Social Marketing for Health: Did It All Begin with Condoms?
This report explores the contributions that contraceptive social marketing (CSM) has made throughout the last 40 years in Afghanistan, Bangladesh, India, Indonesia, Nepal, Pakistan, Sri Lanka, and Yemen. It is based on the experiences of international health consultant John Davies, who presented his insights at The World Social Marketing Conference (Brighton, United Kingdom (UK), 2008). The report includes key lessons learned, and how those lessons can be applied to such issues as maternal and newborn survival.
Davies begins by examining the expansion of CSM from its 1968 South Asian "cradle" in India to 67 countries in 2007. Based on his experience, Davies outlines the following contributions and lessons learned:
- CSM helps meet national goals. Example: In 2007, CSM provided 40 million couple-years of protection (CYPs) via the private sector. [One CYP is the estimated quantity of a contraceptive method required by one couple for one year.]
- CSM brings private-sector resources to assist hard-pressed public sectors. Example: CSM adds many new outlets such as pharmacies, private doctors, and community groups. CSM also adds behaviour change communication (BCC) such as mass media, entertainment, community groups, and trained private providers.
- Evidence-based approach - Social marketers insist on the centrality of evidence-based planning that includes rigorous monitoring and evaluation (M&E).
- Entertainment informs and changes behaviour of uneducated groups. Example: Davies has found that live, travelling stage shows succeed well in remote areas where access to television and radio is low. Davies has developed a simple system for increasing birth spacing that is designed to lead to a combination of improved health for mothers, newborns, and infants as well as fewer pregnancies and births. This social marketing approach, which features a "Tell the Truth" component, is especially catered toward uneducated, economically poor mothers who state that they want to space their pregnancies, but lack the correct tools. As an illustration, he discusses a project (managed by Population Services International and supported by the United States Agency for International Development (USAID) and the Packard Foundation) centred around an open-air soap opera designed to teach women how to space births using the oral contraceptive pill. In the example he gives, approximately 200 people watch an outdoor soap opera in which a young mother quarrels with her husband and mother-in-law about whether to use contraceptives. Then a character playing a doctor enters and explains the truth about the pill. After the show, young mothers, their mothers-in-law, and children squeeze into the tiny office of the real village doctor, who sold the pill to some mothers after screening them.
- CSM programmes train health providers - Some CSM programmes, such as the Greenstar Social Marketing Company in Pakistan, offer large-scale, high-quality in-service training for health providers where governments do not.
- Key groups want different benefits: Mothers want better health for their children and themselves; fathers want fewer household expenses; mothers-in-law want more grandchildren, especially boys; governments want fewer births.
- Husbands can have key roles as suppliers of female contraceptives - In some Islamic countries, husbands are major shoppers while wives remain at home. Example: A Bangladesh study of disadvantaged couples showed that husbands of pill users often decided which brand to use, purchased the product, carried it home, and explained correct usage to his wife.
- Long-term methods such as intrauterine devices (IUDs) and contraceptive injections may be better choices for disadvantaged couples than condoms or Pills. Example: A Bangladesh study showed that most illiterate mothers who used short-term methods such as condoms or pills, became pregnant within one year.
- Use successful commercial marketing methods - Example: Prior to the CSM era, condoms were stocked mostly in pharmacies, but not displayed. But in 1972, PSI's Kinga social marketing pilot project in rural Kenya brought condoms out of hiding and into cardboard dispensers. Today, CSM condom dispensers are seen in many thousands of places, such as tobacco stalls and small general stores.
Next, Davies discusses what he calls the CSM Monitoring Method, which is based around the "Four Ps":
- Product: Includes the basic product, such as a contraceptive hormonal injection. Also includes the packaging, brand name, and technical information. Tip: Select the information needed when training providers, including benefits, correct dosage, contraindications, side effects.
- Price: Includes price paid for each product at each place in the distribution chain. Price also includes fees for service, such as inserting an IUD. Tip: Don't increase retail prices more than 10-12% each year.
- Place: Outlets for products and services. The Nepal HIV project greatly increased condom access by placing condoms in non-governmental organisation (NGO) drop-in-centres, tobacco shops, and with sex workers. Tip: Select places that are most convenient and comfortable for each intended audience.
- Promotion: BCC aimed at increasing consumption of products and services. Tip: Use all 3 communication channels: interpersonal, community, and mass media. Use entertainment.
Davis then provides his perspective on various CSM evaluation methods, as follows:
- Small formative studies: In-depth peer and focus group studies of beliefs and behaviours. Good for planning and tracking, but not adequate for quantifying changes.
- CYP: Simple calculations; useful for comparisons. Only measures outputs, not impact.
- Retail audits: Good for measuring market growth and market share, but expensive.
- Random household surveys: Good for measuring changes in prevalence of each contraceptive method. Needed for measuring total market size, but expensive.
- Photo-journalism: Eye-catching and memorable. Good for advocating stakeholder support.
Davies is particularly interested in how CSM shifted and grew into a broader concept: social marketing for health. He notes that many CSM programmes have added other health products such as oral rehydration salts, nutritional products, water purifying drops, malaria nets, and safe delivery kits. In addition, some programmes have also added services, such as maternal and child health (MCH) clinics and in-service training of professional and voluntary health providers. Infectious disease control has also been integrated into some CSM programmes, such as those that are working to address HIV/AIDS by marketing condoms and pursuing training for voluntary counselling and testing (VCT). Some programmes have also added health education services via television and radio programmes - sometimes using entertainment as a strategy.
Davies leaves readers with a dicussion of opportunities and challenges shaping future work in CSM:
- Eliminate competition - For Davies, Competition does NOT include other brands, sources, or programmes (e.g., private or public sector, NGOs, other social marketers). Rather, the real competition is non-use, which is often based on 3 fears: fear of contraceptive side effects, fear of family objections, and fear of community religious objections.
- Measure progress by total market size - Whereas commercial marketing companies measure progress by sales volumes and market share, social marketers should also estimate the size of the total market, including changes in numbers of couples served by the public sector, private sector, and NGOs.
- "Tell the Truth" about harmful behaviours: 1) Identify harmful behaviours and medical myths (e.g., the 3 fears; 2) Tell the Truth about each harmful behaviour; 3) Include education-entertainment such as soap operas; and 4) Use all 3 communication media: interpersonal, including interspousal; community/local/group media; and mass media.
- Encourage uneducated users of condoms and pills to trade-up to longer-lasting, more reliable methods such as the IUD (loop) or contraceptive injections, because uneducated users of condoms and pills have a higher risk of pregnancy due to inconsistent use.
- Important emerging issues are those that have not yet attracted much attention from social marketers in developing countries but which are amenable to social marketing techniques: 1) household sanitation; 2) conservation of natural resources, such as water and firewood; and 3) maternal and newborn survival - social marketing methods that promote simple, proven, public health activities such as antenatal and postnatal care, safe deliveries, micronutrients, immunisation, correct breastfeeding and reliable contraceptives.
Email from John Davies to The Communication Initiative on January 27 2009; and John Davies website.