Promoting Reproductive Health for Young Adults through Social Marketing and Mass Media: A Review of Trends and Practices

Table of Contents

I. Introduction

II. Review of Recent Young Adult Reproductive Health Social Marketing Projects

III. Key Program Elements

IV. Next Step Programmatic Recommendations and Research Questions

Appendix A: Bibliography

Appendix B: Summary of Ongoing Social Marketing Projects for Young Adults

Appendix C: List of Interviewees

Appendix D: Glossary of Key Terms

Acronyms and Adknowledgements

I. Introduction

A. Goals and Objectives

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:

• Given their developmental stage, the behavioral practices of many young adults are still in the process of being formed, and consequently are often difficult to define or predict. This "developmental transition" stage of the young adult calls for extensive use of social marketing methods such as audience segmentation and behavioral analysis, so that communications and marketing interventions can be designed and implemented.

• In developing countries, at-risk young adults are often difficult to reach. Many are illiterate, not in school, and unemployed. Mass media can be a useful vehicle for transmitting basic messages to this audience, but social marketers also need to find channels of communication and develop marketing systems that can provide hard-to-reach young adults with supportive reproductive health services and counseling.
• Young adults also are particularly vulnerable to a wide range of socio-cultural environmental variables (e.g. opinions of peers, media images of sexuality, access to contraceptives), which inform and shape their reproductive health practices. In the development of intervention strategies, social marketers cannot afford to ignore these environmental factors.

The ways in which social marketing seeks to address these and related issues is the subject of much of this paper.

B. Summary of Key Design Principles

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.

1. Effective interventions address not only the behavioral issues of young adults themselves, but also environmental factors and social norms that greatly influence young adult reproductive health behavior: The strong relationship between environmental factors and social norms and the attitudes and behaviors of young people means that most young adult reproductive health social marketing programs will involve interventions aimed at many different audiences, including youth themselves, service providers, media planners, peer educators, business and civic leaders, and others. For example, a mass media campaign to raise awareness among youth about the importance of condoms for sexually active adolescents needs to be coupled with a marketing initiative to persuade business and civic leaders to help make condoms available for youth at convenient places. (See Section 3.2 for more details on the need for multiple, reinforcing intervention strategies.)

2. Effective interventions address not only the behavioral issues of young adults themselves, but also environmental factors and social norms that greatly influence young adult reproductive health behavior: The strong relationship between environmental factors and social norms and the attitudes and behaviors of young people means that most young adult reproductive health social marketing programs will involve interventions aimed at many different audiences, including youth themselves, service providers, media planners, peer educators, business and civic leaders, and others. For example, a mass media campaign to raise awareness among youth about the importance of condoms for sexually active adolescents needs to be coupled with a marketing initiative to persuade business and civic leaders to help make condoms available for youth at convenient places. (See Section 3.2 for more details on the need for multiple, reinforcing intervention strategies.)

   Involving key gatekeepers and stakeholders at the outset is a critical project success factor: Given the controversial nature of young adult reproductive health issues, it is important to get key societal gatekeepers and stakeholders on board as soon as possible. Such gatekeepers can include public policymakers, business, civic, and religious leaders, and others. Before detailed project planning begins, meetings with key stakeholders should be held to develop consensus regarding what project goals and objectives can be readily supported. (For examples of how to involve gatekeepers, see Section 3.1.)

3. Young adults need to be involved in all aspects of social marketing reproductive health interventions: The impact of young adult reproductive health social marketing interventions can be greatly enhanced if young adults themselves are involved in the processes of project design, implementation, and evaluation. The participation of young adults enables projects to better understand the needs and wants of their principle target audience, design more effective messages and materials, and gain greater insights into the effectiveness of specific interventions. (For examples of successful approaches to involving young adults, see Section 3.2.)

4. Media advocacy activities are an important complement to social marketing interventions: In recent years, organizations have sprung up in many countries to dialogue with media professionals regarding reproductive health programming themes and values. This dialogue, often referred to as media advocacy, is intended to lessen the use of the media to transmit images and themes of sexuality that often conflict with messages that promote safe sex and sexual responsibility; and also encourage media planners to transmit positive messages and themes that address the reproductive health needs of young adults. Media advocacy experts believe that in most countries, media plays an important roles by helping make reproductive health issues discussible, providing legitimacy for their discussion and even modeling words and terms to make discussion more likely and comfortable. (For more information on approaches to media advocacy, see Section 3.3.)

5. Pretesting of all messages is essential, especially those transmitted through mass media channels of communication: Effective social marketing messages that promote behavioral change should address a targeted behavior change objective, and be culturally relevant, believable, and doable by their target audiences. Message pretesting is essential especially (a) in a field that is as sensitive as young adult reproductive health; and (b) for messages transmitted by mass media that instantaneously reach large numbers of people. (For more details on successful approaches to message and materials pretesting, see Section 3.3.)

6. Relevant supportive networking and training activities need to be carried out throughout the life of the project: The building of effective project support networks is essential to helping shape young adult reproductive health social norms. Such networks can be among and between relevant policymakers, media professionals, health service providers and counselors, peer educators, and others. The provision of relevant ongoing training for the many and varied groups involved in implementing a young adult social marketing intervention is also an important key to project success. (See Section 3.3 for specific examples of networking and training activities.)

