difficulty of obtaining accurate and representative research. Formative research is essential to message design and content. But, issues of obtaining a representative samples emerged. Project Action in its formative research set out to identify its target population's attitudes and behaviours surrounding condom use. The formative research revealed results upon which the program components were developed. Specifically, the vending machine operation to provide access to condoms discretely and at subsidised prices. In later monitoring 93 and evaluation, the sample did not identify accessibility problems, nor were vending machines cited as a condom supply source. Rather, teens over the intervention displayed increasing self-efficacy to obtain free condoms. The survey method was successful in identifying teens who had access to social service agencies. But, the evaluation missed entirely the target population that was identified in the formative research. High-risk youth who did not have access to support agencies or structures. Shortage of funds resulted in Condomania unable to complete its monitoring and evaluation. For the second campaign Condomania was unable to continue the telephone survey or the in-depth interviews. In addition, obtaining a representative sample of the target population was expressed as a concern. Program staff also revealed concerns of the evaluations to fully discern the socio-economic impacts of the program on its target population. For example, the impacts of the peer-to-peer workshops that addressed issues of self-esteem and personal growth could not be measured by the number of condoms used or distributed. The case studies identified the need for additional research in developing more comprehensive research methodologies to better capture the larger impacts of the respective campaigns. 5.3.5 Competing Behaviours and Organisations Social marketing programs are party to competition. Multiple forms of competition were identified in the case studies. The most basic being pre-existing attitudes and behaviours surrounding sexuality that comprise the status quo. Another form of competition is 9 4 organisational competition. Project Action and Condomania both witnessed issues of apprehension and hostility from competing non-profits working in the HIV/AIDS community. Project Action underwent an extensive community mobilisation process to develop a niche and community support, where Condomania undertook an ad hoc community groups meetings and identified heterosexual young adults as the target group. The lesson learned from the two case studies is for the social marketing programme to anticipate and plan a strategy to overcome these competing forces and to reinforce the benefits of behaviour change. Project Action found community mobilisation a useful tool to deal with competition. 5.3.6 Funding Funding was an on-going challenge for both projects. Obviously with more funds and resources more extensive programs could have been developed. Condomania negotiated the budgets on a campaign-to-campaign basis. Condomania's program implementation team member mentioned that additional funding would have allowed access to television, indicated by research the most preferable media form to reach its target population. Resources restrained the first six campaigns to transit promotion. Free air time of PSA's at local radio station proved unreliable. Project Action pursued various avenues to bring the program into fruition. Pro-bono support was obtained by a local ad agency and from the network affiliates. Project Action also illustrated the successful utilisation of academic resources, a local graphic design school in developing promotional material and used interns in their program. 95 Publics and non-profits are always struggling for a limited pool of funds. Further research is needed in how sexual health programs can promote safe sex behaviour with limited funding. Possible avenues for financing and resource sharing include public-private partnership research. For example, a relationship could be developed between a public health agency and or condom or lubricant companies. Another avenue is seeking pro-bono support from ad agencies, television and radio networks, and local schools. 5.3.7 Institutionalisation Condomania is implemented through a public health organisation and is government funded. The program has run successfully since 1991 and its last campaign was held in the fall of 1996. Project Action was a stand-alone two-year project. Suggesting the institutionalisation of sexual health programs could be achieved if such programs are incorporated into existing organisations. But, interviews with Project Action team members indicate otherwise, namely that because Project Action was a not affiliated with any one organisation far more extensive results were achieved. Project Action's replication project supports this perspective. Implementation of these public health projects in existing institutions highlighted issues of hierarchical administration, red-tape, "turf-wars", and clashing personalities. An extension of this research would be to compare the replication projects to Project Action in Portland. Such research would be useful at several levels, to compare the impact and implementation of a stand-alone demonstration project