Promoting Reproductive Health
for Young Adults
through Social Marketing
and Mass Media:
A Review of Trends and Practices
Ronald C. Israel
_____________________
FOCUS on Young AdultsACRONYMS
AED Academy for Educational DevelopmentACKNOWLEDGEMENTS
Many people contributed to the development of this paper. We would like to
particularly acknowledge and thank the 20 experts listed in Appendix D whom we interviewed
and who provided their observations and insights; members of the FOCUS consensus panel who
reviewed this paper, particularly those who offered extensive written comments, such as
Karusa Kiragu and Phyllis Piotrow of the Johns Hopkins University Center for Communication
Program, Dominique Meekers and Renee Wessels of Population Services International (PSI),
John Strand of the Academy for Educational Development (AED), and Judith Senderowitz; Anne
McCauley, Ann Klofkorn, and Lindsay Stewart of the FOCUS project staff at Pathfinder
International who guided our work; and Isolde Birdthistle and Cheryl Vince Whitman, our
colleagues at EDC who reviewed and commented on various drafts.
Over the past decade, techniques of modern marketing and mass communications have been used with increasing success to promote the reproductive health of young adults in different countries. These efforts harness marketing’s ability to analyze target audience behavior and use the media’s persuasive power to support health-enhancing objectives.
The following paper reviews the application of these "social marketing" approaches to strengthen reproductive health practices among young adults. It summarizes the analytical literature and lessons learned from relevant projects; describes key elements of successful project design, implementation, and evaluation; and identifies a set of critical research questions that need to be addressed to enhance the effectiveness of future interventions.
The paper is intended for use as an analytical tool and reference guide for the research and evaluation and program staff of USAID’s FOCUS on Young Adults program, and as a resource document for USAID Cooperating Agencies (CAs) and other organizations working to strengthen the effectiveness of reproductive health programs for young adults. It is one in a series of four complementary technical papers on the state-of-the-art of young adult reproductive health interventions that the FOCUS program has commissioned. The three other papers cover school-based programs, health facility programs, and outreach programs.
The term "social marketing" is intended here to refer to a process for designing health-promotion interventions that utilizes techniques drawn from commercial advertising, market research, and the social sciences. (Key elements in such a process are described in Section 3 of this paper.) Social marketing strategies can be used to achieve a variety of health promotion objectives, including: increased use of health-related products, such as condoms, increased access to health services, and changes in health behavior and practices, e.g. the practice of abstinence or having sex with a single partner.
Social marketing defines its objectives (e.g. health-related products, services, or practices) in terms of the beliefs, practices, and values of its target audiences. Extensive audience research guides the ways in which social marketers position project objectives in terms of the benefits that they offer a target audience.
Mass media are frequently used as one of the major channels of communication in social marketing intervention strategies, as is the case in all of the projects reviewed in this paper. The term "mass media" refers to self-contained audio, visual, or print distribution systems that can simultaneously reach large numbers of people with the same message. Examples include radio, television, computers, newspapers, magazines, billboards, direct mail, and telemarketing systems.
Social marketing strategies have been widely used for more than two decades to help strengthen public health promotion efforts. Well designed social marketing campaigns have demonstrated how mass media and marketing can be used to improve the health-related knowledge, attitudes, and behaviors of at-risk populations. Major public health social marketing interventions have included: the promotion of breastfeeding and appropriate weaning practices, diarrhoeal disease prevention and treatment, the design of campaigns to promote immunization against childhood diseases, the marketing of contraceptives to support family planning programs, the promotion of safe motherhood practices, anti-smoking efforts, and heart disease prevention programs.
This paper is informed by strategies and techniques that social marketers have developed for efforts such as those listed above. It focuses on how social marketing has been applied to support sound reproductive health practices among unmarried young adults, ages 10-24, in developing countries.
Addressing the reproductive health needs of young adults in developing countries poses special challenges for the discipline of social marketing and its use of media communications, such as the following:
The ways in which social marketing seeks to address these and related issues is the subject of much of this paper.
Well-designed social marketing projects can make a difference in the reproductive health practices of young adults around the world. The sixteen projects described in Section 2 support this finding. The following seven points highlight key principles, discussed in greater detail elsewhere in this paper, that have been shown to be critical to good project design.
A. How the Paper is Organized
Following this Section II "Executive Summary", the paper is divided into three sections plus supportive annexes. Section III, "Review of Recent Social Marketing and Health Promotion Projects" contains a summary table of sixteen recent projects with published evaluation data. More in-depth descriptions are provided for four representative projects with significant outcomes and important lessons learned -- Project ACTION, The Philippines Multi Media Campaign for Young People, the Ghana Mass Media Campaign, and the Colombia Profamilia Mass Media Campaign. An additional table that summarizes other noteworthy projects still in process is provided in Annex B.
Section 3, "Key Program Elements", describes a five stage process for the design, implementation, and evaluation of successful young adult reproductive health social marketing projects. The process includes situation analysis and the establishment of project objectives (stage # 1), design of an intervention strategy (stage # 2), establishing a project infrastructure -- prerequisite materials production, training and networking (stage # 3), implementation and monitoring (stage # 4), and evaluation (stage # 5). A summary Table of Key Program Element Findings also is provided.
Section 4, "Critical Research Questions", identifies an agenda of issues that need to be answered to strengthen the ability of planners to design more effective young adult reproductive health programs. Recommendations are made for programmatic next steps, and operations research and evaluation studies that can help answer these questions and strengthen the state of the art.
The paper is based on an extensive review of the literature on young adult programs which utilize mass media and/or social marketing approaches to address issues of reproductive health. Sources of information include published and unpublished evaluations of social marketing and communications projects, journal articles, abstracts, working papers and workshop summaries, chapters of books and on-line literature, as well as personal communications with researchers and program experts. (Annex A provides a Bibliography of all references and source documents.) The selection of project literature for review was based mainly on the availability of projects with documented outcome evaluations. Therefore, project descriptions that did not include documentation of impact were necessarily excluded.
II
. REVIEW OF RECENT YOUNG ADULT REPRODUCTIVE HEALTH SOCIAL MARKETING PROJECTS
Objectives of Section II: (a) to provide information on those social marketing projects that are designed specifically to address the reproductive health needs of young adults, and have documented evaluation data on project outcomes; and (b) to provide more in-depth highlights of several projects, in order to demonstrate effective approaches to the use of social marketing methods and tools.
Table 1 below provides a simple typology of social marketing projects according to categories of "objectives" and "intervention strategies." Most projects that address the reproductive health needs of young adults target multiple objectives, and make use of more than one of the intervention strategies listed in Table 1. The table is intended as a tool for project planners to mix and match descriptive categories that apply in different combinations to most projects.
Table 1--Objectives and Strategies
Social Marketing/Mass Media Programs for Young Adults
Objective |
Intervention Strategy |
|
|
|
|
|
|
|
|
|
|
|
|
|
Over 50 young adult reproductive health social marketing projects were reviewed during the development of this paper. Each of these targeted one or more of the objectives and intervention strategies listed in Table 1. Regrettably, there is a dearth of evaluation information for many efforts, particularly for those in developing countries.
