Will balbir pasha get aids full case study

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Will balbir pasha get aids full case study

  1. 1. Will Balbir Pasha Get AIDS? OverviewTopic: The „Will Balbir Pasha Get AIDS?‟ campaignSexual health formed part of PSI India‟s Operation Lighthouse, an HIV/AIDS preventionOrganisation: programme implemented in 12 major portPopulation Services International (PSI) communities in India. The programme aimed toLocation: reduce rates of unsafe sex by motivating people to consistently use condoms, call theMumbai (India) confidential HIV/AIDS hotline, and use theDates: Voluntary Counselling and Treatment services.2001 to 2005 The campaign was built around a fictionalBudget: character called Balbir Pasha. It used aApproximately US$2.5 million storyboard to place him in various high-riskWebsite: sexual situations, with unknown outcomes. This provided a realistic behavioural model for urbanwww.psi.org/india men living in Mumbai. Using a mixture ofContact: outdoor communications, television and radioSanjay Chaganti messaging, and comprehensive newspaperEmail: exposure, the campaign succeeded in personalising HIV risk and bringing the topic ofschaganti@psi.org.in HIV/AIDS into the public sphere. Results: Increase in proportion of individuals reporting last-time condom usage with commercial sex workers from 87 per cent to 92 per cent Threefold increase in retail sales of condoms in the red light district Increase in Voluntary Counselling and Treatment services usage ShowCase │ Will Balbir Pasha Get AIDS? 1
  2. 2. Unlike previous programmes, OPL sought to develop public health campaigns that successfully engaged with at-risk individuals and personalised the risks for the individuals. One of the biggest OPL campaigns was conducted in Mumbai and is the focus of thisIndia is home to the third largest number of HIV case study. PSI had been conducting work withinfected people in the world. In 2002 there were commercial sex workers in Mumbai‟s red lightan estimated 3.5 to 4 million HIV-positive districts since 1991. Mumbai was the home ofpeople living in India (this has since been the largest red light district in India, and sorevised downwards, with an estimated 2.3 previous work had focused on educating andmillion people in India living with HIV in 2009). empowering the 6,000 to 10,000 commercial sex workers operating in the red light district.Approximately 80 per cent of HIV cases in India The work of OPL would instead work tohave been attributed to heterosexual motivate the clients of sex workers to practiceencounters and are concentrated among high- safe sex across the city in a sustained andrisk groups including commercial sex workers, effective manner.men who have sex with men (MSM), andinjecting drug users, as well as truck driversand migrant workers. Staggeringmisconceptions regarding HIV/AIDStransmission as well as a reluctance to publiclydiscuss HIV/AIDS has fuelled the spread of HIVacross India.Against this backdrop, Population ServicesInternational (PSI) received funding fromUSAID in 2001 for five years to develop andimplement programmes across India aimed atreducing the spread of HIV/AIDS. Thesubsequent programme, Operation Lighthouse(OPL), was conducted in 12 major portcommunities across India: Chennai, Goa,Haldia, Kandla, Kochi, Kolkata, Mangalore,Mumbai, Paradip, Tuticorin, Vashi, andVishakhapatnam. India‟s port cities andsurrounding communities were the chosen An extensive scoping phase guided thefocus of the programmes because these areas development of the campaign in Mumbai. Thisserve as points of convergence for people at included:highest risk of contracting HIV and transmittingit to others. Port communities directly and Segmentationindirectly employ large numbers of men – PSI segmented the audience according toformal and informal port workers, truck drivers demographics, socioeconomic and geographicand their helpers, migrant workers, fishermen, characteristics, as a review of existing researchday labourers and others – many of whom revealed a strong prevalence toward high-riskspend significant parts of their lives away from attitudes and behaviours among these groups:their families and who move continuouslybetween urban and rural environments. ShowCase │ Will Balbir Pasha Get AIDS? 2
  3. 3. Demographic – Men between the ages of The research also identified barriers to using 18 and 40, and those at highest risk for HIV Voluntary Counselling and Testing (VCT) infection (such as men who were clients of services and a HIV/AIDS helpline: sex workers) Socioeconomic – Men belonging to lower Practical barriers socioeconomic groups, particularly truck Individuals are unable to travel to VCT drivers services Geographic – Men living in Mumbai, where VCT facilities and HIV/AIDS helpline are not India‟s urban HIV epidemic is centred available when individuals are able to go,A review was conducted of existing research and they have inconvenient opening hours,around high-risk audiences‟ attitudes and especially for working menbehaviours around unprotected sex with Individuals are too busy to travel to VCTcommercial sex workers. This included a sites due to their jobs, especially if thereview of studies conducted by the Avert service is hard to get