7. All major projects should include a well designed evaluation component: In a climate of competition for development resources, it is essential that the impact of young adult reproductive health social marketing interventions be fully documented. All of the projects included in Section 2 invested in evaluation activities that yielded information on the extent to which project interventions succeeded in changing the reproductive health knowledge, attitudes, and behaviors of young adult beneficiaries. Data on project impact helps contribute to project sustainability and expansion, advances the state of the art of project design, and builds a receptive climate for investment in similar projects. (See Section 3.5 for examples of evaluation measures used to assess the impact of young adult social marketing reproductive health projects.)

 C. 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.

A. Overview

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

 

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.

B. Highlights and Lessons Learned from Four Recent Projects

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.

1. Project ACTION

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.)

a. Target Audience, Goals and Objectives

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.

b. Project Strategy

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.

c. Project Impact

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:

• The focus on community mobilization helped the project manage controversy around the promotion of condoms as an HIV prevention strategy for teens. Representatives from different community organizations provided letters of endorsement; served as members of a project community advisory board; and served as advocates for the project when contacted by the press or another agency. Cultivating allies in the community created a strong diverse base of support which helped neutralize opposition to the use of condom vending machines in public places.

• Effective young adult reproductive health programs need to involve youth in design, implementation, and evaluation efforts. Project designers found that working with teens is no different than working with other cultures � programs must be sensitive and responsive to cultural differences, develop materials that are culturally appropriate, and involve representatives from the local culture in the development of program strategies

• Targeted behavior change interventions need to be supported by interventions that help to create an environment for youth that supports adoption of safer behaviors. The Project ACTION components, taken together as a whole, are greater than the sum of the individual components. The Project components complement and support each other to have an impact on both the broader community norms and to motivate individual behavior change.

• Media professionals need to be considered as key project stakeholders. For example, to place project PSAs on all the television network affiliates in Portland, Project staff sought and received technical assistance from the media in designing a public relations strategy related to the mass media campaign. This way media professionals were sensitized to the issue that the project was trying to address, and the effective overall role of mass media channels of communication in most countries in shaping the reproductive health behaviors of young adults.

• The need to develop a targeted marketing strategy to make condoms easily accessible for teens. Focus group research pointed to the need for at-risk young adults to have access to convenient, discreet, reliable access to affordable condoms. In many countries, a focused young adult audience contraceptive social marketing strategy may be needed to address this need.

2. The Philippines Multi Media Campaign for Young People

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.)

a. Target Audience, Goals and Objectives

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.

b. Project Strategy

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.

c. Project Impact

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).

d. Financial Information

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.

3. The PROFAMILIA Mass Media Campaign

(Source Document: JHU/CCP. Final Report Summary. PROFAMILIA. Colombia: Freedom Sells Condoms in Colombia).

a. Target Audience, Goals and Objectives

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.

b. Project

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.

c. Project Impact

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.

d. Financial Information

The budget for the Qualitative Research Project was $17,300. The total budget for the Mass Media Promotion Project was $187,000.

4. Ghana Mass Media Campaign

An example of a mass media focused intervention that had an impact on target audience behavior. ( Source Document: McCombie, Hornik, and Anarfi, 1992.)

a. Target Audience, Goals and Objectives

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.

b. Project Strategy

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.

c. Project Impact

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).

III. Key Program Elements

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. ^**

A. Stage # 1: Situation Analysis and Establishment of Project Objectives

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:

• a description of the major components of a social marketing young adult reproductive health situation analysis (A.1);
• a guide to target audience segmentation (A.2);
• a process for establishing project objectives (A.3);
• a guide to the major conceptual models of behavioral change (A.4)

1. Situation Analysis

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)

2. Understanding the Young Adult Target Audience

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)

Sources:

• Centers for Disease Control and Prevention. (1996). The Prevention Marketing Initiative: Applying Prevention Marketing. US Department of Health and Human Services.
• Slater, M. D. & Flora, J. A. (1991, Summer). Health Lifestyles: Audience Segmentation Analysis for Public Health Interventions. Health Education Quarterly. 18 (2): 221-233.

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:

• the urgency of the problem (e.g. the number of AIDS cases among young adults has dramatically risen);
• planning research studies of target audience reproductive health knowledge, attitudes, and behaviors (are there identifiable resistance or intervention points that should become the focus of a social marketing intervention ?);
• socio-economic environmental factors such as opportunities to access reproductive health services that can support or constrain the health practices of young adults;
• the amount of resources (both cash and in-kind) available to support an intervention effort; and
• the degree to which consensus for program objectives can be achieved among key stakeholder groups.

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).

4. Conceptual Models of Behavior Change

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.

B. Stage # 2: Development of a Social Marketing Intervention Strategy

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:

• marketing interventions, such as pricing, promotion, and distribution, intended to persuade a target audience to purchase/use a specific health-related products, e.g. condom, or access a health service;
• communications interventions through mass media, interpersonal and other channels of communication, intended to raise awareness, and change health-related attitudes and practices; (communications interventions also can be used to help market products and services);

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:

• creating a positive socio-cultural environment to promote behavior change (B. 1);
• using reinforcing channels of communication, particularly mass media and peer education (B.2);
• designing messages that address the specific needs and concerns of young adults (B.3);
• enhancing the ability of at risk young adults to access reproductive health services and products (B.4).

1. Creating a Positive Socio-cultural Environment to Promote Behavior Change

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.

2. Using Reinforcing Channels of Communication, Particularly Mass Media and Peer Education

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.

