BALBIR STO
An innovative approach to reducing HIV/Aids prevalence through targeted mass media
communications in Mumbai, India
Kaveeta Jayaraaman
Communications Manager, Population Services
Varsha Chawda
Unit Head SOMAC

India is poised on the precipice of devastating HIV/AIDS epidemic. Fifteen years after the first case of AIDS was reported in India, it is now home to second largest number of HIV infected people in the world. Although national HIV prevalence currently hovers at about one per cent, the sheer volume of cases in this country of one billion people makes India’s AIDS problem explosive, particularly in certain states where the epidemic has been localised since the earliest stages of the epidemic. In the state of Maharashtra (where the “Balbir Pasha” campaign was launched), Tamil Nadu, Karnataka, Andhra Pradesh, Manipur, and Nagaland, over one per cent of antenatal women tested positive for HIV infection (NACO BSS, 2002). The latest estimates by Indian government and international agencies suggest that there are now 3.5 to 4 million HIV - positive Indians (UNAIDS, 2002; NACO, 2001). Although intensive efforts to promote awareness of HIV/AIDS have been made, the disease remains widely misunderstood in India.

Given the stage of the epidemic, it is clear that HIV/AIDS incidence is escalating in high-risk groups such as commercial sex workers (CSW’s) and truckers. Tragically, key bridging populations (for example, clients of CSW’s) are now rapidly expanding the reach of the epidemic into the general population. In fact, data from various sentinel sites in Maharashtra suggests a time lag of just two to three years for HIV infection to spread from high-risk groups such as commercial sex workers to their clients who, in turn, can infect their non-commercial partners such as wives and/or lovers (NACO, 2001). If not addressed immediately, the total number of people in India infected with HIV could skyrocket to 35 million over the next five years - nearly doubling the total number of HIV infections globally.
Approximately 80 per cent of HIV cases in India have been attributed to heterosexual encounters (UNAIDS 2000). Mumbai sits at the epicentre of India’s HIV/AIDS problem and has been the city ravaged most by the disease. A review of existing research reveals high-risk attitudes and behaviour prevail among urban men in the lower socio-economic groups in Mumbai. The city is home to the largest brothel based commercial sex (CSW’s) worker area (“Red Light district”) in India, and therefore, most HIV/AIDS prevention in Mumbai have focused on educating and empowering the 6,000-10,000 in the Red Light District with varying degree of success. However, very little work has been done in motivating the clients of sex workers to practice safe sex across the city in a sustained and effective manner.

Operation Lighthouse
With funding from USAID, PSI is currently implementing a five-year (2001-2005) HIV/AIDS STI intervention program in India entitled “Operation Lighthouse (OPL)”. This national program is being implemented across twelve port communities along the east and west coasts of India, with a core technical team coordinating the activities from Mumbai. This program deploys a set of integrated communication and service provision strategies to decrease the spread of the epidemic among vulnerable groups associated with the port facilities. Supporting this effort is an advocacy component targeted to the senior management of the port, related industries, and the local government and public health facilities. This component is designed to support the institution of supportive HIV/AIDS workshop policies and extension of communication and education programs for employees. The project has documented notable success, including the inception of targeted communication activities in all port communities, expansion of condom access in areas of high risk behaviour, the creation of mobile or conveniently-located voluntary counselling and testing (VCT) facilities for vulnerable populations, and, most notable for the purposes of this case study, the development and dissemination of a ground-breaking mass media campaign targeted to men in Mumbai.

Underlying program success is the PSI/OPL team’s ability to conceive, implement, and monitor integrated HIV prevention programs in cities separated by great distances. This allows PSI to target resources effectively in the Indian context, where concentrated epidemics of varying severity are separated by vast geographical, Socio-cultural and linguistic divides but connected by vulnerable, migratory populations.
In sum, OPL is a behaviour change project designed to promote safer sexual practices among those with multiple partners, particularly those who engage in commercial sex.
Three principles guide the OPL approach:

1. Targeting. When achieved, targeting allocates scarce resources to activities that promise the highest impact among those likely to contract and transmit the virus. This concept is upheld in designing all of OPL’s activities, from communications to counselling.
2. Integration. In an integrated approach, mass media, mid-media and inter-personal communications are designed to inform, motivate and create demand for services and products, which include phone help-lines, STI and VCT services and condoms.
3. Information. Changing behaviour is an iterative process, demanding and over-expanding base of knowledge across a wide range of topics, including beliefs and habits, socio-cultural characteristics affecting gender and empowerment, patterns of migration and sexual behaviour. Over time, steady production, analysis and use of good information feeds into continuous program improvement.

