Sara Husain  ( Department of Radiology, Dow University of Health Sciences and Civil Hospital, Karachi. )
Babar T. Shaikh  ( Department of Radiology, Dow University of Health Sciences and Civil Hospital, Karachi. )

Over the last two decades HIV/AIDS has evolved from a series of interesting case-reports to a growing epidemic that threatens the entire world. It is feared to cause devastation among large pockets of populations and may roll back more than thirty years of public health achievements. This killer disease has been more amenable to behavioral change than by provision of curative services and attempts are being made to educate the public about this threat. Various techniques of promotion have been tried through out the world including television dramas/soaps, mass media and school curricula. Social marketing is an evolving strategy used to influence human behavior and choices. By using the principles of marketing and promoting behavior as a product, social marketers attempt to understand the dynamics of human behaviour and devise messages and products to change, modify, accept or reject unsafe behaviors or practices. Thus, social marketers provide an effective force to combat the spread of HIV and may serve to be invaluable allies in health promotion efforts. In a complex and diversified cultural milieu of Pakistan, social marketing can have a significant impact on health determinants and the conditions that will facilitate the adoption of health-oriented behaviors and practices. This paper gives an account of the elements needed for the success of a health promotion strategy adopted in a developing country and makes a case for social marketing to be adopted as the lead strategy for stalling HIV/AIDS in Pakistan.

Pakistan despite being a densely populated country in South Asia, has a low to moderate sero-prevalence of HIV/AIDS unlike its neighborhood in the region.1-3 By June 2003, only 2086 cases of HIV and AIDS were reported throughout the country, however, the WHO/UNAIDS estimates are much higher.4,5 Of the diagnosed cases, males predominate (87%), most belonging to the 20-40 years age group.2,3 Majority of these males are deportees from abroad but many are being identified within the indigenous population.2 Heterosexual transmission has been identified as the predominant mode of viral spread in the country; and groups exhibiting high-risk behavior include commercial sex workers, intravenous drug users, jail mates and professional blood donors. The identification of HIV cases in the country has initiated a multi-sectoral response involving the government, non-governmental and donor agencies.3,6 Various strategies to combat spread of HIV have been designed and implemented within the country, including health education campaigns for health personnel and general population, provision of prompt clinical care to afflicted patients, and establishment of HIV centers for counseling and surveillance activities. However, the efficacy of these strategies varies between provinces and the federal level due to dearth of effective inter-provincial and cross-sectoral coordination.3 The non-governmental organizations (NGOs) in Pakistan have designed strategies for segments difficult to map out and monitor, whereby the impact has been difficult to measure and so was the possibility of replication.7

Since the time, HIV/AIDS was reported first, the preventive strategies are deemed essential to decrease the extraordinary growth of this disease. These strategies must logically address the known mechanisms of spread and should integrate biomedical and behavioural approaches. However, the application of a single isolated strategy will undermine the purpose of a preventive programme by laying stress on one aspect of complicated human behavior. Thus, a combination of specific and culturally acceptable strategies need to be adopted, which must address the existing modes of HIV transmission and have proven efficacy in various settings.8-10 Social marketing has emerged as one such strategy successfully adopted by various countries to address the issues requiring behavior change. This paper gives insight into the popular approach of 'social marketing' that has been instrumental in bringing about behavioural transformation among vulnerable population groups around the world. It scans the prospects of applying the same principles of social marketing to combat the challenge of HIV/AIDS in Pakistan.

Social marketing has evolved as a strategy for promoting healthy behaviors, where theories and principles of commercial marketing are applied to promote social causes with an objective of achieving 'common good'.11 The idea emerged when marketing principles were applied to promote use of contraception to reduce an impending population explosion in low-income countries. These campaigns began in the late 1960s and gradually became more widespread during the late 1980s and early 1990s. Currently, Contraceptive Social Marketing (CSM) programs are well established in several countries of the world, including Bangladesh, Thailand, Colombia, Jamaica, Mexico, Egypt and more recently, programs have been established in Honduras, Guatemala and Barbados.12 Given the active involvement of organizations in contraceptive marketing which promoted condoms as the prime product, inclusion of prevention of HIV and other sexually transmitted infections became a natural development. The scope of social marketing has gradually evolved and the strategy is applied to address a diverse range of public health issues, including Oral Rehydration Salts (ORS) use in summer diarrhoea, safe driving, use of seat belts and bike helmets, childhood immunizations and smoking cessation.