Section II.B provides highlights and lessons learned from four recent projects that help advance the state-of-the-art using social marketing to meet the reproductive health needs of young adults in developing countries -- Project ACTION, the Philippines Multi Media Campaign for Young People, the Ghana Mass Media Campaign, and the Colombia Profamilia Mass Media Campaign. Each of these projects is unique because of (a) its systematic use of a methodological approach to changing target audience behavior and/or related social norms; and (b) the amount of information (both descriptive and quantitative) collected regarding program processes, outputs, and outcomes. We focus on these four efforts to extract key elements and salient lessons learned from project experience. Excerpted highlights are synthesized from recent project documents.
Section II.C provides a Table of sixteen reviewed projects which have published evaluation data. The projects are profiled according to country, goals/objectives, target audience, duration, program activities, and evaluation outcome measures. Annex A provides a related table of projects that will yield evaluation data, but which are still in process.
Section II.B provides more in-depth descriptions for four projects that illustrate different social marketing strategies and approaches for addressing the reproductive health needs of young adults in different counties. Each of the four projects -- Project ACTION (Oregon), The Philippines Multi-Media Campaign for Young People, The Profamilia Mass Media Campaign (Colombia), and The Ghana Mass Media campaign - have had significant impact on the reproductive health social norms and behavior of its young adult target audience.
A multi-faceted intervention strategy that directly addressed the reproductive health
practices of young adults and related socio-cultural environmental factors. (Source
Documents: Blair, 1995; Population Services International, 1996.)
Project ACTION was a social marketing HIV/AIDS prevention project targeting young people, ages 12 to 21, who are at highest risk for infection with HIV. It was designed and implemented by Population Services International (PSI) as a national model in Portland, Oregon from July, 1992 through December, 1994. The model is intended to have an impact on both the behavior of individual teens and the broader community in which they live, in order to build a supportive environment in which teens adopt behaviors that will decrease their risk of infection.
The assumptions behind the program, based on an analysis of the target audience, are that young adults in Oregon are aware and afraid of contracting the HIV virus; but they do not feel supported in practicing safer sexual behaviors, either abstinence or correct and consistent condom use. Instead, they receive very conflicting messages, reflecting society’s deep ambivalence about teen sexuality. When these conflicting messages and lack of overall support are combined with the competing concerns and issues that adolescents face, many young people do not develop and maintain safe sexual behavior.
The Project ACTION model starts with the premise that knowledge alone is not enough for teens to change their behavior. The decision not to have sex or to consistently use a latex condom when having sex will be affected by several factors in a young person’s environment: the physical environment (are condoms affordable and accessible?); the social environment (are peers using condoms? Are parents discussing human sexuality, AIDS prevention, and condom usage?); the educational environment (are schools providing accurate information about HIV transmission and prevention, including correct condom usage?); and the cultural environment (are condoms incorporated into the television shows, music, and movies that teens absorb?). To have a positive impact on teens’ choices about sex, prevention programs need to influence the total environment in which young people live.
Project ACTION utilized a multi-faceted intervention strategy that included (a) community mobilization, designed to create broad-based community support for a comprehensive teen AIDS prevention program, with emphasis on young people at highest risk; (b) a mass media campaign that relied on televised public service announcements and environmental media, such as t-shirts, key chains, posters and flyers that carried key messages to the target audience; (c) a condom accessibility campaign that provides discreet, convenient access to affordable condoms by placing vending machines that sell high quality latex condoms for 25 cents each in businesses identified by teens; and (d) a peer counseling program in which trained teen educators lead workshops to help their peers identify sexual boundaries and develop communication and negotiation skills to maintain safer behaviors.
Major results of Project ACTION include: an increase in condom use among target group young adults with new (casual partners, from 72% to 90%); an increase in consistent use of condoms among target group young adults with new/casual partners and a decrease in reported sexual activity among the teenage population.
Project designers cite a number of important lessons learned from Project Action including:
An example of a project that uses the "Enter-educate model" to combine the use of popular media formats with the marketing of a referral service. (Source Document: Rimon, J., et al., 1994.)
The Philippines Multi Media Campaign for Young People was conducted from June, 1987 through July 1990 through a joint effort between the Population Center Foundation (PCF) in the Philippines and Population Communication Services (JHU/PCS) of Johns Hopkins School of Public Health. The project sought to address a trend toward teen age premarital sex and pregnancy, and promote responsible sexual behavior among young adults. Its intervention strategy focused on the production of popular songs with reproductive health messages coupled with the promotion of telephone hotline counseling service.
The Multi Media Campaign is an example of the "enter-educate" approach to mass media health communication developed by PCS. This approach uses entertainment to model targeted behavioral change objectives. "Entertainment can attract attention and simultaneously provide a guide for reinforcing existing behavior or demonstrating new behavior. This approach arouses emotions in the viewer or listener -- an often neglected factor in health communications." (Kincaid, Larry, Johns Hopkins University, quoted in the source document.)
The project produced two popular songs --- "That Situation" and "I Still Believe" sung by two highly popular entertainers -- Menudo and Lea Salonga. Shortly after the songs began to be played on local radio and television stations, the project launched a public relations campaign to promote the use of the "Dial-a-Friend" Hotline. Young adults were urged to call the hotline, and discuss reproductive health and relationship issues in confidence with trained counselors. Lea Salonga and Menudo also helped promote the hotline in radio and television promotional spots.
The project evaluation design was based on three sample surveys of youth in Metro Manila, and a monitoring system for "Dial-a-Friend". The research team focused its data collection on the song "I Still Believe," because project planners had chosen it as the primary backdrop to promote Dial-a-friend, and because reactions to the song were gathered during both the mid-term and final surveys.
Ninety-two percent of youth questioned in the second survey in August 1988, when "I Still Believe" was at its peak of popularity, recalled the song and almost all of them (90%) liked it. Seventy percent of those interviewed could appropriately interpret the message, and 51% said that it had influenced their behavior. Twenty-five percent said they had sought information about contraceptives as a result of hearing it.
The "Dial-a-Friend" hotline, during its year and a half of operation logged a total of 22,285 calls, averaging 293 calls a week. About 59% of these calls were actual problem cases; the other 31% were inquiries about "Dial-a-Friend," requests to talk to Lea, and general questions. The most common types of problems presented by callers included: problems with boy-girl relationships, including pressure to have sex, pressure to get married, etc.; problems with parents, such as parental disapproval of boyfriend/girlfriend; problems with self-concept, including feelings of inferiority, guilt, etc.; problems with peer relationships; and problems related to sexuality, including unwanted pregnancy, premarital sex, and family planning (26% of the callers sought information about contraceptives).
Cost-sharing by means of attracting corporate and mass media support was a key component of the music project strategy. Non-mass media corporate support such as collateral materials for singer’s campus tours and contests on radio and television was estimated at US$74,150 and donated by major corporations such as Pepsi, Nike, and Nestle Philippines. Free air time and press coverage were estimated to be worth US$ 1,250,698 and US$57,608, respectively, and came from variety shows, music videos on television, hotline featured on television program, radio airplay, and press coverage of songs and "Dial-a-Friend." The campaign recovered a total cost of US$1,382,456 through cost-sharing.
(Source Document: JHU/CCP. Final Report Summary. PROFAMILIA. Colombia: Freedom Sells Condoms in Colombia).
In the late 1980s, the Atlantic coast of Colombia had the lowest prevalence rate of temporary family planning methods and the highest rate of voluntary sterilization in the country. To address this issue, in 1987, PROFAMILIA, the nation’s largest private sector family planning organization, launched a six-month condom promotion campaign in the region in collaboration with JHU/PCS and the Futures Group/SOMARC.