versus one incorporated in existing institutions; the replication of PSI's teen risk reduction social marketing program (e.g. five components); and, test the program modifications incorporated from the lesson learned in PSI Project Action 9 6 5.4 Implications to Theory and Planning The case study research was specific to social planning with its focus on public health and health service delivery. The incidence of HIV/AIDS is growing world-wide and presents a serious public health policy concern to communities. To date, new treatments offer hope, but there is no cure. Prevention remains the only option. The challenge posed to societies is affecting the necessary behaviour change to slow the disease's spread. Social marketing offers one approach to change. Social marketing seeks to understand the behavioural motivations of its target population. Repeatedly, studies have indicated that education alone is insufficient to induce a desired behavioural change. Especially, if those benefits are not immediately recognised. Nor is law always the most effective or appropriate means. If behaviour change is to occur, barriers to the desired behaviour must be removed. Social marketing seeks to understand and remove these barriers. These barriers may be internal such as lack of awareness or external such as access to products or services to carry out the behaviour change (Mackenzie-Mohr, 1998). Understanding human motivation to effect behaviour change is applicable to a range of planning issues. The approach is avidly being applied to promote sustainable development through the . promotion of sustainable behaviour. It is being used to promote alternative transportation, water conservation, energy use, and recycling efforts. Social marketing lends to the planning field a tool to further the public interest. It has been successful in inducing social behaviour change that has implications to individual, social, and public health in the broadest sense of the term. 97 Social marketing as an approach is an evolving process. More recently there has been a movement toward community-based social marketing. This transition signifies the melding of planning and business approaches. Project Action incorporated community mobilisation in its social marketing program. Both project implementors and community spokesperson accounted to the benefits of such an approach to project implementation and community support building. The planning field encompasses community development, participatory planning, and public policy related issues. In this respect social marketing can draw and learn from the planning tradition. 5.5 Social Marketing Theory to Practice: A Final Comment Social marketing offers an innovative, disciplined approach to HIV/AIDS prevention. Evidence indicates that the approach, though imperfect, does lead to positive behaviour change. Marketing, ideally applied to the selling of goods and services, also has proven to be a valuable tool in the public and non-profit sector. Marketing draws from a range of disciplines, such as, anthropology, psychology, sociology, and economics, to influence individuals and social norms that a given product and/or service is desirable, wanted, or needed. It has successfully sold smoking, Levi's, and draft beer to millions within North America and abroad. The argument forwarded in this research suggests marketing's theoretical underpinnings can be used to instil positive behaviour change that benefits the individual and society, specific to this research increase safer sexual behaviour. The social marketing approach aims to develop a campaign that effectively and efficiently 98 reaches its target audience. It involves the development of a marketing strategy that incorporates the principles of a customer-orientation, including, understanding the customer's needs, wants, values, and perceptions. The marketing mix: price, product, place, and promotion are individually and interdependently considered when developing a marketing strategy. Research is key in the formative, process, and summative parts of the social marketing process. The iterative and cyclical process built into the marketing methodology allows for timely feedback. Monitoring and evaluation makes it possible for an agency to take necessary corrective actions and lessons learned can be applied to future campaigns. The above characteristics give social marketing its edge, versus more traditional approaches such as education and media. Forwarded in this thesis is the application of marketing techniques to AIDS prevention efforts. Specifically the application of social marketing to AIDS prevention aimed at youths and young adults. The evaluation revealed the marketing campaigns were regarded as 'hip' and relevant to the target population. The case study analysis indicates both marketing campaigns had a positive impact on behaviours and attitudes regarding condom use, at least in the short-term in Project Action and among females in Condomania. But, similar to other programs the challenge of sustained behaviour and attitude change remained. It appears the issue is not awareness, but behaviour change with respect to disease prevention. Studies indicate the need for continual programming to challenge social sexual norms, repetitive messages, and incorporating sexual