1. Mass Media

   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.

2. Peer Education and Other Forms of 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.

3. Designing Messages that Address the Specific Needs and Concerns of Young Adults

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.

1. The Importance of Role Models

   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)

2. The Need to Focus on Relationship Skills

   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).

3. The Need to Focus on Messages That Give 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".

4. Enhancing the Ability of At-Risk Young Adults to Access Reproductive Health Services and Products

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:

1. Product Marketing

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:

• selecting the product to be marketed: A choice of methods and products attracts more buyers, but social marketing projects need to weight the costs, quality, popularity, and availability of various products for each country.

• deciding on brand names and packaging: Packaging not only protects the products but also carries the brand name and creates a distinctive image. Because attractive packaging is expensive, projects may try to economize -- a practice which will be counterproductive if it impedes sales. Brand names are often used as promotional vehicles. For example, the Colombia Profamilia Campaign used the brand name "Tahiti" for its condoms, because its principle target audience of young adult males were more interested in having a good time and an unrestrained lifestyle, than in issues of birth spacing or maternal-infant health.

• setting an appropriate price: The price for which socially marketed contraceptives ranges from 5% to 50% of the commercial price. Price level depends on whether or when the program expects to reach self-sufficiency; what price the mass of consumers is willing to pay, and what markups are necessary to satisfy distributors and retailers. While high prices will discourage some people from buying, very low prices may convince others that the product is inferior or not worth selling.

• recruiting sales outlets: Point-of-purchase outlets for social marketing range from pharmacies to groceries, bazaars, street hawkers, and vending machines. The more outlets that carry contraceptives, the more convenient for users, but assuring regular supplies, accurate and relevant information, ample promotional display material, and above all, a reasonable level of sales at each outlet is a continuing challenge. Project ACTION provided young adults with convenient access to affordable condoms by placing contraceptive vending machines in businesses frequented by teens.

• arranging and maintaining a distribution system: A good distribution system is indispensable for social marketing. In many countries, commercial distributors are more effective than government distributors and can perform many useful functions. Nevertheless, special efforts may be necessary to persuade commercial, multi-product distributors to carry new, controversial, and low-profit items such as contraceptives.

• carrying out promotion: Consumer demand responds to promotion and product advertising, but many governments have hesitated to permit full-scale public promotion of condoms. Where initial reluctance has been overcome and products have been well promoted, public opposition has proved minimal, and both social marketing sales and contraceptive distribution through other channels have expanded. For example, the "When You Can't Protect Them Anymore - Condoms Can" Campaign in the Eastern Caribbean used a broad-based promotional campaign to overcome the barriers to condom use among sexually active teens. The campaign included 60 second radio ads, bookmarks, brochures, and stickers; radio call-in shows; public forums; a telephone hotline; and an eleven part radio drama series.
2. Services Marketing

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.

C. Stage # 3: Establishing the Project Infrastructure: Prerequisite Materials Production, Training, and Networking Issues

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.

• pretesting of messages and materials (C.1);
• training programs to facilitate the participation of youth in all phases of project activities (C.2);
• advocacy among media policymakers and program planners (C.3);
• building networks of support through social mobilization (C.4).

1. Pre-testing of Messages and Materials

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)

• Training Programs to Facilitate the Participation of Youth

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.

• Advocacy Among Media Policymakers and Program Planners

"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.)

• Building Networks of Support Through Social Mobilization

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.)

D. Stage # 4: Implementation, Monitoring, and Management

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:

• Organizational issues: What configuration of public and/or private sector resources are needed to effectively implement a social marketing intervention? How can needed institutional resources be most effectively coordinated? (D.1)
• Resource allocation issues: How much of the total project budget should get allocated to the wide range of tasks that must be completed if the intervention is to reach its goal? (D.2)
• Monitoring and Supervision Issues: (D.3)

1. Organizational Issues

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.

• The single ministry model generally relies on the Ministry of Health to provide all needed funding and resources to carry out the project. This model is perhaps most appropriate for small-scale pilot interventions, where personnel resources from other branches of the Ministry (e.g. epidemiology, health education, communications) can be secunded for the project.

• The inter-ministerial model draws on other public sector resources to compliment those in the Ministry of Health. This model is most effective in countries where the government owns and operates all of the major channels of communication. In such cases, the Ministry of Information or the Broadcast Ministry can often supply requisite broadcast time for health promotion purposes. The inter-ministerial model is also effective in campaigns that require social mobilization efforts, e.g. schools can be accessed with help from the education ministry and used as a vehicle that reinforces campaign messages. For example, the Minya Initiative in Egypt was implemented by a number of state agencies, including the National Population Council, the State Information Service, and the Directorate of Health (See Annex A for more specific details.)

• The public-private sector collaboration model is often appropriate for projects that have large mass media advertising or health services marketing components. In these domains, expertise often resides in the private sector in many countries. Sometimes private sector services, including air time on privately owned broadcast stations, are available free of charge or at reduced rates. An example of the public--private sector collaborative model is the Ghana Mass Media Campaign to Prevent AIDS Among Young People. The campaign was organized by the Ministry of Health and implemented by Apple Pie, a local advertising agency. (For more details, see Highlights of this project in Section 2.)