Young men between the ages of 15 and 25 were the principle target audience. Pharmacy owners were also a key audience in the project. In response to their interest in receiving information on temporary methods, a reference materials, point of purchase mobiles, posters and stickers, and leaflets were developed.
The project had two components: the Qualitative Research Project and the Mass Media Promotion Project. The research project was intended to provide the research basis and marketing strategy to promote temporary family planning methods among potential users, retailers, and community distributors in the region. In response to the PROFAMILIA’s declining market share, the mass media project was designed to: 1) increase awareness and use of temporary contraceptive methods among sexually active young adults; 2) increase the sales of Tahiti-brand condom; 3) to increase PROFAMILIA’s market share; and 4) to increase pharmacists’ knowledge and sales of Tahiti condoms.
Research indicated that young men were not concerned with birth spacing and maternal/infant health, but with freedom and unconstrained lifestyle. The campaign message, "keep being free, use Tahiti condoms," and materials were developed according to these findings. The campaign messages were aired in four radio spots over 15 stations, and complimentary print materials were distributed in pharmacies and other outlets.
During the period of the campaign, Tahiti condom sales increased by 77 percent over pre-campaign levels. Though the post-campaign period showed a drop in sales, average sales for the six months following the campaign remained almost 60 percent above the pre-campaign levels. The post-campaign survey indicated that 3.8 percent of men interviewed expressed the intention to use condoms in the future, compared with 1.7 percent in the pre-campaign survey. Similarly, in the post-campaign survey 42 percent of men interviewed felt condoms were safe and effective compared with only 24.5 percent at the pre-campaign. These results show that machismo need not pose an obstacles to family planning in Latin America.
The budget for the Qualitative Research Project was $17,300. The total budget for the Mass Media Promotion Project was $187,000.
An example of a mass media focused intervention that had an impact on target audience
behavior. (Source Document: McCombie, Hornik, and Anarfi, 1992.)
Between August 1991 and June 1992, the Ghanaian Ministry of Health sponsored a multimedia campaign designed to increase AIDS awareness and promote AIDS prevention among young adults in Ghana. The campaign was implemented by Apple Pie, a local advertising agency with assistance from AIDSCOM, a USAID technical support project.
The campaign used a combination of television and radio advertisements designed to disseminate the following messages: (a) that AIDS is not a foreign disease; (b) a person can have the virus for 5 or more years and still look healthy; and (c) personal behavior changes were necessary to prevent its spread. The campaign also sought to mitigate the stigma in Ghanaian society surrounding those who have the disease, and address the issues of early sexual initiation and multiple partnerships.
Campaign materials included 3 television spots (television has a high rate of penetration in Ghana), radio PSAs, and ancillary materials such as posters, comic books, badges, key rings, and t-shirts. The campaign tag phrase was "Don’t be careless, get protection," with advice to visit a health center for more information. The campaign also included a school outreach component, in which assemblies where students could engage in question and answer sessions with medical experts were held at secondary schools around the country.
In order to evaluate the impact of the campaign, pre and post surveys of knowledge, attitudes, and practices related to AIDS were carried out among persons aged 15--30 in two regions of Ghana--Central Cape (Cape Coast) and Brong-Ahafo (Techiman). The evaluation report indicates that the campaign was successful in meeting the major objectives of increasing awareness and knowledge. For example, the number of persons who named AIDS as one of the 3 most serious diseases in Ghana rose from 28% to 50% during the course of the campaign. In 1992, respondents were less likely to believe that most young people did not need to worry about AIDS than in 1991 (15.9% to 25.4%), and less likely to agree that many of their friends had multiple sexual partners (47.1% to 40%).
There was also evidence of an increase in safer sexual behavior. For example, fewer 15 year olds were sexually active at the end of the campaign than at the beginning (27% in 1992 compared with 44% in 1991). Their evaluation recorded an increase in the number of persons who reported using a condom the last time they had sex, particularly among those who were unmarried or had a partner in addition to their spouse. However, interestingly, pregnancy prevention rather than disease prevention was the major reason given for using condoms (perhaps because pregnancy prevention is a more socially acceptable reason, or perhaps because it is more of a motivating factor for young adults).
Objectives of Section III: (a) To identify a series of process steps that planners can use to guide the design, implementation, and evaluation of young adult reproductive health social marketing efforts; (b) to help answer the question included as part of the scope of work for this paper -- "What design for social marketing programs leads to positive outcomes -- knowledge, attitudes, service utilization, and behavior change?"
Section III discusses important programmatic elements in successful young adult
reproductive health social marketing projects. The Section is organized according to the
following five different stages in the project design, implementation, and evaluation
process: situation analysis and establishment of project objectives (Stage # 1: Section
A), development of an intervention strategy (Stage # 2: Section B), establishing the
project infrastructure: prerequisite materials production, training and networking (Stage
# 3: Section C), implementation, monitoring and management (Stage # 4: Section D), and
evaluation (Stage # 5: Section E). A table that summarizes the key program element
findings in each of these five stages is included as Section F.**
Section A describes how social marketers assess and analyze the reproductive health needs and wants of young adults, and establish project goals and objectives. It includes:
Each social marketing project begins with an analysis of the reproductive health-related needs of young adults and other target audiences; and also of the environmental factors and social norms that affect the reproductive health-related behavior of youth, e.g. the mass media, existing health services, current government policy. Such a situation analysis enables social marketers to understand their target audience(s), establish project objectives and evaluation indicators, and develop messages and materials that appeal to user beliefs, values, and practices.
A social marketing reproductive health situation analysis should be carried out in a highly participatory manner. All major stakeholders need to have an opportunity to provide input. It is especially important to consult with and involve young adults themselves.
A situation analysis for a young adult reproductive health social marketing program also includes a review of existing epidemiological information, e.g. trends in the prevalence of AIDS or other STDs among different segments of the young adult population, so that interventions can be more targeted and impact can be more readily assessed.
Given the sensitivity of the subject area, and particularly the potential for backlash associated with reproductive health promotional campaigns in some countries, a situation analysis should also look at the attitudes and concerns of key gatekeepers, such as policymakers, religious and civic leaders, and others whose support is needed for the project to succeed. Therefore, at the outset, it is useful to interview high level officials, identify groups opposed to young adult reproductive health programs and understand their positions, and assess the views and opinions of community leaders. (Personal communication, Rhonda Smith, PRB, April 16)
Table 3 below provides a more detailed framework for carrying out a situation analysis of the young adult target group. It provides a variety of variables --- demographic, psychographic, media habits, and health status --- that can help social marketers better understand young adult reproductive health beliefs, attitudes, and behaviors.