health negotiation skills in campaign programs work to sustain safer sexual behaviour. With respect to implementation, social marketing offers a systematic approach to reach its target 99 audience and carry-out a marketing campaign. The case studies reveal some of the intricate challenges of the implementation process with respect to STD and HIV/AIDS prevention. The sensitive nature of HIV/AIDS and pubic/non-profit sector orientation of the efforts did present some common implementation barriers, which included conservative opposition, corporate and business apprehension, censorship, and funding. Budget and resource limitations fed into other issues of campaign design, implementation, outreach activities, and monitoring and evaluation. The study did reveal the power of community mobilisation to counter many of these implementation problems. The case studies also acknowledged the importance of research in the social marketing process and the difficulty presented with survey research upon which campaign impact and effectiveness is assessed. Lastly, the research presented imparts the need for ongoing examination of the application of social marketing to HIV/AIDS prevention. 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Personal Interviews: Interviews with Project Manager and Team Member of Condomania. Permission Granted Participant B, E - July, 1998. Interviews with Project Manager and Team Members of Project Action. Permission Granted. Participant A, C, D, F - July, 1998. Interment Sites: 1 0 5 Appendix 1 : Behavioural Theories The following describes some of the theories that form the foundation for AIDS prevention interventions. These theories indicate the diverse range of factors and variables affecting human behaviour. A l l the above theories hold certain assumptions of human behaviour which in turn define the duration, form, and implementation of prevention interventions. In practice, no one theory applies to the diverse circumstances and audiences that are the focus of AIDS prevention efforts. It is likely, that social marketers will find themselves employing a combination of behavioural theories in their prevention program. The Heath Belief Model: The Health Belief Model (HBM) is the predominant model used by health professionals to explain health-related behaviour. H B M uses several variables to explain an individual's likelihood in engaging in preventive health behaviour. The variables include: the individual's perception of their susceptibility (or risk) to the disease; perception of the disease's severity and consequences; that protective actions will be effective in reducing susceptibility and/or severity; that perceived benefits of performing the preventive behaviour outweigh the anticipated barriers and costs; cues to action (e.g. physician advice, death); demographic, structural and social/psychological factors to enable behaviour (Rosenstock, 1994, Fishbein et al, 1997) and self-efficacy the "conviction the one can successfully execute the behaviour required to produce the outcomes" (DiClemente and Peterson, 1994:9). 106 The above stated variables are hypothesised to have a multiplicative relationship with one another. For example, the likelihood of condom use as a means of preventing HIV infection will be greater when people perceive themselves as susceptible to HIV infection, perceive the consequences of infections as very severe, perceive protective action to be effective, see few costs or barriers to self-protection (such as embarrassment over condom purchases, have a cue to action (such as a physician, peer-group), and have the skills to carry out the protective behaviour themselves(Valdiserri, 1989). However, the H B M has several specific weaknesses. Studies indicate that perceived severity or risk does not always translate to predictable behaviour and preventive actions are not reflective of the severity of a condition. Health promotion research indicates information alone is often inadequate to get people to change a health-related behaviour (Valdiserri, 1989), as illustrated by HIV/AIDS and the persistence of risky behaviour (Wagman, 1993, Valdiserri, 1989) Theory of Reasoned Action The Theory of Reasoned Action provides information of the links between knowledge, beliefs, attitudes, and behaviour. "The theory holds a person's intention to act as an immediate determinate of behaviour. Fishbein et al (1994) identify two factors affecting intention: 1) one's overall positive or negative feeling (attitude) toward performing the behaviour and 2) one's overall perception of the social pressure/subjective norm to perform or not to perform the behaviour. Subjective norms are viewed as a function of normative beliefs, acting as references and motivation for behaviour (Fishbein et al, 1994). 