toSociety in Maharashtra (of which Mumbai is the Some lack access to a phone and/or fearcapital). This was combined with informal that the helpline will show up on telephonediscussions with stakeholders to gain billsunderstanding of which aspects of previous Many worry about the financial costs ofhealth communications in India had previously phoning the helpline or visiting VCTworked well and which had not. servicesLifestyle research, including one-to-one Knowledge and psychosocial barriersinterviews with clients in red light districts andfocus groups, were conducted to establish Fear of being HIV-positivepatterns of behaviour and relevant Fear that use of the helpline or VCTcommunication channels. services will not be confidential If positive, fear that HIV status will be madeThis research revealed several key reasons public, or if negative, fear that usingwhy men were having unprotected sex with services will cause others to speculatepartners: about their HIV status Fear of oneself or family being judged and Misconceptions surrounding HIV ostracised if use of services surfaces transmission Stigma or taboo associated with discussing Poor personal risk assessment – Men HIV/AIDS and other sex-related matters believed that while commercial sex workers Lack of awareness of helpline or VCT were at high risk of contracting HIV, the services men who patronised them were not Low personal risk perception Belief that individuals infected with HIV would appear outwardly ill – One-third of Competition men who visited commercial sex workers The research identified two main sources of were unaware that a healthy looking, competition for the campaign: asymptomatic individual could potentially be HIV-positive 1. Apathy of the male target audience towards A strong relationship between alcohol public health campaigns or health-related consumption and high-risk behaviour messages Negative attitudes towards condom use 2. The need to break through the media clutter in an already media-dense Mumbai ShowCase │ Will Balbir Pasha Get AIDS? 3
  4. 4. Behavioural goals “Mumbai is a chaotic place where people live inBased on all of this research, it was decided very cramped environments, so when we‟rethat the programme‟s overarching behavioural trying to target a low income consumer, whilegoals would be to: he may have a TV at home, most of his time is spent on the streets, rather than at home or in Motivate people to access a HIV/AIDS a formal work environment. So the use of helpline and VCT services different kinds of outdoor media therefore Generate discussion about HIV/AIDS became an important component of the media among the target populations and opinion mix. Understanding his lifestyle was the key to leaders trying to focus on which communication medium should be used.” (Sanjay Chaganti,The programme would also have awareness Programme Director)and attitudinal goals to: Dispel barriers or myths preventing the consistent use of condoms with female sex workers Increase perception of risk from unprotected sex with non-regular partners PSI sought to develop a strong marketing mix – including communications materials and service provision – to elicit the desired behavioural changes in the target population. Theory A review of behavioural learning theory and the value of behavioural models for the relevant target audience revealed that people learn by observing the behaviour of others (Social Learning Theory). This led to the development of „Balbir Pasha‟ – a fictional character who acted as a behavioural model for the target audience. The campaign would be organised into five stages, each of which progressively builds intrigue and gossip value, like the plots in a TV soap opera, with Balbir Pasha as the protagonist.Lastly, an informal qualitative study wasconducted with media professionals in India to Stage One: The teaser campaign wouldunderstand what mass media campaigns had depict typical Mumbai lower and middle incomepreviously worked with the target audience men asking each other the following question:(men aged 18 to 40 from lower socioeconomic “Will Balbir Pasha get AIDS?”. During thisgroups), whether these campaigns were health teaser phase, viewers would encounter peoplepromotion or commercial. ShowCase │ Will Balbir Pasha Get AIDS? 4
  5. 5. speculating on Balbirs future in a series of Stage Three: Non-regular partnerscenarios that reflected real-life situations. Issue addressed – I only have sex with one person (sex worker or casual partner) and hence I am safe Message – „Balbir Pasha only goes to (has sex with) Manjula. But others go to Manjula too‟ Stage Four: Healthy looking partner Issue addressed – If a person looks healthy he/she must be safe from HIV/AIDS Message – „Balbir Pasha only has relationships with healthy-looking people. But you cant tell by looking who has AIDS‟ Stage Five: The Saadhan helpline number was finally revealed in the last phase, and consumers were directly asked to call this number and to access available HIV/AIDS services To address competition in the form of apathy to health-related messages and the media-denseAfter this initial launch, the campaign would environment of Mumbai, the Balbir Pashaunfold to address three different themes. The materials were developed to be