• The NGO model is frequently used to support young adult reproductive health interventions that many governments may find too sensitive to implement directly. NGOs and local foundations are particularly effective in working on training and advocacy issues, such as in organizing youth counselor programs, or engaging in policy dialogue around issues of media content. Partnership models between NGOs and public or private sector organizations are also possible. For example, the Philippine Multi Media Campaign for Young People involved a partnership between a local foundation and a number of local corporations, such as Pepsi Cola, Pizza Hut, etc. (For more details, see Section 2). Most local NGOs, however, require further training to increase their ability to design and implement complex social marketing interventions.

2. Resource Allocation Issues

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.

3. Monitoring and Supervision Issues

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.

E. Stage # 5: Summative Evaluation

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.

1. Output Measures

1. Reach

   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.

2. Frequency

   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.)

3. Product Sales/Service Access

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)

2. Outcome Measures

1. Changes in Knowledge, Attitudes, and Awareness

   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)

2. Behavior Change

   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.

3. Health Status

   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)

4. Changing Social Norms

   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.

5. Cost

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.

IV. Next Step Programmatic Recommendations and Research Questions

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:

• the need to develop more social marketing interventions that target young adult reproductive health issues other than HIV/AIDS, e.g.,. pregnancy prevention, adolescent nutrition, sexual abuse;
• the need to more systematically examine the ways in which social marketing projects for adults and married couples, such as family planning IEC and contraceptive social marketing, impact the knowledge, attitudes, and behaviors of young adult cohorts;
• the need to develop special strategies for out-of-school, hard-to-reach youth;
• the need to make greater use of social marketing approaches to strengthen access by young adults to reproductive health services and products;
• the need to collect and analyze more detailed information on the costs of young adult social marketing reproductive health interventions, and their impact on demographic trends and health status;
• the need to develop more information on factors that contribute to project sustainability;
• the need to develop better measures for assessing changes in perceived social norms as a result of young adult reproductive health social marketing interventions;
• the need to develop additional measures for evaluating the impact of interventions.

A. Programmatic Next Steps

• Conduct capacity-building workshops on young adult reproductive health social marketing strategies and techniques that work: Workshops could be organized for potential implementors and sponsors of projects, such as government agencies, developing country NGOs, and public and private sector organizations. Such workshops could cover basic elements in project design, implementation, and evaluation, as well as approaches to media advocacy and social mobilization.
• Convene a meeting of current USAID Cooperating Agencies to assess (a) the degree to which more targeted social marketing interventions can be developed within existing contractual scopes of work; and (b) the degree to which opportunities exist for CAs to collaborate with one another on such interventions.

B. Operations Research Studies

• Organize social marketing demonstration projects that focus on the broader reproductive health agenda for young adults. To date, most social marketing young adult reproductive health interventions have focused on HIV/AIDS prevention (See Section 2). Given the success of these projects, it is worth exploring greater application of social marketing approaches to issues such as pregnancy prevention, the prevention and treatment of other STDs, sexual abuse and violence against adolescents, adolescent nutrition, et al.

• Development and field testing of social norm guidelines. The literature is replete with references to the importance of social norms in shaping adolescent reproductive health practices. However, little guidance is provided on what social norms actually are and how to measure their effect. It would be useful to develop and field test a set of program planning guidelines on ways of identifying, interpreting, and measuring the impact of social norms on young adult reproductive health behavior. The guidelines could be developed through the use of focus group and other qualitative research techniques with a cross-section of young adults and key stakeholders in different settings.

• Culture-specific sexuality studies. It is important for social marketers to understand what is considered normal, sexual practice in different settings, e.g. the use of non-penetrative safe sex methods in Sri Lanka. Culture-specific sexuality studies will help identify young adult reproductive health behavior change objectives that can be promoted through social marketing.

• Studies of delivery systems for reaching adolescents who are not in school. Operations research studies should be developed to explore the relative effectiveness of different communications and service delivery strategies to reach these populations.

• Studies of factors that lead to project sustainability. More information needs to be collected on projects that have sustained themselves beyond the funding and support provided by an initial external donor. Operations research studies on project sustainability should address such issues as: what data convinced the government or other sponsoring agencies to assume responsibility for supporting the project? Has the cost effectiveness of the project improved over time?

C. Evaluation Studies

• Studies to assess the impact of CSM interventions on young adults. More information is needed regarding the impact of CSM projects on adolescent reproductive health practices. For example, perhaps existing sales figures could be more systematically analyzed for numbers of married users of adolescent age. Separate surveys also need to be designed and implemented to capture the "halo affect" on unmarried adolescents.

• Cost effectiveness studies. Information on cost effectiveness is conspicuously absent from the literature. It would be worthwhile, and should be possible, to develop cost indicators that can be used to enhance existing information on the impact of many adolescent reproductive health communication projects. It is also important to get more detailed information on the relative costs of different intervention vehicles within the same project, i.e. within a mass media intervention using a combination of television, radio, and print, which media proved to be more cost effective.

• Long-term impact studies. Long-term impact studies are needed in countries where a significant investment has been made over time in adolescent reproductive health communications. Such studies should compare long-term trends in fertility, contraceptive use, and the prevalence of HIV/AIDS and STDs among adolescents with the resource investment that have been made in various social marketing and communications interventions.

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Centers for Disease Control and Prevention. (1996b). The Prevention Marketing Initiative: Applying Prevention Marketing. US Department of Health and Human Services. Public Health Service.