Table 3. Illustrative Adolescent Segmentation Variables (Ages 10-24)
Variables |
Significance |
| Demographics
|
The most common approach to segment audiences in public
health. Young adults have different developmental interests and abilities, depending on their age; messages will be different for different age groups-e.g. with 11 year olds, you want to talk about abstinence, not condom use. |
|
There are often differences in reproductive health-related attitudes, perceptions, and behaviors between boys and girls. |
Status |
Lower socio-economic groups tend to be higher at-risk groups for health problems. |
Status |
Important to know cultural norms that relate to reproductive health behaviors. |
|
Enrolled in primary school; enrolled in secondary school; many young adults in developing countries are not in school. |
|
Many young adults in developing countries are homeless and live on the streets; others still live at home with parents and extended families; others have their own households. |
|
Urban/peri-urban/rural; differences in where people live influence their behavior and also affect the design of communications strategies for reaching them. |
|
The reproductive health behavior/needs and concerns of younger, single young adults often will differ from those who are married. |
|
Homosexual young adults will have different needs from heterosexual adolescents about how to deal with social norms or peer pressure. |
Table 3. Illustrative Adolescent Segmentation Variables (Ages 10-24)
(continued)
Variables |
Significance |
| Psychographics (Lifestyle Analysis)
|
Statistics commonly used in commercial marketing to identify
subgroups sharing similar patterns of social norms, beliefs, and behaviors. Examples are:
information about target audience’s work and leisure activities, willingness to try
new things, hopes, fears, and dreams. What formal and informational associations do young people join? Do they provide a channel for communicating messages about reproductive health? Are they effective in promoting behavior change? Knowledge/Skills, Attitudes, Beliefs, and Behaviors (or Knowledge/Skills, Attitudes, and Practice) surveys are at the core of learning about the target audience. For example, do they know that latex condoms can help prevent HIV? Can they put them on correctly? How do they feel about abstinence? What do they believe about condoms? The answers to these questions help fine-tune the intervention strategies. All drugs or substances tend to reduce the likelihood of responsible behavior. Messages targeting sexually active young people should stress the correct and consistent use of condoms, while those for the sexually non-active must emphasize the abstinence or delay of sexual practices. |
| Media Usage/Habits | Target audiences, including young adults, can be segmented according to their media habits, e.g. radio, television. This indicator can get quite specific, e.g. young adults who watch music video television in the late afternoon. |
| Health Status (Epidemiology) | Review epidemiological data to determine trends among young people, e.g. rates of pregnancy, STD’s, prevalence of AIDS, incidence of HIV infection, etc. |
Sources:
The projects described in Section II of this paper have a wide range of objectives, including: awareness-raising; knowledge and attitude change, increased usage of products and reproductive health services, target audience behavior change, and the development of a supportive community environment. Identification of specific objectives for each project will depend upon such factors as:
Project designers will need to consider these factors simultaneously, in an iterative process in which empirical information about the target audience is analyzed and shared with key stakeholders. This results in broad-based consensus on goals and strategies, e.g. should the project promote the use or sale of condoms to young adults?
Planners need to keep in mind that in establishing project objectives, they are also
defining the basis for evaluating the impact of their intervention strategy. Evaluation
indicators and data collection instruments will need to be developed for each targeted
goal and objective. Therefore, it also is important to involve those responsible for
evaluating the project in the goal and objective setting process. (For more on the key
elements involved in the evaluation of young adult reproductive health social marketing
projects, see Section 3.5).
Some projects, such as the Botswana Tsa Banana program, frame their objectives within the context of a conceptual model of behavioral change. Table 4 on the following page, adapted and modified from a paper for the Institute of Medicine workshop by Flora, Maibach, and Holtgrave (1995), provides a guide to current behavioral conceptual models, and the outcome indicators that can be used to measure project impact.
As pointed out in their paper and elsewhere (Sutton, 1996), social marketing is not a theory of human behavior but a philosophy and a set of practices for developing behavior change programs. It does not explain human behaviors. Behavioral theories can help campaign planners shape audience research, interpret data on target audiences, and make informed decisions about program development; e.g., what behaviors are most likely to change. Social marketing programs can be most effective when they are combined with theories of behavior which best suit particular audience or behaviors in question. Table 4, following, highlights leading conceptual models of individual behavior change, and the outcome indicators that can be used to measure the validity of each model within an intervention context.
Social marketing strategies consist of well designed communications and marketing interventions to help achieve the project goals and objectives identified in Stage # 1. Such interventions can include the following:
Most young adult reproductive health social marketing projects make use of multiple interventions that both directly address the at-risk behaviors of their target audience, and environmental factors (e.g. access to contraceptives and supportive counseling services), needed to reinforce individual behavior change. Therefore, in the development of a social marketing intervention strategy, project designers working on issues related to the reproductive health of young adults will want to pay careful attention to the following tasks:
State-of-the-art projects, such as Project ACTION, illustrate the need to focus social marketing/media efforts, not just on a targeted awareness raising or behavioral message, but on the entire socio-cultural environment that influences the reproductive health practices of young adults. It is through this environment that young adults receive reproductive health-related knowledge/information, counseling, access to health services and contraceptives, relationship skills, emotional and moral support, and an understanding of their culture’s social norms and political will. Unless the relevant socio-cultural environmental factors, as illustrated in Figure 1 which follows, are supportive and reinforce one another, it is unreasonable to expect at-risk young adults to act in a sexually responsible manner. Figure 1 following illustrates the environmental inputs that can inform young adult reproductive health practices.
Different delivery systems have been developed for each of the eight inputs identified in Figure 1. Several of these delivery systems such as mass media are discussed in this paper; while others are described in greater detail in related consensus papers that have been developed for the FOCUS project: i.e., School-Based Reproductive Health Programs for Young Adults (Education Development Center, 1997) Health Facility Programs for Young Adults (Senderowitz, 1997) and Health Outreach Programs for Young Adults (Senderowitz, 1997).
Program designers and planners can use a variety of social marketing/media strategies and techniques to help develop a supportive socio-cultural environmental climate for safe and responsible sexual practices among young adults. Such strategies/techniques range from broad-based approaches and methodologies of contraceptive social marketing and media advocacy to specific techniques and formats, e.g. music videos and telephone hotlines. Many of these strategies and techniques also are described in greater detail elsewhere in this paper. However, Table 5 which follows summarizes the ways in which social marketing/media can be used to enhance each of the major socio-cultural environmental factors which influence the reproductive health behavior of young adults.
The literature on health communications indicates that young adults are influenced greatly by the mass media (The Center for Population Options, 1993). Mass media alone can help raise awareness and change behavior, influence social norms, and help increase product sales and access to health services. The effectiveness of mass media to influence behavior change is increased when media-based interventions are reinforced through the use of interpersonal channels of communication, such as peer counseling.
Most young people today are greatly influenced by what they see, hear and read in the mass media. (Mass media are defined in this paper to include any self-contained, broad-based channel of communication, e.g. radio, television, video, Internet, newspapers, magazines, direct mail, and telemarketing systems). Young adults value mass media because they are: (a) very much influenced by their perceptions of what others are doing; and (b) very tuned into what is going on in the outside world. Hence, in most societies, mass media are often a very good way to communicate reproductive health messages and information to young adults. "You can get the message across that everyone isn't doing it, i.e. not sleeping with everyone else; or that not everyone sixteen years of age is pregnant." (Slater, M. D., personal communication, December 17, 1996)
Because mass media can increase the salience and importance of health topics, audience members are more likely to discuss messages with each other and, in the case of young people, sometimes with their parents. This increased discussion permits the initial messages to diffuse through the audience and to magnify their influence. (Nowak, Szamvej, and Latane, 1990, in Romer and Hornik, 1992.) This process also can make it more likely that the audience will see the recommended practices as normative and socially acceptable. Because of their greater reach and agenda -setting capabilities, mass media are often more effective than personal communication in activating informal networks. (Romer and Hornik, 1992)
Mass media are extremely effective tools for reaching large numbers of young people with basic messages and information. However, what the media can't do very well is address individual concerns of young people about specific issues. "What do I do if my boyfriend says I don't trust him unless we have unprotected sex?" "Will it break the mood if we stop to get a condom?" Such personal kinds of issues and concerns, which are at the heart of many behavioral transformations, often need to be addressed more extensively through interactive interpersonal communication channels.