bold,three selected themes were developed and controversial and eye-catching, andpretested among sexually active males from deliberately positioned to become a „talkinglow socioeconomic groups to test relevance point‟ or gossip item amongst the targetand appropriateness. The themes intended to audience. Social interest in the human story ofaddress some of the key barriers or myths Balbir thus took over the health element of thepreventing the consistent use of condoms that programme, so that a traditionally hostile targethad been identified in the scoping phase. audience became engaged with the materials.These personalised the risks and weredeveloped to make the target audience In order to disseminate these messages,question their own sexual behaviours and appropriate media channels were identifiedbeliefs: based on the research conducted, which identified areas often frequented by the targetStage Two: Alcohol population. These included: billboards and posters in the red light area; posters on trains Issue addressed – „I often use condoms, and at train stations to reach the four million but when I get drunk, I sometimes forget to people travelling on the Mumbai train network use them‟ each day and to create a conversation buzz; Message – „Balbir Pasha sometimes forgets use of cinema halls to capitalise on the to use condoms when he is drunk. But by popularity of Hindi and Marathi films, not wearing a condom just one time, it is communicate complex ideas to a captive possible to get AIDS‟ audience, and use the many B and C grade ShowCase │ Will Balbir Pasha Get AIDS? 5
  6. 6. cinema halls located in areas where the target Saadhan telephone hotlinepopulation lives; hard-hitting television and Research showed that telephones are widelyradio adverts across a broad mix of networks; accessible in Mumbai (cellular phones,ubiquitous print advertisements and landlines or public phones, which are availablecomprehensive newspaper exposure, with at almost every 100 meters). This easyBalbir Pasha featuring in the major language accessibility made the development of anpapers (Hindi/Marathi) available in Mumbai. HIV/AIDS helpline particularly appropriate forPSI negotiated on average a 40 per cent Mumbai. The helpline would be staffed fromdiscount on media space in newspapers, the 10am to 9pm, Monday to Saturday, providingradio and outside advertising (from CBS confidential HIV/AIDS information andoutdoor). counselling to callers. PSI would provide training to ensure that all telephone counsellors could address the issues raised by the Balbir Pasha campaign and make the appropriate referrals to various local VCT services. To overcome the barriers to using a helpline identified during the research, the helpline would be low-cost, anonymous and confidential, and the long opening hours would make it accessible for most working men. Interpersonal Communication Workers PSI had teams of Interpersonal Communication Workers to work in and around the brothels of Southern Mumbai, educating both commercial sex workers and their clients about HIV risk behaviours. The Balbir Pasha themes would be used as a way of starting discussions with these target audiences.This awareness-raising work would be Each of OPL‟s 12 sites, including Mumbai, hadintegrated with on-the-ground activities and 3 units that oversaw the implementation of theservices, which were implemented in all of OPL work: a marketing team that worked on the saleprogrammes, including: and distribution of condoms; a communications team that managed the interpersonalVoluntary Counselling and Testing (VCT) communicators and any mass mediaservices campaigns; and a medical services team thatVCT services would be endorsed on the oversaw the VCT services and helpline.ground to ensure saturation of behaviourchange messages from all possible angles. ShowCase │ Will Balbir Pasha Get AIDS? 6
  7. 7. Subsequently it was initially very easy to identify where the Interpersonal Communication Workers needed to operate. Then because of an increase in awareness of HIV, men were less interested in coming to a brothel but were looking for sex in places outside brothels. This meant that the Interpersonal Communication Workers had to be flexible and operate in numerous locationsPhase One around the city where commercial sex workersIn Mumbai, the Balbir Pasha mass media were now working, and had to be adaptable tocampaign (Phase One) ran from November further changes in these locations.2002 to February 2003: “Brothels had suddenly become blacklisted as Stage One – Teaser (ran for three weeks in the bedrock of infection, so they started moving November 2002) out of the brothels and into lodges and small Stage Two – Alcohol (ran for three weeks in hotels. So we went from operating in 2 red light December 2002) areas of Mumbai, to working in 10 to 15 Stage Three – Non-regular partner (ran for different locations across the city. That posed three weeks in December 2002 to January considerable challenges. It‟s a big city. That 2003) was something we had to be flexible with and Stage Four – Healthy looking partner (ran ensure our programme implementation was in for three weeks in January 2003) alignment with the needs.” (Sanjay Chaganti, Stage Five – The Saadhan Helpline (ran for