107 Social Cognitive Theory Social cognitive theory identifies self efficacy (e.g. the belief that one has the skill and abilities necessary to perform the behaviour under a variety of circumstances) as a necessary component for behaviour change (Fishbein et al, 1997:125). An individual belief in their ability to carry out a behaviour, increases the likelihood of positive behaviour change. Learning Theories: Learning theory emphases the identification of environmental conditions leading to a desired and maintained behaviour. The theory of operant behaviour falls into this category. This theory relies on environmental reinforcement to explain and maintain behaviour. When applied to AIDS Prevention it helps identify the environmental reinforcements that maintain high-risk behaviours. For example, visits to bath houses or shooting galleries place individuals in circumstances where there is a higher likelihood of contracting AIDS: sex without condom and sharing IV needles. Operant theory allows the identification of harmful environmental stimulus and with self-monitoring eliminates them or recognises them as cues to a given behaviour (Valdiserri, 1989). Transtheoritical Model of Behaviour Change/Stages of Behaviour Change: Often behaviour change occurs gradually. Five stages have been identified in behaviour change process: 1) Precontemplation, in which people do not seriously consider protecting themselves; 2) Contemplation, in which an individual considers and forms an intention for behaviour change; 3) Preparation Stage, which involves further forming of the intention and possibly exploratory 108 attempts to adopt behaviour.; 4) Action Stage, which involves adopting a new behaviour, and 5) the Maintenance Stage, is when it becomes a routine part of everyday life (Fishbein et al, 1997) Accurate identification of these stages leads to more effective prevention interventions. For instance, at the precontemplation stage, the intervention may concentrate on raising awareness (e.g. PSA's on HIV/AIDS), while at the Action Stage, efforts would emphasise making the behaviour change accessible (e.g. distribution and availability of condoms) (Fishbein et al, 1997. Theories of Fear Arousal, Motivation and Emotion: In order to better explain observed human behaviour, theories of emotion, especially fear, have been integrated with cognitive theories. There is evidence of successful applications of fear to achieve behaviour change. But, it is also known to produce dysfunctional effects that interfere with the behaviour change process. Fear can also cause anger in individuals resulting in target groups to disregard messages. Campaigns targeted at the gay community in the initial years of the AIDS outbreak were regarded with scepticism and as originating from persons/ organisations opposed to the lifestyle. Fear may also instil a fatalistic response and inhibiting behaviour change. Interestingly, research indicates that regardless of the fear generated communication, people show greater acceptance of a recommended behaviour if they perceive its effectiveness (Sutton, 1982 in Valdiserri, 1989). 109 Appendix 2: Survey Questions Interview Questions: To Project Management Team Members: (Modified for Community Representatives) Name (Optional): Title: Sex: Age: Educational Background: Program History: 1. What brought the program about? 2. How did you become involved with the project? Marketing Strategy: 1. What was the criteria used to segment the target population? (Enough info, available?) 2. Was the target market too broad/narrow? 3. What stage was the target audience? (Precontemplation/Action) 4. What was rational for the marketing strategy? Project Action(Vending Operation) Condomania - Transit and Community Education b. Overall, was the program effective? How would you evaluate it? 5. What was rational for the pricing? 6. What did the product consist of ? b. Was promoting a female condom ever considered? 7. What was the rational for the chosen communication/promotion channels? b. How would you evaluate the communication channel(s) Project Action: PSA's, Environmental Media, Peer-to-Peer c. Of the communication strategies employed in Project Action/Condomania what do you think was most effective? 8. What methods were used for monitoring and evaluation? b. How would you assess and evaluate the monitoring and evaluation? c. Was there problems with obtaining data? and correlating/associating it with program strategies? d. Do you think that monitoring and evaluation was helpful in the program implementation? Would you do things differently in the future? 9. What is your criteria for an effective program? b. Was this criteria met? Implementation Process: 1. What barriers did you face (question specific to each program) Project Action (re: community moblization, Safer Sex Media Campaign, Condom Vending Operation, Peer Motivation, Research and Evaluation) Condomania (re: transit, community education, environment media, Radio PSA) 2. What was the initial community response? Apprehensive? Positive? 3. What was the initial community response? i n 4. What part did the community play in determining price, product, place, promotion? 5. What impact did conservative forces in the community have on the marketing strategy? 6. Was there ever concern over a duplication of services with other organizations? Community Assessment: Specific to Project Action? 1. What prompted the community mobilization strategy? 2 . How did this work? Did community mobilization make a difference? 3. Do you think community mobilization had lasting effects in the community? Is it being replicated? Specific to Condomania: 1. Was community participation/mobilization a part of the campaign strategy? a) If yes, how? b) If no, what was used instead to ascertain community concerns? c) Would Condomania do things differently- in terms of community involvement? Role of Government: 1. What kind of role did local and state government play in the program? 