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Appendix B: Summary of Ongoing Social Marketing Projects for Young Adults

Appendix B provides summary information about thirteen ongoing social marketing young adult reproductive health projects. Each of these projects plans to have an evaluation component that will eventually provide useful information on project impact.

 Africa

Country	Project Title/Agency	Project Activities
Benin	PSI condom and ORS social marketing projects	IEC activities. Promotional events -- soiree Prudences, sponsorship of music concerts, sports events (basketball tournaments, Africa boxing championship, bicycle races, etc.), 100 AIDS awareness "sensibilizations" in high schools for about 15,000 students with basic HIV/AIDS information and condom use. 6 training workshops in high schools to develop HIV/AIDS youth committees to undertake education and outreach activities. 12 nationwide "Amour et Vie" (Love and Life) comic strips including basic information with 75,000 copies per strip.
Congo	PSI social marketing and communication activities	"Prudence Clubs" at 10 high schools disseminate reproductive health information and distribute condoms by way of peer educators.
Malawi	PSI Malawi HIV/AIDS condom social marketing project.	10,000 reproductive health booklets on STD/HIV/AIDS prevention and teen pregnancy. Youth-targeted video in local language shown on the mobile video units in rural areas. Rap music jingle and rap music competition. Sponsorship of National Basketball Tournament.
Rwanda	PSI condom social marketing project including extensive IEC activities:	Cinemobile videos throughout the country with informative IEC messages. Comic books HIV/AIDS Information kiosk in Kigali's main round-about.
Zaire	PSI's continuing HIV/AIDS condom social marketing project:	A one hour concert style spectacles created by peer group facilitators which features music, theatre, and a Q & A session. With handouts and awareness manuals, it is estimated that 50,000 students will be reached in 1997. Five information kiosks disseminate reproductive health information and distribute condoms, staffed by male-female couples from local youth groups.
Latin America and the Caribbean
Dominican Republic	AIDSCAP AIDS Prevention Campaign for the Youth (national coverage). Implementing/cooperating/ fund-in agencies: National STD/AIDS Prevention Program (of the MOH), USAID, AIDSCAP/FHI/DR, and 14 NGOs.	Objectives: (1) to promote behavioral changes -- the adoption of preventive measures for STD/HIV/AIDS among youth (13 - 19 years of age); (2) to promote the demand of services that support these behavioral changes. Goals: (1) 65 % of the target population will increase their knowledge of STD/HIV/AIDS and adopt preventive measures; (2) develop unified criteria on services, orientation, education, and counseling for youth among institutions providing these services; (3) 20 % of the target will ask for orientation, education, and counseling on STD/HIV/AIDS. Target audiences: (1st phase) the primary target audience was 13 to 19 years of age male/female youth throughout the country, while the secondary audience was Dominican families; (2nd phase) the primary target was the institutions that work with youth offering services in AIDS prevention, the secondary was the institutions working with youth in other areas of development; (3rd phase) the primary audience was 13 - 19 year-old adolescents, the secondary was their parents. Duration: September 1995 - February 1997. Program Activities: TV and radio spots, press coverage in the newspapers, materials production and distribution, Criteria Unification Manual, and training workshops on the Manual. Outcome evaluation: the campaign spots were broadcast free of charge by almost all TV and radio stations (about 9 million dollar's worth), with nationwide coverage in newspapers; an impact study based on focus group discussion after the first phase indicated that the majority of participants understood the messages. They considered themselves "at higher risk" than before the campaign. Recommendations: more correct information tailored to the target population is needed; teachers and counselors must be involved in providing information; a campaign for parents must be developed. The last recommendation led to the production of spots for parents. Since the production of broadcasting spots, teachers and parents are seeking information in increasing numbers.
Bolivia	PSI HIV/AIDS condom social marketing project targeting young people throughout the country launched in 1994.	Mobile video units and interactive sessions, television dramas (Historias del Vecino), and radio soap operas and discussion guides. Product marketing for male and female condoms, oral contraceptives, and a lubricant. Exposure of the first 7 television dramas has reached more than 2.5 million Bolivians, over one-fourth of the entire population. PSI's male condom sales increased by over 400% (monthly sales of 300,000) for the first 18 months, while female condoms sold 900 monthly. The project has started selling oral contraceptives and will sell injectables soon.
Haiti	PSI Haiti project conducted many IEC campaigns for young adults.	Carnival 1996 Adolescent Activities: "It's Cool" Campaign with posters and T-shirts, radio messages, and sponsorship of 9 Soiree PANTE events with condom demonstrations and game shows. Sponsorship of Sports Activities: provide 48 athletic teams with $72,500 worth of equipment and promotional items, condom demonstration with HIV/AIDS messages were also given. It is estimated that 129,500 adolescents were exposed to the messages. Sponsorship of Local Music Bands: 12 popular bands were sponsored with T-shirts, hats, sales training for the bands. Sponsorship of the Fugees concert, " The Fugees Coming Home Tour," along with 885 radio spots, 90 TV spots, 17 newspaper ads, and 1,000 AIDS/STD prevention pamphlets. Youth AIDS Prevention Comic Book: 4 stories on AIDS/STDs developed through by students. 11,064 copies distributed and a 6 series comic book will follow.
Paraguay	Adolescent Reproductive Health Communications Project (ARHCP) by PSI and FOCUS (for 8 months from February 1997):	Objectives: to increase adolescents' (15 - 19 yr.) knowledge of sexual and reproductive health issues; to increase the media's understanding and coverage of YARH issues. Technical Advisory Committee formation. 80 hours of intensive skill building workshops by 23 peer educators on adolescent development, pregnancy, STDs/HIV/AIDS, and negotiation skills. "Lovers Straight Talk" booklet on adolescent sexuality. Editorials in weekly newspapers Future activities: road show (peer educators skit), condom demonstration, a one-hour radio program by teen for teens, and research (pre- and post-study on adolescents' knowledge, intention, and behaviors).
Asia
The Philippines	The Foundation for Adolescent Development (FAD) video series JHU/CCP	Six videos with discussion guides to address sexual responsibility, STDs and HIV/AIDS prevention, and peer-, parent- and opposite-sex relationships will be shown in schools and communities, promoting FAD's counseling hotline.
CIS/Eastern Europe
Russia	The Russia Reproductive Health Project JHU/CCP	It will produce a video for youth and an accompanying user's guide. The video will be shown in family planning clinics and school sex education classes. Print materials on contraceptives will be also developed.
Ukraine	Night Saxophone, a 20-minute video JHU/CCP	A 20-minute video is being produced in Russian and Ukrainian to be shown in schools, clinics, and possibly on TV. The video promotes sexual responsibility and contraception, and will be accompanied by a user's guide and brochures.