Programme Director) three weeks in January 2003 to February 2003) Despite the successes of Phase One of the mass media campaign, it also came under“I think we did something special with this mass criticism from some non-governmentalmedia campaign, simply because it broke the organisations (NGOs) in Mumbai. The NGOsmould in how advertising and communications felt that the focus of the campaign was toowere done in India with respect to public narrow as it focused only on heterosexualservice announcements. Even today it‟s transmission, that it was too frank, and that itreferenced to. What was unique with that was it was not gender sensitive (many believed theused great consumer insight, and secondly it campaign was anti-women, as it implied HIVspoke in a manner that was natural and not was passed from women to men only).didactic as typical health communications tendto be.” (Sanjay Chaganti, Programme Director)The Balbir Pasha mass media campaignreceived great attention and successfully gotpeople discussing HIV/AIDS, but importantlywas supported by work on the ground throughthe Interpersonal Communication Workers toeducate commercial sex workers and theirclients. However, when the research was Phase Twoconducted to inform the programme, there For the second phase of the campaign, PSIwere very clearly defined red light districts worked with the Mumbai District Aids Controlaround Mumbai. Society (MDACS) to obtain stronger NGO buy- ShowCase │ Will Balbir Pasha Get AIDS? 7
  8. 8. in. All messages and concepts were tested with Theme threeNGOs to ensure messages were deemedacceptable. The messages were adapted to Issue addressed – Sexual relationships withask „Who will become Balbir Pasha?‟. Three any non-spousal partner put one at risk ofthemes were used to address issues agreed contracting HIVwith stakeholders: Message – „Will Manu and his „date‟ become Balbir Pasha? Manu and his dateTheme one know each other. But both of them could have other relationships too‟ Issue addressed – Married men and the risk they put their families at when they indulge in extra-marital affairs Message – „Will Hariya‟s wife and his to-be- born child become Balbir Pasha? Away from his wife, Hariya fulfils his needs elsewhere. It‟s men like these who often infect their wives and children with HIV/AIDS‟ These new messages formed Phase Two of the mass media campaign, which ran from November 2004 until February 2005. All materials contained a tagline: „Brought to you by PSI in partnership with MDACS‟ to highlight the NGO endorsement. While the second phase of the campaign built on the successes of the first phase, it did notTheme two appear to have the impact and resonate with the target audience in the same way Phase Issue addressed – Not wearing a condom is One of the campaign had done. While Phase a misplaced sign of being macho Two had obtained the key stakeholder buy-in Message – „Will Rocky become Balbir from the NGO sector which Phase One had Pasha? Rocky has many girlfriends and he failed to achieve, it is thought that Phase Two never wears condoms. This sense of did not reach the target audience as bravado has left many men infected with successfully because the message had HIV/AIDS‟ weakened. “HIV is not just a very sensitive topic but it is also a very politically charged topic. The data at that point in India showed that something akin to 80 per cent of new infections were happening because of men having unprotected sex with commercial sex workers, so therefore we focused on that behaviour. However there were many vocal groups, which said: „Why are you only focusing on this behaviour? What about mother to child transmission? What ShowCase │ Will Balbir Pasha Get AIDS? 8
  9. 9. about men having sex with men? What about Risk perception changesintravenous drug usage?‟ Therefore, variousgroups who very justifiably sometimes feel Increased proportion of those who feel atmarginalised can often influence the agenda by high risk of HIV from unprotected sex with aspeaking up the loudest, and I think that was non-commercial partner, from 17 per cent tothe mistake we made the second time around, 43 per centbecause it meant we lost focus and diluted the The percentage of those who believed thatmessage.” (Sanjay Chaganti, Programme using condoms all the time reducesDirector) HIV/AIDS risk increased from 80 per cent to 86 per cent An increasing proportion realised using condoms half the time did not reduce risk at all (from 43 per cent to 53 per cent) Respondents showed an increase in risk perception regarding healthy looking and more expensive commercial sex workers Over a third stated that one should notAn independent research agency (Mode) engage in sexual intercourse with non-conducted a post-campaign impact evaluation regular partners without a condomfollowing the first phase of the campaign Creation of an icon(November 2002 to March 2003). Results One of the most striking aspects of the Balbirrevealed that campaign messages and Pasha campaign was its assimilation intoservices were well received and effective. popular culture.1500 interviews focused on awareness, attitude Amul, one of India‟s leading dairy cooperativesand behaviour change. The street intercepts mimicked the idea of a regular partner in afocused on men visiting commercial sex billboard advertisement which featured theworkers. caption: „Who does Balbir Pasha wake up withBehavioural changes every morning? Amul Butter. Regular Item.