Other constraints to the use of mass media include: the resources involved to mount and sustain an effective campaign (media are costly though their net cost per person goes down over time); the issue of message dissonance and confusion, created in situations when media are also used to transmit images and messages that mitigate against sound reproductive health practices; and the related issue in many "transitional societies" of transmitting reproductive health messages that confront or conflict with traditional social norms.
Health communication planners need to know the media practices of their adolescent audiences, and the attributes of specific media channels and formats. Table 6 which follows provides examples of the ways in which different communication channels and material formats have been successfully used to promote young adult reproductive health practices.
Interpersonal Education
Interpersonal channels of communication are an integral component of many successful social marketing young adult reproductive health interventions. Interpersonal channels provide young adults with information about reproductive health problems, services, and products, and sometimes more importantly, with the opportunity to explore their own concerns, in confidence with a trusted counselor. Perhaps the most widely used form of interpersonal education for young adults is peer counseling.
Peer education's effectiveness is due in part to the reluctance of young adults to confide in adults** , and to the fact that most young people need positive role models their own age to offset pressure from other peers to adapt at-risk behaviors.
Peer education was first made popular in the United States twenty years ago by Dr. Richard Evans at the University of Houston. Evans developed a "social inoculation model" that relied on high school students making anti-smoking presentations in junior high school classes. In the 1980s, as part of a smoking cessation program, John Elder at San Diego State University introduced telephone-based peer counseling between first and second year university students and at-risk junior and senior high schoolers. An evaluation of Elder's Project Shout demonstrated a significant reduction in the incidence of adolescent at-risk behavior as a result of the telephone campaign. Elder found that the telephone model allowed for the in-depth personal one-on-one counseling that is often needed to address the individual concerns of at-risk youth (personal communication, John Elder, January 2, 1997).
The use of the telephone hotline provides young adults with an opportunity to speak about sensitive issues using anonymous platforms that are non-threatening. The telephone hotline approach has been adopted by many projects around the world as an effective vehicle for talking with and educating young people about issues of adolescent health. For example, the Planned Parenthood Federation of the Republic of Korea started a telephone counseling service run by about 120 trained volunteers in 1985. Over a period of six weeks, the service was advertised as a "youth sex telephone counseling service" in a daily newspaper, various magazines, and broadcasting outlets. In the first three months, over 2300 calls were received, of which nearly 70% were male young adults. (Chang Han et al., 1986, in WHO, 1993)
Peer education projects are now found in many developing countries. For example, in the PSI-sponsored Botswana Social Marketing Program, peer educators perform live shows in retail outlets, wholesale warehouses, markets, and schools, tailoring their AIDS prevention message to the audience at hand. (Population Services International, 1995)
A critical element in the success of most peer education projects is the ability of educators to listen well, empathize, and respond to the specific needs of those whom they are counseling. An AIDSCAP review of 21 peer education projects in Africa, Asia, and Latin America found that "if peers are already knowledgeable about STD/HIV infection, then peer education should address the skills and attitudes necessary for behavior change and maintenance. Project managers should conduct a training needs analysis and strengthen their training curriculum by adding such topics as counseling skills, skills to teach home care, and information about family planning". (Flanagan, Williams, and Mahler, 1996)
Most well designed peer education, and other kinds of interpersonal adolescent communication efforts, work well for the young people that projects are able to reach. The difficulty comes in going to scale with such approaches when critical issues of resources, quality control, and management become important. A specific critique of adolescent peer education activities is the constant turnover among peer education providers that takes place as young people develop and mature and move on to other activities.
Peer education is not the only type of interpersonal education program that has been used to reach adolescents. The PCS projects at Johns Hopkins, wherever possible, work with adult counselors and educators in existing organizations, such as PTAs, businesses, Rotary Clubs, etc. These organizations usually have local chapters all over a country through which volunteers and outreach workers can reach young people. However, such highly visible organizations also are sometimes resistant to working with sensitive young adult reproductive health issues. (Piotrow, P., personal communication, January 1997)
At-risk young adults in many developing countries are often out-of-school, illiterate, and live on the streets. Reaching them with counseling support can often be a challenge. Models that have proven to be effective in reaching this audience include the establishment of youth centers in poor neighborhoods that provide access to reproductive health services, as well as literacy and basic skills training.
Effective reproductive health messages must appeal to the beliefs, practices and values of young adults. The process of designing reproductive health messages for young adults should be informed by the following lessons learned from the literature and programmatic experience -- the importance of using role models, the need to focus on relationship skills, and the need to focus on messages that help give youth a sense of control over their lives.
In his work on Social Learning Theory, Albert Bandura contends that a person becomes confident about his or her ability in part as a result of observations of others who successfully perform this behavior (1977). For young adults, the "others" could be their peers or a social figure such as an athlete or an artist whom they admire.
For example, in the U.S., adolescent role models were effectively used in Smart Sex -- a widely acclaimed CDC-sponsored AIDS prevention program on MTV (Music Television, a popular television channel in the U.S. and many other countries). The program highlights stories of individual teen-agers who successfully try to protect themselves against HIV infection. Some succeed, while others don't. However, the program doesn't pass judgment, but assumes that viewers are able to make up their own minds and draw their own conclusions about what works best (Centers for Disease Control and Prevention, 1996b).
The PCS project has worked with entertainment artists from around the world who use their talent and role model status with young adults to promote sexual responsibility: e.g. a popular reggae group in Jamaica, Tatiana and Johnny in Mexico, and Lea Solonga in the Philippines. A new term has been coined -- "enter-educate" -- to describe the contributions of performing artists to the health education of young people. (For more on the "enter-educate" approach, see Section 2, Highlights of the Multi Media Young People’s Project in the Philippines.)
Austin (1995) cites the use of local sports heroes, popular drug-free celebrities, and older peers as key role models. However, Austin also points out that exploitation of celebrities can backfire. Teenagers report that some celebrities' motives are suspect, that rock stars are often hypocritical, and that too many athletes have "messed up."
The Tri-Ethnic Center for Prevention Research at Colorado State University suggests the importance of using cultural role models for communicating health promotion messages to Native American young people. Their approach promotes establishing a healthy lifestyle as part of what it has always meant to be Native American. (Slater, M. D., personal communication, December 17, 1996)
Many projects, including almost all that have behavioral change as their principal objective, focus on the need to communicate messages about relationship skills. The emphasis on relationship skills reflects the widespread observation that the resolve of young people to practice safe sex and related behaviors often breaks down in specific relationship threatening situations.
