Challenging Dogma

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

Friday, April 27, 2007

Ignorance is Bliss: A critique focusing on the Botswana female condom campaign’s avoidance of social components- Kim Burke

Sixty nine percent of women in their early 30s carry HIV in Francistown, Botswana(1). A disquieting statistic, yet one that also renders a wordless response. The government of Botswana has found such a word to respond: Bliss. The Bliss female condom is apparently one of the answers to the startlingly high prevalence of HIV in Botswana. In the female condom, Botswana is putting its hope, however the Bliss campaign centers itself around social marketing theory.
The Bliss Campaign in Botswana promotes women’s empowerment through the use of the female condom. Women play a crucial role in the success of this HIV prevention strategy, because they control this method of protection. The Bliss campaign was developed around social marketing theory defined as “the design, implementation, and control of programs seeking to increase the acceptability of a social idea or practice in a target group”(2). In this case, Bliss is trying to improve the social acceptability of the female condom as an HIV prevention tool and form of contraception. Bliss’s marketing focuses on making the product more sexually appealing to increase use and sales. According to the marketing strategists, the earlier product had dull packaging, so the developers used bright colors and a sexy name. They think the name will spark the attention of men and women with its sexual connotation(3). Collaborating with the Ministry of Health, Bliss has been releasing leaflets and posters, as well as TV advertisements to spread awareness of this new product. The minister of health, Professor Sheila Tlou, reported that she was re-launching the new condom free of charge at all health facilities(3). She also stated that the ability of women to have control over their own fertility forms a foundation for the enjoyment of other rights, such as uninterrupted education and career opportunities. For men and women alike, their empowerment on sexual and reproductive health is the best entry point for HIV prevention (3). Professor Tlou proposes several strong points, and the female condom will certainly aid in women’s empowerment. By increasing promotion of the product, reducing the price, and making it accessible through all health clinics in Botswana, the marketing company believes that people will be more likely to use the female condom. However, Bliss fails to maximize its promotional power of the female condom because it relies solely on social marketing theory to effectively reach its target market and abstains from addressing the social and behavioral barriers to condom use in this population.
Also Bliss does not use social marketing adequately to recognize the social context of HIV/STI transmission and the sexual behavior of the people of Botswana. A critique of Bliss’s reliance on social marketing theory reveals its insufficiency to address three critical social elements which I will examine within this paper. The status of Botswana women, the sexual behavior of Botswana, and the difficulties associated with female condom use provide the explanation for why social marketing theory will fall short of maximizing female condom use in Botswana.
Status and lack of empowerment as a barrier to sexual precautions in Botswana Women
In a country with the second largest prevalence rate of AIDS( 24.1% in 2005(4), women face a rate of 17.8% for 15-19 yr olds and 30.6% for women 20-24(4). First, understanding women’s status in Botswana helps to explain their increased risk of HIV transmission.
Women in Botswana cope with high rates of domestic violence (60 % of women experiencing this in their lifetime)(5). The threat of domestic violence may discourage a women from introducing the female condom to her partner. The woman may choose to avoid a beating or clash with her partner by complying with his sexual preferences. A study on Sexual Power and HIV risk in South Africa noted that many women do not bear the right of refusal, because men are the primary sexual decision makers, and may coerce women in sexual situations(6). Additionally, a study exploring culture, sexuality, and women’s agency with regards to HIV prevention in Southern Africa, women of Southern Africa reported that they had no say in the bedroom and they could not ask a man to use a condom or discuss any other sexual issue(7). When asked why their male partners were not using condoms one woman replied “It is good to have women’s groups to help us, but there is no group to support you when you are alone with you husband”(s). These studies point to domestic violence as one of the key issues surrounding sexual behaviors, and Botswana’s female condom campaign does not address them.
These studies clearly demonstrate the compliance that men expect of their partners, and the limited power women possess in Sub Saharan Africa. However, there is a definite advantage to the female condom in this instance, because it can be worn up to eight hours before sexual intercourse. Women also reported that their use of the female condom would not incite a beating as it would if they had been bold enough to ask a man to use a condom(7). In this way, a woman might be better able to protect herself if she could wear it in the event that her husband or partner forced sex on her unexpectedly.