Social marketing is not a new phenomenon in Pakistan; promotion of contraceptive use for furthering family planning, use of ORS to reduce childhood mortality from diarrhoea and use of iodized salts in goiter endemic areas are some of the successful campaigns in which the government and the private sector have been involved.13,14 Lessons learned from these successful campaigns suggested a rationale for involving personnels in disseminating information, like family physicians, pharmacists, community health workers, retail shopkeepers and even volunteers on one hand and also building supply and demand in parallel to appropriately satisfy the demand created.15

Social marketing also works with a traditional marketing mix of 4Ps: product, place, price and promotion.16 A product promoted in a social marketing programme must meet client needs and should be compatible with program's focus and expertise. For decades, condoms among other barrier methods have been used as contraceptives. Trials of efficacy among various strategies have shown 'barrier methods' to be consistently and outstandingly the most effective preventive method in combating sexually transmitted infections (STIs).8 However, regular use of condoms among clients is often hampered by perceptions of reduced sensation and fears of unreliability.17 Clients' perceptions about products influence their utilization and adoption patterns, therefore, an ongoing market research and communication with clients is imperative to ascertain their likes and dislikes. This information is invaluable to the marketer to modify existing products or diversify the product line in order to achieve the programme objectives.18,19 Quality of the products being promoted influences the clients acceptance. It ensures sustained use by consumers and enhances client satisfaction and trust. Product packaging is another important aspect to attain recognition by clients. This includes all physical attributes of the product, including the name, colour and product logo.19 In Pakistan, condoms have successfully been made available in the market by the social marketing organizations in private sector. There is now need to assure whether the range of products available to the prospective clients is meeting their needs and wants. High quality condoms in appealing packaging backed up by effective communication and wide advertising can promote the use of condoms thereby reducing HIV transmission in the population.20

The place where the product could be accessed is crucial. It is important that the entire product range being marketed should be made easily accessible to the target population at most frequently visited places and through potential outlets of distribution. If condoms were made available only at family planning centers or in physicians' offices, accessibility of condoms for the unmarried persons and other vulnerable segments of population would be reduced. Making condoms available at places where they can be discreetly purchased; where an unsafe social contact may occur and impulsive decisions could be made; and at outlets which are not stigmatized will significantly increase the buying capability of the individual.19 Established in 1985, Green Star Social Marketing is the pioneering firm and one of the largest contraceptive service provider in Pakistan. It promotes use of condoms by making a range of condoms available, both over the pharmacy counter and in health care provider settings.14 Besides franchising the network of pharmacies and physicians' offices, the general stores, grocery stores and paan shops have been included in the distribution network to promote the sales of condom, in an atmosphere where privacy is ensured.14,21 If similar channels of sales and distribution could serve the purpose of promoting condom as a potential protection from HIV, there is high likelihood that a successful campaign could be generated against spread of HIV/AIDS in Pakistan. However, there is a need to reach out and expand these distribution networks to more peri-urban and rural population segments where many people returning from abroad, if exposed to the HIV infection may prove to be a fatal risk to their families.

Whereby condom is promoted as barrier to HIV infection, its price ought to be affordable to the poorest and those most in need. The advantage of social marketing is that it aims to market public goods which the open market cannot be relied upon to provide without discrimination. Yet, providing condoms free of cost to those in need has been challenged. Research indicates the likelihood of using a condom increases if the individual has paid for it, rather than receiving it free of cost.19 Though most HIV/AIDS and STIs prevention and control programs focus on specific population segments, the shift of client patronage from those with disposable incomes and greater access to the actual population in need is a function of time.22 The unit costs of selected condom social marketing programs from 1990-96 showed a cumulative cost per condom of $0.09-0.14 in countries with long-established family-planning-oriented social marketing programmes serving very large markets such as in India, Pakistan, Bangladesh and Nigeria.23 The international criterion for pricing of 100 condoms has been set at less than 1% of gross national product per capita. If this price threshold is crossed, sales have been noted to decline.19,24 Pricing of condoms available in the Pakistani market very much follows this principle where the cost of a four-condom pack sold in 1995 was Rs. 2, though a near doubling of prices over a four-year period saw a decline in total condom sales. However, the current cost is still well below the recommended price scale and effective. Information, Education, Communication (IEC) campaigns and mass level advocacy have resulted in a gradual rise in sale volumes.21 One salient feature of social marketing is that by virtue of the subsidy and the tax exemption, it can provide the products at lower prices. Hence the fact that condoms are available in Pakistan at quite a reasonable price, fortifies the potential to promote its use to the extent possible to stall the HIV infection. As for non-monetary costs such as loss of pleasure during sex in some cases; time consumed in searching and buying it and at times embarrassment while buying, must be addressed through appropriate placement and positioning of the products in order to facilitate the consumer.

Promotion is imperative for projecting a product image and raising awareness about product range. Done through messages informing and motivating clients to utilize services being offered, planning of promotional activities involves designing messages, their format, content and style, along with decisions regarding when and where to advertise. Marketers may face difficulties in formulating messages as promotion may require explicit information to be communicated and may be met with considerable resistance from conservative and religious elements.19 Various techniques of promotion have been tried through out the world with variable degrees of success; including television dramas/soaps and edutainment (the "Enter-Educate approach"; using entertainment to educate), mass media and school curricula.19,25-27 An important element of planning a mass advertising campaign is 'viewership' and access of the public to the particular medium under consideration. A critique of Bangladesh's promotion of Family Planning Services through mass media was the under-representation of the target group within their viewer profile; despite expenditures of nearly 70% of the advertising budget on mass media, access to the sources of information among the target population was limited and largely focused the urban elite.28