This is why organizations such as Program for Appropriate Technology in Health (PATH) have focused on the content of adolescent reproductive health education programs. PATH's work emphasizes how to talk to young people about AIDS, STDs, and other subjects. PATH and other organizations believe that young people in most countries are starved for information about basic life skills, and that projects focused on specific health problems, such as AIDS or STDs, should not be narrowly confined to these issues. For example, a recent AIDS prevention project in Bolivia ended up providing interpersonal counseling to help young adolescent girls understand their menstrual cycle. (Mohamud, A., personal communication, January, 6, 1997)
Recently, PATH has developed a Lifeplanning Skills Curriculum (adapted from Advocates for Youth) that deals with the values and problems that youth have; allows for exploration of reproductive health and related issues; and focuses on interpersonal skills building, such as how to negotiate relationships, condom use, etc. The approach is based on the premise that youth learn best by exploring ways in which they can resolve the issues that most affect them (Zimmerman, 1996). PATH is training NGO leaders in Kenya and other countries in the use of this curriculum, so that they in turn can train adult and peer educators who work with at-risk youth.
Some projects also have developed materials that focus on building better relationships between youth and their parents. For example, a recent evaluation of a PATH-sponsored Malawi radio soap opera on AIDS showed how the program was used as a vehicle for launching discussions about AIDS between young people and their parents (Douglass, 1995).
Youth a Sense of Control Over Their Lives
Many young people want to take control of their lives; they want to be seen as adults. This desire to be in control has been used by social marketers to design effective prevention messages; e.g. "You can best be in charge of you by remaining safe and sticking to your decision not to get pregnant," (Zucker, D., personal communication, December 19, 1996). In this example, pregnancy prevention was seen as a more direct message than the threat of getting HIV/AIDS or STDs, because the designers felt that their young adult target audience was not in touch with their own mortality.
Self-efficacy is a personal quality which some believe is central to the theme of taking charge. Self-efficacy refers to "a cognitive process indicating people’s confidence in their ability to effect a given behavior (Bandura, 1977 in Maibach, Schieber, and Carroll, 1996). However, experts suggest the difficulties of measuring changes in self-efficacy. It is not a quality that can be globally defined. Within each person there is a lot of variation with regard to areas where one feels self-efficacious. A current approach is to measure efficacy only in relation to a specific focused behavior, e.g. feeling good about one’s ability to act in a sexually responsible way, in contrast with the more global feeling good about oneself. (personal communication, 1996)
Young adolescents are less able to make inferences and integrate disparate pieces of information separated by time or content. As a result, they have trouble sifting out irrelevant information. For the message designer, this means that what characters say and what they do must be focused and clearly consistent for the intended message to be learned (Austin, 1995).
The experience of Project ACTION in Oregon taught PSI the value of focusing on a single simple message, and a step young people could take to make that message "actionable". The Oregon project's message "don't think about sex without a condom" was coupled with the action step to "go find a machine that sells condoms".
Access to contraceptives and supportive health services has been a concern of several of the young adult reproductive health projects described in Section 2, e.g. Project ACTION, the Colombia Profamilia Mass Media Campaign, and the Jamaica Keep on Keeping It On Campaign. Social marketing techniques that have been effectively used to help promote the purchase and access of contraceptive products and health services include the following:
Contraceptive social marketing makes condoms available to at-risk populations at discounted (often subsidized) prices. The goal is to create a mass market for contraceptives sold at the lowest possible price. Most contraceptive social marketing projects are intended for audiences consisting of married couples and adults. However, in all probability, there is a "halo" affect that reaches young adults in target communities. Among the key issues that need to be addressed in the marketing of contraceptives are the following:
In many countries, the provision of targeted reproductive health services for young adults is a highly sensitive issue. The major examples, such as the Philippines Multi Media Campaign for Young People and the Grenada Planned Parenthood Under Twenty Clubs, consist mainly of health education, counseling and referral services. In many countries, the health needs of young adults are covered by services for other population cohorts, such as women, young children, and adults. Consequently, there has not been as much experience in the targeted marketing of reproductive health services to adolescents as there has been with older population cohorts.
Developing a marketing strategy for reproductive health services for young adults should begin with an assessment of the main services that might be offered and their relative importance. Such services may include testing for HIV/AIDs and other STDs, the provision of contraceptives, health counseling and referral services. The types of services to be provided will depend upon the needs and wants of at risk young adults, the epidemiological priorities of public health professionals, and the review and approval of specific services by key gatekeepers.
Marketers must also decide on the forms in which to offer various services. For example, how should each service be priced? How and when should it be delivered? Several of the projects summarized in Table 2 offer innovative examples of ways in which reproductive health services can be brought to young people in developing countries, e.g. through the use of market vendors, scooters, etc.
Finally, a strong promotional effort can be made to make people aware of the services and the benefits they provide. For example, the Philippines Multi Media campaign used popular entertainers to promote the existence of a telephone hotline referral service.
Stage # 3 emphasizes key elements of the materials and human resource infrastructure needed to successfully implement a young adult reproductive health social marketing project, i.e. the production of communications and marketing materials, the training of project implementors, and the organization of networks among and between key stakeholders.
All important messages and materials need to be thoroughly pre-tested before they can be produced, especially in an area as highly charged as young adult reproductive health. There are well defined methods for pre-testing that can be used to help ensure that project materials are effective, engaging, culturally relevant, and politically correct. For example, the Kenya Youth Initiative Project conducted focus group discussions among 32 groups of youth and parents to guide the development of messages and materials.
Training and networking activities should be built into the project at its outset, but certain critical training tasks need to be completed before implementation can begin. For example, media planners need to know when and how often to broadcast project materials; face-to-face educators and counselors need to become aware of target audience behavioral change objectives and how to promote them. If the project involves the marketing of products or services, product distributors and health service workers need to understand and master their roles and responsibilities.
This section focuses on four project infrastructure issues that the literature and project experience indicate are important in the design of reproductive health promotion programs for young adults.
Effective messages and materials are culturally relevant, believable, and doable by their target audience. Messages and materials should always be pretested with the target audience to ensure that they are liked, understood, and help influence knowledge, attitudes, and behavior. In young adult reproductive health social marketing projects, the two principal audiences for pretesting are young adults themselves and key gatekeepers.
Social marketers need to ensure that project messages and materials are appealing to young adults. The risk of sending inappropriate or low quality messages is that the opportunity for change is not only squandered in that instance, but eroded for the future because of the image created by the less than adequate message.
Many messages and materials are developed iteratively. Under this model, the message is first drafted, then tested, then revised, and then put through more tests and revisions until a satisfactory result is obtained. The investment in time and resources required to do this is easily justified for messages that are particularly complex or crucial.
When a unit of media production is to be quite large, such as a half-hour radio soap opera, the pretesting of every component quickly becomes impractical. In these situations, often the best that can be done is to produce a pilot program in the style that the others will follow. The pilot can then be tested with representative groups of the target audience to determine such things as appropriate language level, content density, and pacing. This gives an opportunity to formulate a consistent style to help with recognition of and learning from subsequent programs.
In many countries, key gatekeepers can veto projects if they find something objectionable in the messages and materials. Such problems can be avoided by pretesting messages and materials with opinion leaders. In Oyo and Enugu States, Nigeria, for example, local advisory councils comprised of decision-makers and technical experts reviewed family planning television programs before they were finalized. (Piotrow et al., 1990)
Both the literature and the experts contributing to this paper agree that in social marketing campaigns targeted at young adult audiences, youth themselves need to be extensively involved in all project activities.
"Adolescents live in a world that looks and sounds different from the world of the investigator or the funding agency. To penetrate that world involves discarding traditional notions about sampling frames and the heterogeneity of focus groups. You need to reach kids on their own terms in an environment in which they feel comfortable." (Lefebvre, C., personal communication, December, 1996.)
