Challenging Dogma - Fall 2007

...Using the social and behavioral sciences to improve the practice of public health.

Monday, December 10, 2007

A Job Half Done? A Critique Of “Condom Bindaas Bol” (Say Condom Freely) : A Public Awareness Campaign In India – Tanmya Stuti Ravi

In September 2007, The “Condom Bindaas Bol” ( say condom freely ) Campaign was awarded the UN Public Relations Award. It was created by the public relations company of Weber Shandwick and the collective efforts of PSP-one (a USAID project), the Indian Government’s Ministry of Health & Family Welfare and ICICI Bank . It was designed to overcome the reduction in use and sales of condoms across 8 North Indian states which comprise 45 % of the market (1). Although, “Condom Bindaas Bol” aims to remove the social stigma associated with the word “condom “ and claims to target each individual to encourage safe sex and family planning, it does not address the reasons which led to the reduced acceptance of condoms in the Indian society. Primarily, it fails to understand the religious diversity of the Indian population and the influence of socio- political factors of the past (which act as a deterrent to the campaigns goals)and the complicated relations between each segment of the society in the current socio-political and economic conditions of India. In addition, geographical barriers and poor marketing strategies prevent the campaign from realizing its true potential.
Religious and political influences
The awareness campaign fails to address one of the prime reasons for low condom use in India- Religious norms and socio-political factors and their impact on the acceptance of birth control. India with its rich and diverse culture is home to many religions. The majority of the population comprises of Hindus (80.5%), followed by Muslims (13.4%), Christians (2.3%) and others (3.7%) consisting of Sikhs , Buddhists, Jains. (3)Religion has an important influence on the daily lives of the people. Therefore ,new concepts introduced to the society are weighed by religious principles, amongst other factors. The emergency declare in the 1970 by Prime Minister Indira Gandhi mandated compulsory sterilization, played a pivotal role in reduced acceptance of birth control methods (4,5). Indeed it was the cause of unrest and fear of dwindling numbers of each religion was deeply ingrained in the Indian society.
Each religions views birth control and condom use differently. Islam does not allow a national level policy, which limits the options for a married couple to have more children (6). Hence, this approach to family planning will not generate enthusiasm and is considered improper.(7). Birth control is permissible when the health of the mother or the well being of the family is in question (8).Hinduism does not oppose contraception, however, there is insecurity about the dwindling numbers of a majority religion following birth control.(4) Such fears are not only real but very powerful. Catholics do not promote the use of birth control methods other than abstinence.(8) The religious belief that advocating condoms, subtly encourages pre-marital sex , is also a very strong barrier to the use of condoms. The Vatican recently put this argument forth and many religions share this view (9). The Orthodox Church and Sikhs do not oppose contraception although none promotes abortion or infanticide. Buddhism and Jainism have no established doctrine on contraception.
It would be beneficial to plan acceptable approaches for each religious group, which would address these issues in the context of religious beliefs. A dialogue with the stakeholders of society may lead to educational developments, which are more effective and acceptable, for the concerned section. In a country with a history of communal tension, religion is an inflammable topic. Nonetheless, religious concerns are important factors to be considered in a country of such religious diversity and avoiding them will prevent programs from achieving desired success rates.
Interpersonal relations and personal choices
The campaign is based on the belief that high sales of condom leads to safer sex practices and even family planning. It draws upon the health belief model that intent to use will lead to the desired behavior (10). Therefore, it faces many of the same limitations as the model. In the Indian scenario, the link between the two is often influenced by social factors such as, high infant mortality rate, desire to have a male child, lack of education regarding proper use of the condoms, approval of the partner in condom use etc.
In rural India, large families have great significance. In a country where agriculture is the main occupation, it is considered prudent to have more children as this would provide more working hands in the farm and save spending on extraneous labor. In addition, due to a high mortality rate many families tend to have more children. However, one of the strongest social reasons for large families is the desire to have more sons’ (11). The belief that sons support families through their earnings and through dowry, is still prevalent. Discrimination against the girl child leads to marriage at an early age(12), combined with the social and financial implications of having a son, often dictate the number of family members. Hence, an approach to promoting condom use requires educating entire villages to change their outlook about family planning and other related and equally important issues of dowry and upliftment of the girl child. (13)
A high rate of illiteracy especially in the rural areas has also affected condom use. Lack of education often prevents individuals from having access to information regarding correct use of condoms. This is a barrier to condom use despite having the intent to use it. It is therefore necessary to impart education on the technical aspects of condom use in a practical and simple way such as, so as to reach out to the uneducated masses and reinforce it so as to have long term benefits. For example, street plays or community meetings which stress the importance of education among children, discouraging discrimination and dowry and imparting information of condom use.(14)
In some cases, a person has the intent and knowledge to use the condom, but is unable to use it because the partner disapproves. For example, a sex worker willing to use a condom but is dissuaded by her client because of personal preference. Similarly using a condom when under the influence of alcohol is less likely.(15) This example illustrates that health based decisions are not always rational.
Campaigns based on the health belief model are often limited in their success because of the theories many shortcomings. It does not take into consideration the complex web of social relations and the influence of the environment upon an persons life. Also, the emphasis on rational thought which targets the individual does not allow behavior prediction because all decisions are not made on a pure rationale.
Target population
In a press release, the corporate voice of Weber Shandwick had this to say “The campaign, “Condom Bindaas Bol” (“Say Condom Freely”), addressed the decline in condom use and sales by encouraging people to talk about condoms using two messages. The first is that “condom” is not a sensitive word and its usage should be discussed freely. The second is that condom usage is for everyone, not just individuals in high-risk groups” (1). However, the television advertisements depict only men and that too, of urban India. The role of important stake holders like rural Indians, Indian women and teenagers is sorely missed in the commercials.
According to Social learning theory people adopt a behavior which they identify with , then , they must develop self efficacy to eventually perform the behavior.( 10) To capture the eight north Indian states in their entirety each aspect of society must be addressed. However, they do not utilize this opportunity to the fullest. Therefore, rural Indians , women and teenagers fail to identify with the campaign’s agenda.
The rural population of India comprises more than 70 % (741,660,293) of the country’s population (1,027,015,247)(16). Extrapolating this information to the eight concerned states, rural Indians can contribute significantly to positive results of the health campaign. Ironically, rural areas have a fair number of Female sex workers (17), even though they also have strong social beliefs and less likely to be acceptable of claims which refute their beliefs. It is prudent to include such regions where the high-risk groups are concentrated into the campaign’s focus. It is important to note that since different social and cultural customs apply, rural Indians need to be targeted through different approaches. (14)
Similarly, 40 -50 % of the total rural and urban India comprises of females (495,738,169).(16) Assuming this to be proportional to the target states of the campaign, “Condom Bindaas Bol” fails to target this proportion of the total population across the eight states. The high risk population in India for STD’s and HIV-1 are female sex workers(17,18). Addressing women through the drive will benefit them socially and medically. Women should be encouraged to use female condoms (19). This will allow women to share the responsibility of condom use and break the gender barriers. Female condoms are easy to use and effective. By encouraging women to buy condoms and using them, the problem of declining condom sales and rising incidence of STD’s can be tackled more effectively.(20)
Teenagers in India go through the same experiences as any teenager of another country. Dating and romantic affairs are common, but, due to parental and family pressures, they do not surface. In the given situation, getting information can be difficult from parents who are unwilling or unprepared to answer the questions related to sexual health. Youngsters tend to experiment and often with severe consequences such as teenage pregnancy and contracting STD’s. Initiating sexual activity at a younger age, is considered a high risk factor for AIDS. (22) Targeting the teenage population would increase their awareness about such issues. In addition, when educated early on in life about the importance of their health and its preservation, teenagers are more likely to accept and carry out responsible decisions in the future.
Marketing Strategy and Geographical Barriers
“Condom Bindaas Bol” has failed to engender important marketing principles such as releasing sufficient information about the product, understanding the variation in demographics and increasing access to condoms .(23)
Borden gave the concept of marketing mix in 1964 which was later modified by McCarthy .(24) It is now popularly known as the marketing mix – 4 P’s. It is a simple and powerful tool used in making marketing decisions. The 4 P’s are – Product, pricing, promotion, placing. When assessed by this principle, “Condom Bindaas bol” falls short on many levels.
Product – The product in question is condom use and the advantages and technique of using the product have not been clearly specified by the campaign.
Pricing- It is important to consider the different purchasing powers of people across different regions. The price of condoms is often heavily subsidized for rural areas so as to make the option more attractive to the buyers. This information requires dissemination for greater appeal.
Promotion- The campaign used the media to convey their message including print media. However, if one looks at the literacy levels – the average literacy rate of urban India is approximately 70%, whereas in rural India it is 45 %. Also not every household has a television and therefore the audio-visual aids remain ineffective in such areas. It would have been more appropriate to have street plays or public meetings in villages to communicate this message along with the information on how to use condoms effectively and responsibly. (16)
Placing - To their credit, the campaign enrolled the help of pharmacists, but, they failed to address the geographical barriers to condom use. Some concerns which need to be addressed are uneven distribution of pharmacies and poor access to pharmacies already present. The campaign has failed to address these issues clearly . If the team of “Condom Bindaas Bol” actively participates in encouraging the government, to mandate the setting up of more pharmacies or even vending machines, to increase access for the people at various hours, together they can create a deeper impact. (25)
The “Condom Bindaas Bol”campaign was designed to improve the declining sales of condoms across the eight north Indian states. It based its publicity campaigns on reducing the stigma associated with saying the word condom, however it does not address the reasons for decline of the sales in condoms. It’s focus on individual risk factors prevents restricts the success of the campaign. Humans are social by nature, they learn and interact with the environment they live in, at different levels such as politics, economics, governance, inter-personal relations etc. A public health program which is based on a community oriented approach and encompasses strong marketing tools is likely to be more successful.
References
1. Weber Shandwick. Corporate Voice Weber Shandwick Wins United Nations Grand Award For PR Campaign Promoting Condom Use And Awareness. Available at Http://www.webershandwick.com/Default.aspx/aboutus/pressreleases/2007/corporatevoice%7cwebershandwickwinsunitednationsgrandawardforprcampaignpromotingcondomuseandawareness (Accessed on December 4, 2007)
2. CIA. The World Factbook – India. Available at https://www.cia.gov/library/publications/the-world-factbook/print/in.html (Accessed on December 4, 2007)
3. Census of India 2001: DATA ON RELIGION. Office of the Registrar General, India. Retrieved on 2007-04-17.
4. William k. Stevens. Slowly and hesitantly, india adopts birth control. The New York Times:December 28, 1983. Http://query.nytimes.com/gst/fullpage.html?Res=9D00E0D61538F93BA150751C1A965948260&sec=health&spon=&pagewanted=all (Accessed on December 4, 2007)
5. Pethe VP. Compulsion in family planning: the fundamental considerations. Artha Vijnana. 1979 Mar;21(1):13-38.(Accessed on December 6, 2007)
6. Alyssa. Family Planning in Islam. Islamic Journal, April 1996. Available at http://www.unh.edu/msa/familyp.htm (Accessed on December 3, 2007)
7. Minkler M. "Thinking the unthinkable": the prospect of compulsory sterilization in India. Int J Health Serv. 1977;7(2):237-48.
8. Kathleen O’Grady. Contraception and religion – A short history. Available at http://www.mum.org/contrace.htm. (Accessed on December 3, 2007)
9. International Herald Tribune,. Europe. Vatican cardinal who prepared study on condoms says main weapon in AIDS fight is chastity. The Associated Press. Published on: December 20, 2006 (accessed on December 6 2007)
10. Edberg Mark. Essentials of Health Behavior. Social and Behavioral Theory in Public Healt. Social Leaning Theory (pp 51-56) Ch- 5
11. Sandhya Srinivasan, )info change population ,from http://www.infochangeindia.org/PopulationIbp.jsp# (Accessed on December 5 2007)
12. Sharma A. Socio-cultural practices threatening the girl child. 1995 Jun-Sep;25(2-3):94-106.
13. Devendra K. Girl child in rural India. 1995 Jun-Sep;25(2-3):189-96
14. Bhalla S, Lalchandani K, Singh s, Somasundaram c, Bhalla V. A study of prevalence of stds from a rural village in Gujrat, India among the reproductive age group (15-49 yrs) subjects. Pathog Treat 2005 Jul 24-27;3rd
15. Mbulo, Lazarous ; Newman, Ian M. ; Shell, Duane F. Factors contributing to the failure to use condoms among students in Zambia., Journal of Alcohol & Drug Education01-JUN-07
16. National Commision on population, Government of India. Available at http://populationcommission.nic.in/ (Accessed on December 3, 2007)
17. Blanchard JF, Halli S, Ramesh BM, Bhattacharjee P, Washington RG, O'Neil J, Moses S. Variability in the sexual structure in a rural Indian setting: implications for HIV prevention strategies. Sex Transm Infect. 2007 Aug;83 Suppl 1:i30-36
18. State of Epidemic – India. HIV/AIDS South Asia. Available at http://go.worldbank.org/FKLVQCCF40. (Accessed on December 3, 2007)
19. WHO (2002), 'The safety and feasibility of female condom reuse: Report of a WHO consultation
20. Kumar R, Jha P, Arora P, Mony P, Bhatia P, Millson P, Dhingra N, Bhattacharya M, Remis RS, Nagelkerke N; International Studies of HIV/AIDS (ISHA) Investigators. Trends in HIV-1 in young adults in suthee India from 2000 to 2004: a prevalence study. Lancet. 2006 Apr 8;367(9517):1164-72
21. Bottom of Form
22. Brahme RG, Sahay S, Malhotra-Kohli R, Divekar AD, Gangakhedkar RR, Parkhe AP, Kharat MP, Risbud AR, Bollinger RC, Mehendale SM, Paranjape RS. High-risk behavior in young men attending sexually transmitted disease clinics in Pune, India. AIDS Care. 2005 Apr;17(3):377-85
23. The Concept of the Marketing Mix" from the Journal of Advertising Research, June 1964 pp 2-7
24. Mccarthy, J. (1960 1st ed.), Basic Marketing: A managerial approach, 13th ed., Irwin, Homewood Il, 2001.
25. Theme summary : geographic barriers . Program years – 2001-2008. Available at Http://www.endowmentforhealth.org/_docs/75.pdf (Accessed on December 3, 2007)

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