Appendix C: List of Interviewees

Dr. Alan Andreasen, Georgetown University

Dr. Jane Bertrand, Tulane University

Dr. John Elder, San Diego State University

Dr. Robert Hornik, University of Pennsylvania

Dr. May Kennedy, CDC

Dr. Larry Kincaid, JHU/CCP/PCS

Dr. Karusa Kiragu, JHU/CCP/PCS

Dr. Fred Kroger, CDC

Dr. Craig Lefebvre, Prospect Associates

Mr. Don Levy, the Futures Group

Dr. Edward Maibach, Porter/Novelli

Mr/Dr. Greg Mclure, Dunlop Corbin Compton

Dr. Asha Mohamud, PATH

Dr. Phyllis Piotrow, JHU/CCP/PCS

Dr. Everrett Rogers, University of New Mexico

Ms. Judith Senderowitz, Consultant

Dr. Michael Slater, Colorado State University

Ms. Renee Wessels, PSI

Mr. Kim Winnard, PSI

Mr. David Zucker, Porter/Novelli

Appendix D: Glossary of Key Terms

A

Attention:	a pretesting measure to describe a message's ability to attract listener or viewer attention; this is often called "recall."
Attitudes:	an individual's predisposition toward an object, person, or group, which influence his or her response to be either positive or negative, favorable or unfavorable, etc.
Audience segmentation:	subdividing an overall population into homogeneous subsets of target audiences in order to better describe and understand a segment, predict behavior, and formulate tailored messages and programs to meet specific needs. Segments may be demographic (e.g., age, sex, education, family life cycle), geographic (e.g., Southeastern, U.S., rural, northside of town), or psychographic (e.g. personality, lifestyle, usage patterns, risk factors, benefit sought).

B

Baseline study:	the collection and analysis of data regarding a target audience or situation prior to intervention.
Behavioral science:	an area of social science research that examines individuals' behaviors in depth; it explores what people do and why they do it.
Behavioral Theory/Model:	a theoretical framework that provides causal factors and evaluation indicators for interventions that seek to change the health behaviors of the target populations.

 C

Central location intercept interviews:	interviews conducted with respondents who are stopped at a highly trafficked location that is frequented by individuals typical of the desired target audience.
Channels of communication:	the ways in which individuals receive information; includes large and small media, one-on-one communication, and live entertainment. The route of message delivery (e.g., mass media, community, interpersonal). Refers to specific ways in which different communication delivery systems such as mass media are used. For example, radio and television are examples of channels of communication within the broader communication system of mass media.
Change agents	individuals, organizations, and programs that form the target audience's social network; they directly interact with and influence young people.

 C

Communication strategy statement:	a written statement that includes program objectives, target audiences, an understanding of the information needs and perceptions of each target audience, what actions they should take, the reasons why they should act and the benefits to be gained. This document provides the direction and consistency for all program messages and materials.
Communications science:	systematic, informed creation, dissemination, and evaluation of messages to affect knowledge, skills, attitudes, behaviors, and ultimately, health outcomes.
Comprehension:	a pretesting measure to determine whether messages are clearly understood
Contraceptive social marketing	the use of commercial advertising and marketing strategies and techniques to promote the sale of contraception primarily to adults and married couples in developing countries.
Cultural competence:	cultural sensitivity combined with the ability to successfully intervene in a specific population.

 D

Demographics:	statistics relating to human populations, including size and density, race, ethnicity, growth, distribution, migration, births, and their effects on social and economic conditions.
Determinants of behavior:	the external and internal factors that may determine or influence individuals' actions.
Developmental needs	special needs of young adults for supports in response to the biological, social, and psychological changes they experience in the period of transition from puberty to adolescence and to adulthood. Examples of those needs include: timely and accurate information about how to establish a healthy life, parental guidance and community support, opportunities to learn skills to make a sound life decision, etc.

 E

Environmental media:	campaign promotional materials such as print ads, T-shirts, key chains, posters, and flyers carrying a campaign message to the target audience. They can reinforce the messages aired on the broadcast media such as television and radio.
Epidemiology:	the study of the patterns and determinants of health and disease in populations.