2 . How did government involvement/affiliation influence design and program implementation? Management 1. Did the program have adequate funding, resources, facilities? 2 . What were the funding sources? 3. In terms of management would do any thing differently, timing, scheduling, human resources? Sustainability 1. How has the availability of funding impacted program implementation and sustainability? 2 . What do you perceive as the most significant barrier to sustainability to the program? Is these any one thing that stands out? Funding, Cultural, Political, Infrastructure? 3. What is the future/direction of the program? 4. Did the fact the program was implemented by a non-profit/government organization make a difference in terms of implementation and sustaining the program over the long-term? 5. What is the future of this program and your involvement? Thank You. 1 1 2 Appendix 3: Project Action Media Campaign Source: Convisser, J. and Isleli, N . (1996) Social Marketing in Action: Resource Guide to Strategic Media Campaign. Based on Project Action. Washington, D.C: Population Services International. Convisser, J. and Isleli, N . (1996) Social Marketing in Action: Resource Guide to Condom Accessibility Using Condom Vending Machines. Based on Project Action. Washington, D.C: Population Services International. DO NT EVEN T H I N K a b o u t F F O I w i t h o u t st C O N D O IV! Still shots from one of Project ACTION'S televised public service announcements. a a I N D T H I S fflschifi D O N T E V E N " T H I N K I I a b o u t s e x ! W I T H O U T A CONDOM Environmental media materials, such as this two-sided key chain produced by Project ACTION, are an effective means of getting the message across. Project ACTION condom vending machine at an outdoor community fair. Don', even THINK a W SEX wiflwui P r o j e c t >.c{.on v e n d i n g m a c h i n e s s e l l Kigh-<ru.ili(y latex. conJorrts f o r 25 c e n t s . D O W N T O W N : DjangoRecords... Y W C A Downtown... London Underground... Commodore Cafe... Pacific NW College of Art-. Modem Media Productions... TeleCafe.. Plar.el Rock... Sig Bang... X-Ray Cafe... TKc Quest.. New Market Theater Building... Turntable K t r / ' l . Coffee People... Hot Lips Pizza... NORTHWEST: Powell's City of Books.. Machccsmo Mouse... Howling F r o g -Cinema 21... Pizza Oasis... Blah Blah Cafe... Everett S t Cafe... OZONE Records... Roscland Theater... Ola Town AFS Office... Old Town Cafe... B.Y.O.B.... Friendly House... SOUTHWEST/OUTER WEST SIDE: Ho( Lips Pizza... Dragon Herbarium... B a r b u r Foods. . M u l l n o m a h A r t Center. . . P C C S y l v a n i a Csepus . . . N O R T H / N O R T H E A S T . : Monlavilla Community Center... University Community Center.. PIC Youtli Employment Institute.. S t Johns Community Clr . . . Alberta I 28<h S t Market... Penninsula Park Ctr. One Stop Records... Winehell a Donuls... Albina AFS Office... N . Portland A F S Office... N E Portland A F S Office... Astro/Interstate Grocery... American Dream Pizza... Northeast YWCA.. Columbia Pool. O.S. Varieties... M i Ranchilo... M a l l Dishman Pool I C l r . . . YWCA of St JohnV. Morgan's Child.. Golden House of Style... PCC Cascade.. Sandy Barr Flea Market.. SOUTHEAST: Cafe Lena... M t Seolt Community Clr - . . Think Good Tnoughls.. Directions Hair Salon... Clinton Street Thealer.. Sellwood Community Ctr. Machecsmo Mouse-. Sea Tramp Tattoo Bldg... Produce Row Cafe... Powell's Books... City Skate... Southeast AFS Office... Music Millennium... One With Heart.. L a Luna... Rip Ci ty Pizza.. 12 Step Haven... Caswell's Coffee.. . Break Time Arcade Coffer Isle... Grateful Head Salon... OUTER EAST SIDE/GRESKAM: Easl Portland AFS Office... M.H.C.C. I Aoualic Center... Rose Bowl.. U.R.S. Club... L i Iguana Feliz... Winehell's... El Sombrero... Planned Parenthood H I L L S B O R 0 / B E A V E R T 0 N : Youth Conlae l Office... Su Caaa Imparls... Budget Tapes L Records.. Four Seasons Bowling... PCC Rock Creek This poster was designed for Project ACTION by a student at a local community college in Portland, Appendix 4: Condomania Media Campaign Source: McDougall, G. and Weinberg, C. (1997) Marketing: Canadian Marketing Cases and Exercises. Toronto: McGraw-Hill Ryerson Ltd. 1 1 7 Poster Advertisements/Sample Packet Condom P a c k a g e A l w a y s u s e your condom s e n s e * *.-•, •jeuejeAa.AiiddenaAjTyy--' •-; ^ Call forconfidential information orc;''^f-Sexually Transmitted Diseases^ 660-6161: • „ - \ A I D S - • AIDS VANCOUVER HELPLINB'' '• 687-243T.- >.\r \ ' \ ' •• ' B.C.AIDSUNE^J : - .V ;••]. . 872-6652:••AV^:: • -• ; Sponsored by: • Vancouver Health Department,: Get it on, before you get it on:. peoi am JOJ auo s ^ a g e ^ ^ ^ f ^ Something has to go on before SBK..".-\ inpapuoM piie ia« JI ejpinik-:*.v'i'Sa* T'-Srj^r?'-' Sexually Transmitted Diseasess?'^?^ ' •' AIDSfr?'«' ••• M : >:<-v 'M-AIDSVANCOUVER HELPLINEi'' JSFTC* <T B.C. AIDS UNET 872-665ZV " I Sponsored bySr^- ' ' ^ ; V / ^ Vancouver H e a l t ^ e p a r t ^ ^ ^ ^ ^ ^ The latest in intimate apparel.-. xas •aje^9A(JTs%i^:vi^t^ 118 Poster Advertisements/Sample Packet Bus Poster 1 2 0 


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