• The Campaign
  a. Inherent Communication challenges: Breaking the mould
  The design and implementation of a hard-hitting communication campaign tackling a sensitive issue such as HIV/AIDS in the current socio-political context of India poses some key challenges. Until now, health communication campaign in India, particularly HIV/AIDS communications, were largely informative/educational in nature and rarely addressed the consumer directly (“Lets keep Mumbai AIDS free” or HIV/AIDS does not spread through touch”). These bland approaches, which were neither engaging nor consumer-oriented, have, perhaps complacently so, set the standard for the limited HIV/AIDS communication work in India.
  Further, HIV/AIDS communication campaigns, in general, have perpetually portrayed the disease in a completely morbid and fearful manner. They have used scare tactics to warn the consumer about “the killer disease,” rather than offering positive preventive messaging. Such messages tend to further distance the consumer from the messages as it allows people to naturally seek the security of the “it can’t happen to me” mindset.
  Therefore, it is quite evident that perhaps most debilitating to the goal of HIV/AIDS communications is the fact that despite the fact that the Indian public, particularly urban populations such as that of Mumbai have some basic knowledge regarding HIV/AIDS, communication campaigns have failed to personalise risk for the individual. In other words, there is a significant disconnect between AIDS and the individual consumer, thereby rendering communication messages personally irrelevant and subsequently not being internalised.
• b. Campaign Objectives: Filling a need
  On the basis of research pertaining to the HIV/AIDS scenario in Mumbai, programme staff determined that young men in Mumbai between the ages of 18-40, who hail from lower socio-economic groups and are among the highest risk for HIV infection, should be the primary targets for prevention messages. An extensive mass media HIV/AIDS campaign was designed, to meet the following key communication objectives:
  Attitudinal Change: To increase perception of HIV/AIDS risk from unprotected sex with non-regular partners by personalising the message and creating empathy through identifiable real-life situations
  Changing Social Norms: To generate discussion about HIV/AIDS among the target populations and opinion leaders in order to facilitate understanding and knowledge acquisition
  Behavioural Change: To motivate people to access HIV/AIDS help line and VCT services
• Execution:
  Introducing…Balbir Pasha!
  a. Evolution of a behavioural role model
  The bedrock of the campaign was the principle that people can learn by observing the consequences of behaviours of others (‘Social Learning theory’ of Albert Bandura). An ‘alter ego’ in the form of a fictional character named “Balbir Pasha” was created as the centrepiece of the campaign. This character was portrayed across various communications channels in intriguing scenarios, serving as a behavioural model for consumers to relate to and empathise with. Using this character, HIV/AIDS messages were conveyed in an approachable and familiar manner, rather than the didactic approach that previous HIV/AIDS communication campaigns had unsuccessfully tried. Social psychologists such as Bandura argue that observing can lead to behaviour change, especially when the behaviour is reinforced by the consequences of the role model’s actions. Therefore, if the manufactured symbolic model of “Balbir Pasha” engages in behaviour that may put him at probable risk for HIV/AIDS, the consumer will be vicariously motivated to avoid repeating this behaviour.
• b. Key consumer Insights and Campaign Direction:
  Data from studies carried out by the Maharashtra State AIDS Control Society (MSACS) uncovered the fact that although men in the general population feel clients of sex workers are vulnerable to AIDS, they fail to recognise themselves to be at risk for HIV infection (NACO BSS, 2002). The data points to a strong link between alcohol consumption and high-risk sexual activity, indicates that young men harbour negative attitudes towards condom use, and also reveals a failure to recognise asymptomatic “healthy looking” people as potential carriers of the HIV virus (NACO General Population BSS, 2002; NACO BSS among Bridge Group & High-risk Groups, 2001-20001; AVERT; MSACS).
  In order to meet the campaign’s main objectives of increasing risk perception, three main campaign themes were developed and pre-tested among sexually active males from low socio-economic groups.
  l Alcohol and high-risk behaviour: “I often use condoms, but when I get drunk, I sometimes forget”
  l Faith in “regular” partner: “I only have sex with this one person and hence I am safe.”
  l Failure to recognise asymptomatic carrier: “If a person looks healthy, he/she must be safe from HIV/AIDS”
• c. Surround and Engage - Effective Media Selection
  The campaign achieved incredible visibility and reach through a strategically developed mix of various media. Executions in the form of print ads, television and radio commercials, and, most visibly, outdoor communication (i.e. billboards and posters in trains and on bus shelters) were launched in five phases over a period of four months. As each phase was revealed progressively, intrigue and ‘gossip value’ of campaign increased akin to the way plots are revealed in a TV soap opera. Since print, TV, radio and outdoor mediums were used; Mumbai was simultaneously inundated from all possible media angles. The extent to which each type of media was used and the placement/timing for each message was directly related to the location and lifestyle of the target group of young men in lower SEC’s which helped to define the following strategically placed communication media:

Outdoor communication in the red light area: As men in this target group frequent sex workers, placing messages on billboards and bus shelters in this area helped the campaign achieve high reach and visibility.
Outdoor communication & public transport: With over 4 million people travelling the Mumbai train network daily, many of whom are men practicing high risk sexual behaviours, placing posters in trains and at train stations allowed PSI to geographically target this population while also creating a buzz in the general population.
Outdoor communication at cinema halls: The high popularity of Hindi and Marathi films provides an opportunity to communicate complex audiences to a captive audience through the use of various outdoor media, especially as many B and C grade cinema halls are located in areas where this population resides and/or frequents often.
Mix of TV and radio channels: As the target group profile is quite heterogeneous with regard to ethnic/language groups, religious communities, socio-economic profiles, etc., there was a need to feature messages across a broad mix of television networks and radio stations. This also allowed the campaign to achieve maximum reach to the various general populations of Mumbai.
Print media: Next to television, print media has the highest penetration in the target group, and therefore the “Balbir Pasha” campaign was featured in the major language papers (Hindi/Marathi) available in Mumbai. This promoted high visibility of the campaign’s messages via a medium that allows the consumer to engage himself and ponder as he receives information.

• d. Campaign Roll-out
  Teaser: Building Intrigue (Nov 11-Nov 30, 2002):
  The first phase of the campaign was aimed at building intrigue and cutting through the clutter of advertising in Mumbai through a cleverly crated “teaser” campaign. This teaser campaign also served to build intrigue, and prepare the campaign for subsequent phases. The “teaser” campaign, which ran all media channels discussed above, depicted typical Mumbai lower and middle income men asking each other the following question “Will Balbir Pasha get AIDS?”
  Main campaign -Three Themes
  (December 1, 2002-January 27, 2003):
  The second phase was more strategic, in that it leveraged key insights about a particular target group, specifically young men of lower SES, and comprised of three personalised messages targeted at making these individual question their own behaviour:

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