 E

Evaluation:	a systematic process that records and analyzes what was done in a program or intervention, to whom, and how (process), and what short- and long-term behavioral effects (outcome) were experienced as a result.
External determinants of behavior:	those forces outside the individual that affect his or her behavior (e.g., availability of condoms; laws governing sexual activity).

F

Family life education	Most widespread reproductive health program for young people taught mostly in school and sometimes through community outreach. Subjects often covered include population growth, life planning and decision-making skills, and general health and nutrition; with a lesser degree, sexual abstinence, reproductive health and physiology, gender equality, and contraceptions are being covered (JHU, 1995a).
Focus group interviews:	a type of qualitative research in which an experienced moderator leads about 8 to 10 respondents through a discussion of a selected topic, allowing them to talk freely and spontaneously.
Force field analysis:	an analysis of the forces in a community that may inhibit, impede, or assist a program or course of action.
Formative evaluation	the process used to inform health program planners about how to respond to issues surrounding improvement in the functioning of existing projects: the improvement of the process of a project and the development of the content and format of appropriate messages. Both qualitative (focus group discussion) and quantitative research methods (intercept survey) can be used.
Formative research:	systematic investigations during the development phase of a program or intervention that deepens the planners' understanding of the audience and the environment and that assists in subsequent planning and evaluation. May include state-of-the-art reviews, pretesting messages and materials, and pilot testing a program on a small scale before full implementation.
Frequency:	In advertising, it is used to describe the average number of times an audience is exposed to a specific media message.

 G

Gatekeepers:	influential individuals who serve as access points to the target audience, e.g., school teachers, doctors, or public service directors at local television stations.
Goal:	the overall improvement the program will strive to create.

 H

Health communication:	the modification of human behavior and environmental factors related to that behavior which directly or indirectly promote health, prevent illness, protect individuals from harm (Elder et al., in press, in Graeff, Elder, and Milles Booth, 1993).
Health education:	a means to meet public health objectives and improve the successful implementation of public health and medical interventions. It represents a multidisciplinary perspective that integrates theory, research, and practice from a diverse set of disciplines including the behavioral and biomedical sciences, psychology, sociology, epidemiology, statistics, and medicine (Glanz et al., 1990, in Leventon, Mrazek, & Stoto, 1996).
Health promotion:	it is broader than health education and addresses the full range of "healthful behaviors," from disease prevention to promotion of optimal health, and illness detection through treatment, rehabilitation, and long term care. It has broader application with regard to impacting public health policy and the delivery of health care services. It focuses on determining what interventions work for what types of groups and emphasizes community and control (Leventon, Mrazek, & Stoto, 1996).

 I

Impact evaluation:	research designed to identify whether and to what extent a program contributed to accomplishing its stated goals (more global than outcome evaluation).
In-depth interviews:	a form of qualitative research consisting of intensive interviews to find out how people think and what they feel about a given topic.
Incidence:	the number of new cases of a disease or condition that occur within a given time, often one year.
Intermediaries:	organizations, such as professional, industrial, civic, social or fraternal groups, that act as channels for distributing program messages and materials to members of the desired target audience.
Internal determinants of behavior:	the forces inside the individual that affect his or her perception of a behavior (e.g. the belief that condoms are not "cool").
Interpersonal education:	strategies for information sharing, skills building, and counseling that are transmitted by one or more trained educators to one or more clients.

K

Key informants:

individuals who are knowledgeable about and influential with particular segments of the population.

 L

Large media/mass media:	media channels that reach large or nationwide audiences, such as the three network television networks or national magazines.
Lifepoints:	key places individuals visit in their daily lives, e.g., school, stores, restaurants.

 M

Marketing mix:	the balance of components in a marketing strategy that reflects the different needs of a given audience; the "4 Ps": product, price, promotion, and place.
Mass media	any self-contained, broad-based material distribution system, e.g. radio, television, newspapers, magazines, direct mail, and telemarketing systems.
Media advocacy	the strategic use of mass media to advance a social or public policy initiative. It 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; US DHHS).
Media formats	refers to specific uses of different media channels of communication such as music videos and radio soap opera.
Multimedia	a) the use of different media elements (e.g., radio and television) to transmit similar messages. b) the integration of computer programs and video in an interactive instructional design format.

 N

Needs assessment:	the process of obtaining and analyzing information from a variety of sources in order to determine the needs of a particular population or community; similar to "marketplace assessment."
Niche media:	media targeted to small, specialized audiences.

 O

Objective:

a quantifiable statement of a desired program achievement necessary to reach a program goal.

  O

Outcome evaluation:

a type of evaluation that determines whether a particular intervention had a desired impact on the targeted population's behavior; whether the intervention provided made a difference in knowledge, skills, attitudes, beliefs, behaviors, and health outcomes (also called "impact evaluation").