‟ According to the 14 January 2003 issue of Increase in number of calls to the Saadhan Mumbai‟s Economic Times, „To qualify for an HIV/AIDS hotline, and a shift in types of execution in Amul‟s long-standing series of queries from superficial to more invasive satirical topical ads, a campaign must have and informed really made it into the city‟s everyday talk.‟ This Increase in proportion of individuals and other spin-offs and parodies reflect the reporting last-time condom usage with status of Balbir Pasha as a cultural icon. commercial sex workers, from 87 per cent to 92 per cent Retail sales of condoms in the red light district tripled after the launch of the campaign 54 per cent of the target audience reported having discussed the campaign with someone ShowCase │ Will Balbir Pasha Get AIDS? 9
  10. 10. Phase Two more appropriate for these states) replacingPhase Two of the Balbir Pasha campaign Balbir Pasha.(2004 to 2005) was evaluated as part of thewider OPL programme. The programme sawan increase in men in the 12 port citiesreporting condom use with non-spousal Lessons learnedpartners, from an average of 57 per cent in Several criticisms arose as a result of Phase2002 to 75 per cent in 2006 among truckers, One of the campaign:and from 45 per cent to 71 per cent amongother men. The campaign was too frank: bringing the bedroom into the living room The campaign promoted anti-women messages because of the implication that HIV is passed on from women to men It only focused on heterosexual transmission: it did not address the behaviour of MSM, intravenous drug use orAs with many programmes in developing pre-natal HIV testingcountries and elsewhere, the Balbir Pashacampaign and the OPL work has had to In response to these criticisms, campaigncontend with finite funding cycles from donors. strategists consulted more closely with keyAs a fairly large organisation, PSI received five- stakeholders during the development of theyear funding for the OPL work, whereas often second phase of the campaign. However thisfunding only lasts two to three years. These created further challenges. Having tofunding cycles mean that there are periodic incorporate the opinions and needs of multipleproblems with sourcing funding. Because of stakeholders can water down the final messagethis, while aspects of the OPL work continue – this was found to be the case for Phase Twotoday, the scale of this work has been reduced. of the campaign, which did not have as great an impact with the target audience as PhaseThe VCT services continue to run, alongside One, despite being more preferable to thethe Saadhan helpline. The helpline has been numerous stakeholders involved. Anyexpanded to cover a wider range of programme thus needs to strike the delicatereproduction health issues and is being balance between having broad stakeholdersupported by a private foundation based in the input and buy-in and ensuring that this inputUS. The outreach workers who formed the does not dilute the message to the targetinterpersonal communications part of the audience.campaign continue to operate, however theirnumbers have been reduced to approximately Lessons were also learned about the Saadhanone-third of the levels during the OPL work telephone hotline:because of reduced funding. Monitoring and evaluation: Continuous andThe lessons learned from the Balbir Pasha regular monitoring of the helpline is imperativecampaign have been used to influence to ensure that operations are running optimallynumerous HIV/AIDS campaigns run by PSI and and that the helpline‟s objectives are beingothers. The mass media campaign was later met. It is also important to develop a means toused by PSI in Tamil Nadu and Andhra evaluate the helpline‟s impact on the targetPradesh with the character Puli Raja (a name audience, as well as a baseline survey to do so. ShowCase │ Will Balbir Pasha Get AIDS? 10
  11. 11. Flexibility: As it is virtually impossible toanticipate and forecast all helpline relatedissues, it is vital that helplines remain flexibleand are able to adapt quickly to meet the needsof the programme and target audience.Consequently, the Saadhan Helpline inMumbai has adapted its programme in severalareas and capacities to improve services.Counsellors were trained in MSM sexualityand related sexual issues, the helpline‟s hoursof operation were extended when trendsshowed an increase in evening calls, andmethods were developed to manage prankcalls and even turn them into counsellingsessions.Despite these challenges, the programme wasdeemed successful at combining a mass mediacampaign with interpersonal communications(face-to-face communications on the ground).“Interpersonal communications and massmedia can work wonders, if usedsynergistically. Often people compare the two,and that‟s like comparing a hammer and ascrewdriver. They have different uses, theyshould be thought about differently, but theycan be used synergistically to be very useful.”(Sanjay Chaganti, Programme Director) ShowCase │ Will Balbir Pasha Get AIDS? 11

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