Simple marketing strategies will certainly not be enough to persuade a woman to introduce the female condom to her partner if she fears a hostile or violent response. A woman that feels limited in her sexual negotiating power or acts submissively to her partner, may be reluctant to initiate conversation about the female condom, especially if she considers sexual matters unmentionable. Practical and correct use of the female condom requires communication between partners. Social marketing theory fails to address the violence and status of women as a barrier to safe sex practices. Instead it focuses its marketing strategy on the pleasure aspect of using the female condom with new colors and a suggestive name.
The Bliss campaign seeks to detract from the gawky aspects of the female condom such as squeakiness and external visibility A study among adolescents in Botswana found that females in particular feared they would be stigmatized if they obtained condoms(8). There seems to be a stigma attached to male condoms that if a person buys or uses them, they are unclean or have an STI. Besides the STI connotation associated with condom use, women must overcome the embarrassment of obtaining condoms, and the self consciousness that may accompany wearing them. Young women fear their parents finding out about their obtaining condoms and worry about their reputations. As one young Botswana woman said “Boys are people who are very free in life. They can go and collect condoms when they need them.… Girls are scared of how people will look at them because.… We think that people will call us prostitutes”(9). A social marketing theory may help to spread the pleasure aspect of the female condom, but it will be limited in its ability to dispel deep seated stigma that people hold. Bliss, cognizant of the stigma, has been launching leaflets, fliers, and television ads. With mass marketing of the female condom, Bliss hopes that some of the stigma associated with its use will dissolve with greater familiarity.
Young people also hold the belief that condoms are for those infected with STIs, prostitutes, and people that engage in casual sex outside of relationships. The suggestion of condom use to a partner may imply that one is infected or distrust exists. This may explain why women shy from asking their husbands or partners to use condoms. Therefore a personal component that offers women advice and support for obtaining the condom in order to practice negotiating skills would be more effective than leaflets and commercials.
Social aspects of sexual behaviors in Botswana
In the country’s national language called Setswana, the word fidelity does not exist(1). Sexual promiscuity in Botswana is widely accepted, and both men and women hold numerous sexual partners at the same time. Polygamy, once common in Botswana, still happens in some parts of the country. A US government survey indicated that almost 30% of sexually active men in Botswana reported having multiple, concurrent sex partners, as compared to 14 percent of women(5). Condom use varies with types of sexual partnerships. With a spouse, most men refuse to use condoms (1). The practice of having multiple sexual partners and inconsistent condom use may account for the high rates of HIV transmission in Botswana, since studies show many Botswana citizens are unaware of the high risk of HIV associated with having many sexual partners(1). A condom campaign must concentrate on the practice of concurrent sexual partners and inconsistent condom use for Botswana to connect these behaviors to greater risk of HIV transmission. The Bliss campaign could emphasize consistent condom use and limited sexual partners to differentiate itself from male condom campaigns.
Women may be able to change the trend of inconsistent condom use by wearing the female condom, and taking on some of the sexual decision making leading to empowerment, as the Bliss campaign suggests. However, the Bliss campaign fails to adequately address economic adversity, food insecurity, violence, gender inequality, and limited access to information and services that Botswana women encounter. These factors contribute to the women’s financial dependence on men. With an economic upperhand, men also assume they are entitled to ultimate authority over their female partners. Financial instability is what forces women to stay with husbands that mistreat them, entices young women to sexual partnerships with older men, and compels mothers to sell sex to provide food for their children. In Gabarone, Botswana, economic independence was more strongly related to women's negotiating power in relationships than any other variable explored(8). Of course, solving the problem of women’s empowerment must happen through establishing infrastructure, increasing access to healthcare, education, stronger enforcement of domestic abuse violations, and programs aimed at helping women achieve financial sustainability. In a country where 47% of the population lives below the poverty line(11), and transactional sex is common, a female condom alone will not empower women.
The practice of intergenerational sex between younger women and older men also challenges consistent condom use. Researchers found that women were less likely to report consistent condom use if they were forced to have sex(4). Young women receive economic and material reward within these partnerships in the forms of books, stationary, cell phones and airtime, clothing, and cab fares. Men that might be considered “sugar daddies” are not required to wear condoms, because they are high paying. The President of Botswana, Festus Mogae, explained that the economic disparity between the older men and younger women encourages intergenerational sex. He added “This is clearly demonstrative of the economic power imbalances at play, which leaves the young vulnerable and unable to negotiate safer sex”(5). The age difference and transactional nature of these relationships may discourage a young women from asking her partner to use protection. Here again, the female condom could serve an excellent purpose if it were marketed towards these younger women and they were properly educated about its use.