 P

Peer education/counseling	ways to assist young adults in obtaining the help they need with the help of other young people called peer educators who are more likely to understand the needs of youth of their age. Peer counseling is harder to achieve as it requires youth to be trained in counseling and psychological skills, have adequate knowledge about referral and youths' needs, and receive supervision and continuing support from adults (WHO, 1995).
Pretesting:	a type of formative research that involves systematically gathering target audience reactions to messages and materials before they are produced in final form.
Prevalence:	the number of individuals living with a disease or condition during a given time.
Prevention marketing:	CDC's "brand" of social marketing, which incorporates behavioral science and community participation into the principles and processes of social marketing.
Primary data:	qualitative or quantitative data that are newly collected in the course of research.
Process evaluation:	a descriptive assessment of the implementation of program activities; what was done, to whom, and how, when, and where. Evaluation to study the functioning of components of program implementation; includes assessments of whether materials are being distributed to the right people and in what quantities, whether and to what extent program activities are occurring, and other measures of how and how well the program is working.
PSA:	public service announcement, used without charge by the media.
Psychographics:	statistics relating to the spheres of influence of a target audience and their behavior; includes information about target audience's work and leisure activities, associations with peers, willingness to try new things, social norms, and hopes, fears, and dreams.

Q

Qualitative research:	research that is subjective in that it involves obtaining information about feelings and impressions from small numbers of respondents. The information gathered usually should not be described in numerical terms, and generalizations about the target populations should not be made.
Quantitative research:	research designed to gather objective information from representative, random samples of respondents; results are expressed in numerical terms (e.g., 35 percent are aware of X and 65 percent are not). Quantitative data are used to draw conclusions about the target audience.

 R

Reach:	in advertising, used to describe the number of different people or households exposed to a specific media message during a specific period of time.
Recall:	in pretesting, used to describe the extent to which respondents remember seeing or hearing a message that was shown in a competitive media environment; usually centers on main idea or copy point recall.
Role model	a key element in the social learning (cognitive) theory to enhance one's sense of being capable of adopting a target behavior (e.g., how to use a condom correctly) by demonstrating the desired behavior and illustrating the benefits of doing so as vicarious reinforcement for a change (Corby, Engu�danos, & Kay, 1996).

 S

Secondary data:	published, already available data.
Self-efficacy:	an individual's belief that he or she can do a desired behavior.
Seroprevalence:	the percentage of individuals infected with HIV in a given population in a given population at a specific point in time.
Situation analysis:	review and analysis of the community's current environment with regard to HIV and HIV prevention, including support for and potential barriers to prevention efforts; this information is used in making decisions about target audiences, behavioral objectives, geographic area to cover, and players to involve.
Small media:	often called "personal media"; media targeted to relatively small, specialized audiences and interests, e.g., seminars and workshops, door hangtags.

 S

Social marketing:	the use of modern marketing principles and methodologies to increase the use of a socially beneficial idea, product, or practice; key features include a through understanding of the target audience, creation of beneficial exchange relationships to influence audience behaviors, and a management approach characterized by continuous monitoring and alteration of interventions as needed.
Social mobilization	the process of bringing together all feasible and practical inter-sectorial social allies to raise people's awareness of and demand for a particular program, to assist in the delivery of resources and services, and to strengthen community participation for sustainability and self-reliance. It differs from social marketing in focusing on mustering national and local support for a general goal or program through a much more open and uncontrolled process, giving ownership to the community as a whole. The process is concerned with mobilizing human and financial resources through five approaches: political, government, community, corporate, & beneficiary mobilization(McKee, 1992).
Social norms:	perceived standards of behavior or attitude accepted as usual practice by groups of people.
Stakeholders:	those who have an interest in and can affect implementation of an intervention or program; key players; influential.
Summative evaluation	a structured research technique to assess the overall impact of projects and to calculate the cost-effectiveness of a particular intervention in comparison to alternatives. It can consist of the evaluation of both the performance of the intervention and the effect the intervention has on the outcomes sought by the program managers.
Surrogate indicators:	data such as STD or hepatitis B rates, which do not directly measure HIV infection, but that may indicate unsafe sexual behavior that can put people at risk of HIV infection.
Surveillance:	an ongoing process of information collection, analysis, interpretation, and dissemination to monitor the occurrence of specific health programs in populations.

T

Target audience:

the desired or intended audience for program messages and materials. The primary target audience consists of those individuals the program is designed to affect. The secondary target audience is the group(s) that can help reach or influence the primary audience.

Major Source Unless Otherwise Indicated:

--Centers for Disease Control and Prevention. (1996). The Prevention Marketing Initiative: Applying Prevention Marketing. US Department of Health and Human Services. Public Health Service.

--Department of Health and Human Services. Making Health Communication Programs Work -- A Planner's Guide. Washington D.C.: US DHHS. Public Health Service and National Institutes of Health. 

Acronyms and Acknowledgements

AED	Academy for Educational Development
AIDS	Acquired Immunodeficiency Syndrome
AIDSCAP	AIDS Control and Prevention Project
AIDSCOM	AIDS Technical Support: Public Health Communication Component
AIDSTECH	AID-funded AIDS Prevention Technology Project
CAs	Cooperating Agencies
CDC	Centers for Disease Control and Prevention
CER	Cost Effectiveness Ratio
CSM	Contraceptive Social Marketing
FHI	Family Health International
FLE	Family Life Education
JHU	Johns Hopkins School of Public Health
JHU/CCP	Johns Hopkins Center for Communication Programs
JHU/CCP/PCS	Johns Hopkins Center for Communication Programs/Population Communication Services
KAP	Knowledge, Attitudes, and Practice
MOH	Ministry of Health
NGOs	Non-governmental Organizations
PATH	Program for Appropriate Technology in Health
PSI	Population Services International
SOMARC	Social Marketing of Contraceptives Project
STDs	Sexually Transmitted Disease
USAID	United States Agency for International Development
WHO	World Health Organization

                                      

Acknowledgements

 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.