NGOs in Pakistan are working to promote HIV prevention among selected high-risk groups by providing information and free access to condoms/clean needles. An example is of Green Star HIV counseling center which exclusively caters to long-distance truck drivers near a truck station in Karachi. This center provides IEC material, condoms and STI treatment for their clients. Though useful, these activities restrict information and behaviour change strategies within small groups, and fail to promote preventive activities within the general population. This activity requires initiative from the public sector, which have came to the forefront with Ministerial advertisements on the electronic and print media.6

Marketing whether commercial or social, requires a clear understanding of competing behaviors, socio-economic, political and cultural conditions and in developing strategies compatible with existing socio-economic and cultural values of the population where the strategies are applied. A similar pre-requisite exists for the development of effective communication programs to prevent the spread of HIV/AIDS.8,19,29 Studies looking at HIV knowledge, attitude and practices of safe sex have been conducted in both high-risk and the general population in various countries and are invaluable in understanding risk behavior and in developing strategies to address them. Some elements which may play a vital role in the success or failure of a health promotion strategy adopted in a developing country, like Pakistan include

Behavioral studies lend insight into power dynamics within sexual relations among men and women.30,31 In Pakistan, the low social status of women and their lack of negotiation power exposes them to the risk of unprotected intercourse, a known risk factor for developing HIV. In developing programs promoting use of condoms, care must be taken to involve both partners, as any attempt to introduce a behavior that involves women but fails to include men is likely to fail.

Individuals' belief in disease susceptibility is identified as a preliminary stage of behavior change in most Behavior Change theories.29 Various studies have shown unsafe sexual encounters remain unaltered because of low perceived risk of acquiring HIV.17,32 Perceptions of invincibility grounded on faith in Divine protection, belief that herbal remedies can cure HIV, and stereotyping of infections among high-risk groups reduces an individual's perception of risk.33 Studies conducted in Pakistan indicate to the existence of a poor level of risk recognition and individual susceptibility to HIV among the general population.34

Barrier methods serve the dual purpose of contraception and preventing transmission of HIV. This may interfere with an individuals' desire to conceive and thus may reduce consistency of condom use in a relationship. HIV prevention programs should therefore screen individuals for their desire to conceive, so that prevention messages can be tailored to clients' needs and desires.31

A highly stigmatized disease worldwide, the fear of HIV greatly reduces the possibility of introducing condoms into established sexual relationships.17,35 The associated stigma translates into initial health care being sought from local/traditional healers rather than the formal health care sector, delaying case presentation and continued viral transmission within the general population.34,35 Conservative elements in various societies have often challenged the moral value of condom promotion, arguing that promotion and distribution of condoms will increase adolescent sexual activity. A study conducted among Latino adolescents however, negates this claim by showing delayed initiation of sexual activity and an increased prevalence of safe sex practices among adolescents.36

The field of Social marketing is still an evolving one, but an impressive series of successes in various settings speaks much of its potential in addressing health behaviors and in disease prevention on a large scale. Activities conducted by Social marketing organizations can serve to supplement public programs of 'Health for all' by improving market access to public goods, making them easily, economically and abundantly available. However, prior to launching a heavily financed marketing scheme, it is essential to gain an understanding of the health needs and status of the population under consideration; market research on client preferences and demands will assist in designing effective and efficient health promotion strategies.12 Social marketing organizations tend to utilize existing wholesale and retail infrastructure within a country, thereby greatly enhancing the probability of having the demand met. The distribution network, however has to be extensive and should make available reasonable profit margins to both wholesalers and retailers in order to persuade and motivate them to stock and display condoms.19 Financial sustainability of the social marketing organization, although not exclusively dependent on product sales, should attempt to recover some costs by boosting sales targets.19,22 Social marketers rely heavily on governmental and donors' support and so, earnestly look forward to friendly policies and minimum sanctions.11,37 These are pre-requisitely desired to achieve collaboration between the private and public sectors addressing important social issues.

Many donors and countries are striving to respond to the HIV/AIDS epidemic by implementing cost effective programs, considering the resource constraints faced by lower and middle income countries. In 1993, the World Bank suggested a per capita cost of $50 ($62 in 2000) to be reasonable for any developing country in order to adopt a comprehensive strategy for HIV/AIDS prevention.38 Today strategies adopted to prevent spread of HIV, (including blood screening, marketing of condoms, treatment of STIs, commercial sex workers (CSW) interventions, voluntary counseling and testing and programs to reduce mother to child transmission) cost less than $50,39 with an estimated cost of $9.60 being incurred in averting a single infection of HIV, and cost per life year saved as low as $0.83.40 Reducing transmission of HIV/AIDS in Pakistan through social marketing of condoms could certainly be a cost-effective strategy. Though HIV/AIDS has not begun to spread rampantly in Pakistan, the country is threatened by continued high-risk practices, necessitating a comprehensive strategy to prevent further virus spread. Social marketing is an invaluable approach, if integrated with other strategies for bringing social change. In the complex and diversified cultural environment of Pakistan, social marketing can have impact on the conditions that facilitate the adoption of health-oriented behaviours and practices.

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