One recent promising approach to learning about the perceptions of young adults involves conducting interviews with small groups of teens (pairs and triads) who know each other. Researchers have found that the familiarity and intimacy of such settings have encouraged young people to say what's on their minds. (Lefebvre, C., personal communication, December, 1996.)
The CDC-sponsored Prevention Marketing Initiative organizes special social marketing training workshops for young adults who participate in program activities. The workshops enable the program to successfully integrate young people in formal and informal design, implementation, and evaluation activities. Young adults have helped the program develop research instruments, design intervention strategies, and monitor implementation activities. (Centers for Disease Control and Prevention, 1996a.)
PSI in South Africa is experimenting with formative research strategy where youth lead focus group sessions involving their peers, as opposed to using outside adult moderators. (personal communication, 1996.)
"TV is a legitimizer of open communication between kids and between kids and their parents. The message television should provide is to get kids to talk to one another rather than to have sex with no communication." (Senderowitz, J., personal communication, January 6, 1997.) However, often what is communicated through mass media about sexuality is far from being wholesome and health enhancing. Media advocacy approaches seek to counter media depictions of irresponsible sexual behaviors.
The U. S. Department of Health and Human Services defines media advocacy as the "strategic use of mass media to advance a social or public policy initiative." Media advocacy can help set the public health issue on the public agenda, frame the issue properly by looking at societal level causes, and propose specific social or public policy initiatives to address the issue. (Maibach and Holtgrave, 1995) The ultimate task of any youth program is to help change social norms which go against health education efforts to provide young people with information, services, and counseling they need. (Johns Hopkins School of Public Health, 1995U) According to Griffiths et al. (1991), media advocacy activities can make policymakers more aware of the health issues that young adults face and create a more favorable policy environment for promoting adolescent reproductive health.
Two well known programs that seek to utilize the media in this way are Advocates for Youth and the Johns Hopkins Population Communication Services Program (PCS). The Media Project of Advocates for Youth works to encourage the American television industry to show positive and responsible aspects of sexual behavior to adolescent audiences. The project tries to discourage exploitative or misleading sexual images in the media. It works with producers, writers, and creative people, encouraging them to incorporate educational messages into plot lines and to use positive adolescent role models. (Senderowitz, J., personal communication, January 6, 1997.)
The "media advocacy" approach of Advocates for Youth is being adopted in the developing world. For example, the Kenya Association for the Promotion of Adolescent Health (KAPAH) coordinates a project to counter distorted images that local media presents of adolescent sexuality and reproductive health. KAPAH's approach is to first review how the media is addressing the needs of youth (through a content analysis); then meet with the media, discuss what has been observed, and suggest ways in which misstatements or distorted images can be corrected. KAPAH also develops fact sheets that can help the media develop accurate reproductive health messages. (Mohamud, A., personal communication, January 6,1997.)
Another lesson learned from the PCS project is the need to involve key gatekeepers and stakeholders in designing and implementing adolescent focused communication projects. Such gatekeepers include government decision makers, community and religious leaders, business leaders and others.
An effective method for mobilizing such broad-based stakeholder support for health promotion efforts is "social mobilization". Social mobilization refers to "the process of bringing together all feasible and practical inter-sectoral social allies to raise people's awareness of and demand for a particular development program, to assist in the delivery of resources and services, and to strengthen community participation for sustainability and self-reliance". (McKee, 1992)
Social mobilization has been effectively used by UNICEF and other international agencies to promote broad-based, inter-sectoral participation in immunization campaigns in Project ACTION and nutrition promotion programs. It was recently successfully applied to support an adolescent reproductive health behavior change intervention. (See Section 2 for descriptive highlights of Project ACTION.)
Social marketing/media communications interventions require sound management skills. For example, different channels of communication must be utilized in a timely way to maximize target audience penetration; distribution /delivery systems must ensure that supportive products and services are within easy access of the target audience; and the resources of key stakeholder groups, such as schools, need to be accessed in an effective manner.
Section D identifies three priority issues in the management and implementation of social marketing campaigns. The issues discussed are generic to most social marketing projects. However, examples of how these issues have been addressed in young adult reproductive health social marketing projects are cited wherever possible. The three priority issues are:
Successful social marketing interventions effectively blend different disciplines and functional areas of expertise. Figure 2 diagrams the types of professional input that contribute to campaigns, such as the four projects highlighted in Section 2.
At the center of Figure 2 is the core campaign Management Team. The core team needs to include experienced project managers with previous social marketing campaign management experience, representatives from the young adult target audience population (see Section IV.C), and representatives of local stakeholder organizations.
There are at least four organizational models that have been used successfully to implement young adult reproductive campaigns in developing countries -- the single ministry model, the inter-ministerial model, the public-private sector collaboration model, the NGO model, and the research model.
Perhaps the most important decisions facing a social marketing project manager relate to cost and time allocations: how much money and time should be spent on research? how much time on message design and materials development? on media time and/or space? on training? evaluation? etc. Answers to these questions depend upon weighing such variables as: the goals of the project, the length of the campaign, the availability of pro bono or reduced cost services (especially media), funds available, evaluation needs, and the complexity of behavioral problems. All of these variables should be reviewed in tandem at the outset of each project for their impact upon resource allocations, and upon whether a project design should be undertaken at all at available funding levels. Once initial resource allocations are made, project managers still need to have the ability to make line item adjustments in response to on-going implementation needs.
Priority issues associated with the supervision and monitoring of a social marketing campaign relate to ensuring sufficient target audience coverage and access, and the timely and effective provision of supportive environmental inputs.
For example, if the campaign relies heavily on radio messages, there are several levels of possible problems related to target audience coverage. Campaign messages might fail to reach the target audience for a variety of reasons -- the stations contracted to transmit them might not be on the air or might not broadcast the messages in the amount or at the time of day they have agreed to; competing programs might have been scheduled by other stations at the same time and diverted the anticipated audience; there might be a nationwide shortage of batteries that reduces audience size; or language diversity might exclude a large segment of the audience.
The delivery systems for environmental inputs, such as condoms, also have to be carefully monitored. Do all of the end user levels have sufficient stocks of material? Is there a bottleneck somewhere in the delivery system? Has the correct price been charged? The primary objective of project monitoring activities is to get information quickly, routinely, and inexpensively, and utilize it for improving ongoing implementation efforts.
Summative evaluation looks at a completed project to assess the extent to which desired outcomes or objectives have been achieved. It can include an evaluation of the effectiveness of the implementation process (process evaluation); an assessment of the impact of the intervention on the outcomes sought by the implementors; and an assessment of the validity of the conceptual model (such as those described in Section III.A) or strategic assumptions that framed project activities. (Israel, Foote, Tognetti, 1987)
The design of a summative evaluation for a social marketing intervention begins when project goals and objectives are defined (See description of Stage # 1, Section III.A above.) At this point, project planners need to identify indicators and instruments to measure the ability of the project to reach its intended objectives.
The social marketing projects reviewed for this paper (see Section II) sought to achieve objectives related to raising awareness, changing knowledge, attitudes, and behaviors, and/or strengthening social norms. Evaluation indicators used by these projects fall into two categories -- (a) output measures, which help measure the effectiveness of the intervention process; and (b) outcome measures, which help gauge the extent of project impact. Examples of indicators in both categories are provided below.