Barriers related to design and usage of female condom
In an ideal situation, female controlled contraception would be imperceptible to her partner, easy to use, and invisible in accordance with cultural norms that seek to preserve femininity and male preferences. Unfortunately the female condom has been described as squeaky, difficult to use at first, and is externally visible. These aspects of the female condom, may dissuade sexual preference for the female condom. If the woman does introduce the condom properly to her partner the first time and understand how it is used, the complexity may discourage its future use.
Proper use requires basic sexual education and information on the female condom. There is no complementary educational or instructional program that accompanies the Bliss female condom. This would serve Botswana men and women well considering many of them have inaccurate or incomplete information about reproductive physiology and the transmission of HIV. Many people in Botswana still believe that HIV can be transmitted through the supernatural and more than 50% agree that it can be obtained from a mosquito bite(3). Understanding that HIV is transmitted through unprotected sex, and that holding concurrent sex partners increases risk of transmission is crucial to curtailing the spread of HIV in Botswana and Sub Saharan Africa. Ignorance of female physiology may also deter women from using the female condom. Research groups for the female condom in Zimbabwe revealed that several women were worried that they would be unable to urinate or defecate while using the female condom(13). A woman ignorant of her own female anatomy will most certainly encounter difficulty during insertion.
Trouble with insertion along with discomfort during sex, squeaky noises during use, and excess lubrication were difficulties reported by 30% of men and 57% of women in a study on the Dynamics of Female Condom use in Zimbabwe(14). With its oily texture and ample lubrication, the female condom may not appeal to the many men that prefer dry sex(15). Dry sex is dangerous for women and puts them at a higher susceptibility for AIDS.
A woman that decides to use the female condom will need to communicate with her partner in order to benefit from its correct and consistent use. The sexual power and HIV risk study found that the strongest risk factor for inconsistent condom use with the most recent sexual partner was not talking to that partner about condom use(5). Because communication is limited, the Bliss campaign should advise women on how to approach their partner, or offer reasons for use other than HIV protection. To appeal to men some female condom promotions encourage women to tell their partners that sex would be more satisfying with the female condom or that sex would be possible during menstruation. Bliss could have also offered these suggestions for women in its ad campaign. Altering its ad campaign would have been one of the easiest strategies to employ.
The failure of the Botswana government and Bliss to use an effective marketing strategy and complementary educational component to their female condom campaign, will underscore the reintroduction of the female condom in Botswana.
Alone, the female condom will probably not be used consistently, and the female population most at risk will not be encouraged to obtain it based on new packaging only. As Dr. Mhloyi of the Centre for Population Studies at the University of Zimbabwe explains "The best intervention is holistic empowerment, of which the female condom is just one part." (16)
1) Timberg C. In Botswana, unsafe sex couples with AIDS. The Seattle Times. March 18, 2007
2) Meischke Hendrika. Social Marketing Theory. Seattle, Wa: DocReview: International Council of Nurses. Tlou promotes female condom in Botswana. Yokohama, Japan: International Council of Nurses
4 ) Smart Theo. HIV prevalence among young women in Botswana falls to lowest level since early 1990s, but still high. London, UK:NAM Publications.
5)10 stories the World Should Hear More About. Behind Closed Doors. New York, NY: UN Office for Human Rights:
6) Pettifor AE, Measham DM, Rees HV, Padian NS. Sexual power and HIV risk, South Africa. Emerg Infect Dis. 2004 Nov [March 26, 2007]. Available from
7) Susser I and Stein Z. Culture, Sexuality, and Women’s Agency in the Prevention of HIV/AIDS in Southern Africa. American Journal of Public Health 2000;90 1042- 1048.
8)UNAIDS/UNFPA/UNIFEM. Women and HIV AIDS: Confronting the Crisis. New York, NY: UNFPA.
8) Finger William R.. Condom Offers STI Protection. Durham, NC: Family Health Initiative.
9) Ashford Lori. SMASH: Social Marketing for Adolescent Sexual Health. Washington, DC: Population Services International.
10)Hoffman S, Mantell J, Exner T, Stein Z. The Future of the Female Condom. International Family Planning Perspectives; 30: 3-12.
11)United Nations Development Program. UNDP Botswana: Poverty Reduction. Gaborone, Botswana: United Nations Development Program
12) Roelf W. Female Condom Usage on the Rise. Cape Town, South Africa: Independent Online.
13) Hyena H. "Dry sex" worsens AIDS numbers in southern Africa. New York, NY: Salon.
14)Kerrigan D, Mobley S, Rutenberg N. The Female Condom: Dynamics of Use in Zimbabwe. Washington, DC: Horizons Population Council.
15)Kotler, P. (1975). Marketing for nonprofit organizations. Englewood Cliffs, NJ:Prentice Hall.
16) amfAR. AIDS in Africa: Overview of the Epidemic. New York, NY: amfAR.

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