Reach can be quantified as the percentage of the target audience that are exposed to a message at least once during a fixed period (e.g. the first year of the program). (Rohmer and Hornik, 1992) For example, 92% of young adults, aged 12 --24, surveyed by the Philippines Multi Media Campaign for Young People had heard the program’s popular songs; 70% said they understood the songs’ reproductive health messages (Rimon et al., 1994). Reach can be assessed readily for many mass communication channels by conducting surveys of media use (or by consulting available listenership or readership data) that determine the times of day and programs that are watched or listened to, newspapers or magazines that are read, and the ages and sex of the audience for these channels (e.g. Alcalay and Taplin, 1989, in Romer and Hornik, 1992). Appropriately selected mass media will have greater reach than personal channels within reasonable time periods.
Repeated message exposure is critical for the adoption of new behaviors. Repetition makes messages more familiar and acceptable. It also increases the salience and importance of messages, making it more likely to set the audience’s agenda and to increase the interest value of health recommendations. (Israel, Foote, and Tognetti, 1987.)
Message frequency can be established through the use of different channels of communication, such as mass media and interpersonal. Mass media tend to have regular audiences that can be reached repeatedly over time. However, particular mass media may not permit more than one or two exposures to a message. For example, if a television drama is to educate young people about the dangers of HIV infection, then the show may have wide reach but it will not be able to support repeated viewing without costly efforts to develop new plots and extended story lines. Interpersonal channels of communication, such as peer counseling, help sustain messages over time, and allow young adults the opportunity to explore the way in which messages apply to their own individual situation. (Rohmer and Hernik, 1992.)
Output measures also are needed to measure the effectiveness of the service delivery or product distribution components of young adult social reproductive health marketing programs. For example, projects such as Project Action used condom sales as an indicator of program effectiveness. Condom sales components of young adult programs often seek to identify and target sexually active non-users. However, among young adults, particularly those having sex only occasionally, contraceptive use is often discontinuous; use or non-use at one point (as measured through sales figures or personal reports) may not be indicative of usual behavior. (Stewart and Eckert, 1995)
Media pre- and post-tests as well as knowledge, attitudes, and practices (KAP) surveys are used to measure changes in target knowledge, attitudes and awareness. For example, the MUDAFEM campaign in Nigeria used a pre- and post-test audience survey and recorded a 22% increase in students’ knowledge about the transmission of HIV/AIDS, and a similar increase in knowledge of contraceptive methods. (Johns Hopkins School of Public Health, 1995b)
All of the projects reviewed in this paper seek to achieve behavioral objectives. Some try to promote behavior change directly, by postulating specific behavioral objectives as direct outcome measures of project interventions. For example, the Ghana Mass Media AIDS campaign reported a decrease in the percentage of sexually active 15 year olds, from 44% to 27% (McCombie, Hornik, and Anarfi, 1992). Other projects take a mediated approach to behavior change, i.e. they seek to directly influence knowledge, attitudes, and social norms as a means to change behavior as in the Communication for Young People Project in Mexico (Johns Hopkins School of Public Health, 1995b).
The USAID-sponsored Indicators for Reproductive Health Program Evaluation Report (Stewart and Eckert, 1995) suggests a variety of behavioral outcome measures for adolescent reproductive health programs, including: age at first intercourse; percentage of previously sexually active adolescents who abstain from sexual intercourse; age at first birth; percentage of adolescents who used protection at first/most recent intercourse.
The report also points up problems associated with the measurement and use of such indicators. For example, sexual activity among young adults is usually sporadic, and depends on the existence or absence of a relationship, rather than on a conscious decision to abstain. Therefore, abstaining for a period following the participation in/exposure to a particular program may be coincidental. Furthermore, young adults who state that they intend to abstain for a period may not follow through with their stated intention.
Policymakers and program planners may want to refer to health outcome trends when attempting to assess the impact of young adult reproductive health social marketing campaigns. These would include trends over time in the incidence of HIV/AIDS infection, trends in the prevalence of sexually transmitted diseases, changes in fertility rates among young adult adolescent populations, and trends in the incidence of adolescent maternal mortality and low birth weight babies. While it is, of course, difficult to ascribe direct causal relationships between health status trends and communications campaigns, it is nevertheless useful to look at such trends as a general indicator of program impact over time. (Stewart and Eckert, 1995)
Although many young adult reproductive health projects list changing social norms as their principle objective, in practice there have been few effective ways to measure this variable. The Empowerment Theory of Zimmerman and Rappaport (Zimmerman, 1992; Rappaport, 1984, in Flora, Maibach, and Holtgrave, 1995) asserts that changing social norms is a function of (a) community-specific knowledge of particular health issues; (b) community norms regarding expectations for participation in related health programs; and (c) community participation in those programs or activities. According to this theory, key social norm indicators for reproductive health programs for young adults could include: the level of participation of community groups in reproductive health promotion activities, the collective ability of community leaders to help improve reproductive health indicators for youth, and the extent to which community mobilization efforts result in improved reproductive health delivery systems for young adults.
The cost-effectiveness of alternative channels can be compared by calculating a cost-effectiveness ratio (CER). The CER indexes the cost of achieving education goals for the average audience member. For example, in the case of HIV education, these goals might be adoption of safe sex or safe needle practice for a specified period of time. A more stringent goal might be prevention of HIV transmission or of acquisition of some other sexually transmitted disease. The CER is a function of the total cost of an education program divided by the number of people for whom the education goal is met. The number of people for whom the goal is met is, in turn, a function of the exposure and influence of the program. CER = (Cost of Program) (Exposure x Influence). (Rohmer and Hornick, 1992.)
The CER can be compared across channels if the messages transmitted, the audiences targeted, and the education goals are the same. For example, the relative effectiveness of using different channels (radio, television, schools) to transmit pregnancy prevention messages to at-risk young adults could be calculated using the CER method. The lower the CER, the more effective a channel is per unit of cost. (Altman et al., 1987; Weinstein et al., 1989, in Romer and Hornik, 1992.)
Unfortunately, little information on cost is provided in the published literature on young adult reproductive health social marketing programs. However, there are impressive data available on the cost effectiveness of using mass media to promote broader family planning objectives. For example, the Turkish multimedia campaign reached more than 6.5 million married women of reproductive age at a direct project cost of US$0.04 per woman reached. After the campaign, an estimated 345,000 more women were using modern contraceptive methods, about a three percentage point increase. If this increase is attributed to the campaign, the cost amounts to about US$0.67 for each new modern-method user. Similarly, the Kenya Youth Initiative Project reports that the cost of reaching one young person with reproductive health information using mass media is .03 US cents, and the cost of prompting them to change behavior is only $11.63.
Summative evaluation makes use of a variety of qualitative and quantitative research instruments to measure output and outcome indicators, such as those listed above. A representative sample of these instruments is described in Annex D.
Section IV Objectives: Identify a set of programmatic next steps and a research agenda that can help inform the work of the FOCUS project and others engaged in addressing the reproductive health needs of young adults in developing countries.
A great deal of experience in designing and implementing successful young adult reproductive health social marketing projects has been accumulated over the past decade. The need to do more to diffuse the lessons learned from this experience informs the next step programmatic recommendations described in Section IV.A.
There also are research needs that, if addressed, could help strengthen the state-of-the-art of program design, implementation, and evaluation. These needs include: