Companies invest a significant amount of time and money into market research that helps them to understand the behaviors, beliefs and motivations of their potential customers. By then “segmenting” people into groups according to these characteristics, marketing messages can be produced that target specific groups more effectively.

Most public health efforts are either mass communication campaigns or target particular age groups. However, some public health organizations are starting to study whether the segmenting tactics used by companies could also help to promote healthy behaviors. For example, male circumcision has been shown to reduce the transmission of HIV in Africa. Identifying the beliefs, emotions, motivations or other barriers that stop men from getting circumcised and then targeting specific messages to different groups could help to increase the number of men who opt for circumcision.

Sgaier et al. now present evidence that suggests that segmentation could help to promote circumcision in Zimbabwe and Zambia. 4,000 men from these countries answered a survey that had been designed based on previous research that investigated how men make the decision whether to be circumcised. Analyzing the results using k-means clustering, a machine learning algorithm, enabled Sgaier et al. to identify six distinct segments in the men from Zimbabwe and seven in the men from Zambia. Further analyses found that the risk of contracting HIV also varied by segment.

Sgaier et al. then demonstrated that field workers could use a series of questions to allocate men to each of the groups with an accuracy of over 60%. The segmentation method therefore looks like a promising tool that could be applied to a wide range of public health campaigns. As well as targeting specific groups of people with messaging that resonates specifically with them, segmentation could also highlight those people who are likely to be most easily convinced by a particular health intervention. More research is now needed to improve the usability of the tools that field workers can use to segment their audience.

Voluntary Medical Male Circumcision (VMMC) is a critical strategy for HIV prevention in countries with high HIV and low circumcision prevalence (Auvert et al., 2005; Bailey et al., 2007; Gray et al., 2007; World Health Organization and Joint United Nations Programme on HIV/AIDS, 2007; Njeuhmeli et al., 2011; World Health Organization and UNAIDS, 2011). The VMMC program has been scaling up rapidly across 14 eastern and southern African countries and close to 12 million circumcisions, against the 20 million target among 15–49 year old males, have been achieved to date (World Health Organization, 2016). However, given that resources for VMMC scale-up are finite, achieving the desired impact of VMMC on reducing HIV incidence will require prioritizing sub-populations of males and generating demand for VMMC amongst them (Sgaier et al., 2015; Sgaier et al., 2014).

There is a need for a greater evidence base, including the use of new approaches adapted from the private sector, to inform the design of demand generation approaches for VMMC (Sgaier et al., 2015). In particular, taking a ‘market segmentation’ approach has been highlighted as an important strategy to implement and enable more efficient use of resources. With ‘market segmentation’, the target population is sub-divided into groups where members of the group share elements in common (Thomas, 2016; Wedel and Kamakura, 2006). Segmenting the target populations along demographics, such as age or geographic location, has been commonly used in public health. In the private sector, the use of behavioral or psychographic segments has been prevalent (Bhatnagar and Ghose, 2004; Wade and Eagles, 2003; Desarbo et al., 1995; Gloy and Akridge, 1999). These segments are constructed based on factors including shared attitudes, values, emotions, perceptions, beliefs and behaviors. Given that these factors play a critical role in driving decisions, often more so than age or other demographic factors (Carpenter, 2010; Velicer et al., 2007), segmenting the population along psychographic and behavioral parameters should provide a more powerful tool to target them effectively for behavior change. The application of segmentation has been such a successful strategy to marketing of products and services to consumers that it is now often executed to inform the design of most marketing campaigns in the private sector. We are not aware of any public health or development program that demonstrated the application of behavioral psychographic segmentation. On the other hand, many academic models of behavior, such as the Health Belief Model, Self-determination Theory, and the Reasoned Action Approach, have used differences between individuals in behavioral variables such as (risk) perception, beliefs, and motivations to explain why a behavior has or has not occurred (Carpenter, 2010; Armitage and Conner, 2001; Fishbein and Ajzen, 2010; Ryan and Deci, 2000). However, segmentation techniques are not well-established in the application of these theories to design interventions.

We designed and implemented a hybrid behavioral-psychographic segmentation study in Zambia and Zimbabwe. This quantitative study was conducted among males 15–29 years old, given previous evidence that identified this as the most efficient and impactful age for the VMMC programs in both countries to target (Awad et al., 2015a; Awad et al., 2015b). In an age-structured mathematical model, Awad et al. (Awad et al., 2015a; Awad et al., 2015b) assessed the impact of prioritizing different age groups for VMMC in Zimbabwe (Awad et al., 2015a) and Zambia (Awad et al., 2015b). The model took multiple factors into account, including VMMC effectiveness, cost-effectiveness, reduction in HIV incidence, program cost, and programmatic feasibility. Overall, the analysis found that targeting young males, especially the 15–29 age group, combined some of the largest reductions in HIV incidence with some of the highest program efficiency gains. Therefore, we focused our study on this age group. Both psychographic and behavioral factors were investigated to reveal specific groups of men based on their needs, perceptions, attitudes and behaviors towards VMMC.

This research was built on findings from an integrated qualitative study that combined consumer journey mapping, a market research approach that maps the context and sequence of experiences and interactions along the path to decisions from the perspective of the individual, and a behavioral economics game that simulates the real world context of participants to identify context, emotions and mental models that underlie behaviors (Eletskaya M, Sgaier SK, Kretschmer S, Prasad R, Mulhausen J, Vaish A. 2017. Employing consumer journey research and behavioral science to understand decision making for Voluntary Medical Male Circumcision in Zimbabwe and Zambia, in preparation). In both countries, this integrated qualitative study identified the men’s journey to getting circumcised, the intention-to-action gap that stalled the journey of many to undergoing circumcision, and the underlying factors that inhibited or facilitated the progression of different men to complete their journey.

We also explored how the different segments differed in their perceived and actual risk towards HIV/AIDS infection. Finally, we developed a typing algorithm to help programs classify men into the different segments and profile men on risk. Collectively, the insights and tools enabled the development of more effective demand generation activities targeted to specific segments.

To our knowledge, this is the first study that uses a hybrid behavioral-psychographic segmentation approach in a public health program at national scale. Our approach, analysis and findings will not only help the national VMMC programs in Zambia and Zimbabwe, but also lay the groundwork for segmentation based on behavioral variables to be used in other development programs.

Adapting the use of ‘market segmentation’ from the private sector, this research demonstrated the application of a hybrid behavioral-psychographic segmentation for men to investigate types of obstacles to demand for VMMC in Zambia and Zimbabwe. Importantly, the research design was built using prior evidence that identified underlying factors – beliefs, barriers, influences – that inhibit or facilitate men to mentally commit to and then take action to getting circumcised (Montaño et al., 2014; Price et al., 2014). Characterizing males aged 15–29, the resulting segmentation solutions in each country identified segments which are strongly differentiated in their levels of circumcised men, levels of commitment to VMMC among uncircumcised men and, crucially, the underlying factors, e.g., beliefs, fears, social influences, important for influencing them to take action to getting circumcised.

It is worthwhile to compare this behavioral-psychographic segmentation approach to a popular categorization provided by the Diffusion of Innovation Theory (Rogers, 2003). This framework specifies that in a given population, a novel product or innovation is first taken up by Innovators. It then spreads to Early Adopters, Late Adopters, and finally - after reaching critical mass - to Laggards. This typically happens in a sigmoidal (‘S-shaped’) fashion (Dearing, 2009). Diffusion of Innovations Theory emphasizes that different segments can be targeted in different ways. For instance, Innovators can be partners along the way to generate support for a new idea. In contrast, early Adopters are a testing ground and need close support, but Late Adopters are more likely to follow social norms and the fear of being left behind. This classification system is useful if behavioral-psychographic segmentation is not possible, but does not take the specific beliefs, attitudes, and emotions into account that place individuals in either of these categories. Without knowing the underlying reasons for why someone is an adopter or not, little can be done to anticipate and shift behaviors in a specific case. In sum, while Diffusion of Innovations Theory provides a generalized and parsimonious classification, the segmentation approach we outline here provides a generalizable method. The segments that result from the behavioral-psychographic technique will be situation-specific, and therefore provide a foundation for more targeted interventions, than the fixed segments of the Diffusion of Innovations Theory. For instance, Diffusion of Innovations Theory outlines that Laggards need a great amount of familiarity with an innovation before they use it (Rogers, 2003). However, the characteristics of some segments we found that would most closely fit into the ‘Laggards’ category, such Embarrassed Rejecters and Highly Resistants in Zimbabwe, suggest that lack of familiarity is not at their root of resistance to VMMC.

The segment classification algorithms provide the ability to accurately classify any man in the field into his segment in order to provide messaging and interventions most appropriate to influencing him individually to take action to getting circumcised. For example, interpersonal communicators can use the segment classification tool to identify to which segment a man belongs and use a pre-scripted and/or ad hoc approach to counseling that man targeting the issues specific to that segment. For instance, if a man in Zimbabwe is identified as uncircumcised and belonging to the Scared Rejecters segment, the focus of the counseling for that man can quickly address the need to provide clarity on the process of getting circumcised, offer reassurance around the pain that will be felt (for example, by providing anchors about how much and when in the process of the procedure and healing period pain can be expected) and how the pain will be able to be managed. In addition, well-crafted mass media communications can be used, which focus on specific critical and differentiating factors for different segments. Men in the segments targeted will then self-selectively pay attention to those communications based on the interest the segmentation results have identified they have for them (for example, a Scared Rejecter will be more likely to respond to reassurance about pain than would an Embarrassed Rejecter).

Adding two additional questions to the end of the segment classification tool asking the self-reported number of times a man has sexual intercourse in a typical month and the self-reported number of different partners with whom a man has sex in a typical month would provide the ability to specifically identify and counsel men with regard to their personal estimated risk of HIV infection.

Having identified the relative proportions of each segment still uncircumcised, and the proportions of these men committed to getting circumcised or not, the segments in Zambia and Zimbabwe each have been prioritized for targeting. Highest-priority segments can be those that have the most ‘low-hanging fruit’ – uncircumcised men already mentally committed to getting circumcised (Table 3). Prioritizing these ‘low-hanging fruit’ is especially key in resource-constrained settings, where mass targeting can be replaced with smaller-scale, but focused, communications and interventions which specifically focus on the factors determining action for each targeted segment. Even mass media communication campaigns can be designed to create self-selected attention to them by target segments by using messaging especially relevant for each target segment. For example, a sports car commercial and a truck commercial will draw variable attention by those more interested in owning and driving each type of vehicle. Additionally, specific strategies for targeting each segment, based on the factors which can most influence men in that segment to take action, have been summarized. These strategies include key messages to use, appropriate use of mass media and interpersonal communicators, use of the men as advocates for VMMC, and perhaps the potential offering of device options for getting circumcised.

In Zimbabwe, for example, the highest priority segment for targeting is the Enthusiasts, who represent 21% of uncircumcised men, with 85% already committed to getting circumcised. They have relatively higher-risk sexual behavior, but are more likely to advocate for VMMC to other men, once circumcised, because of their strong beliefs about the benefits of VMMC for themselves and their community. For greatest influence, messaging for this segment should focus on detailed information on the procedure, the healing process and pain management to reduce uncertainty, and the potential for improved relationship with their partner, but they should also be counseled on their risky behavior. These communications would be best accomplished through interpersonal communicators. Once circumcised, these men should be actively engaged as VMMC advocates to promote it to other men of their peer age groups.

The relative sizes of segments within provinces differ at the province level, and are likely to differ at the district level. Understanding these differences provides programs with the ability to develop more localized programming. For example, districts with higher proportions of segments of men who are more fearful of surgery can prioritize particular interventions designed for these men, such as communications about the safety of the procedure and pain management during the procedure.

Targeted strategies using the segmentation results will require adoption of these results and recommended strategies into local VMMC program planning and tactical implementation efforts. While this will initially require additional efforts and potential reprogramming of some strategies, the potential to target and convert men to action for VMMC could increase demand, while doing so with greater efficiency. Similar segmentation solutions could be created and used in all countries where VMMC targets are far from achievement. To date, the segmentation tool has been implemented in pilot tests in both Zimbabwe and Zambia. This ongoing work is conducted in partnership with two non-governmental organizations with extensive experience in VMMC program delivery, Population Services International in Zimbabwe and Society for Family Health in Zambia. An evaluation of initial data is currently underway. Unpublished preliminary findings suggest that training community health workers to use the segmentation tool has measurable effects on overall conversion rates to the VMMC procedure in both countries. Policy makers in both Zimbabwe and Zambia have expressed interest in scaling up the segmentation approach once pilot data has been published.

The study has several limitations. The segmentation study was conducted with males aged 15–29 (core target audience), although the VMMC program is targeted towards men up to the age of 49. Thus, accuracy of the results among the older men requires additional evidence. HIV positive men also were out of scope of this research. For this research, data was collected only once and changes in the population over time will be measured in each country after implementation of the strategies in order to monitor the validity of the results. Any self-report design will also be subject to potential biases, such as social desirability bias. For instance, men may be reluctant to disclose unflattering attitudes to researchers. While self-report biases cannot be fully avoided, they are also pervasive among respondents in all contexts (Nederhof, 1985), and so unlikely to differ starkly between segments. In addition, the economic decision game asked men to select the option they thought other men would choose (rather than the one they themselves would select), thereby reducing perceived judgment on their own attitudes. Further studies could estimate the extent of existing biases by comparing face-to-face self-report with self-administered, or forced-choice designs.

Besides the limitations of the survey, there are some challenges related to translation of these results into action and their proper implementation. The crucial factors in regard to implementation of the results include proper prioritization of the segments, assessment of investments needed for implementation of interventions and strategies, created based on the results and effectiveness of interventions, and strategies need to be evaluated to ensure that they resonate with chosen segments.

In conclusion, behavioral-psychographic segmentation is a viable method to identify the diversity of drivers or barriers to a behavior that may exist within a group of healthcare beneficiaries. In this case study, we focused on revealing the different factors that prevented men in Zimbabwe and Zambia from taking up a crucial HIV prevention intervention. In the field, respondents can be allocated to segments with substantial accuracy, using simple decision trees. On the policy-making level, we then provided strategies for targeting the different segments with different messages and channels. In any segmentation application, the identification of ‘low-hanging fruit’ segments will be crucial to maximize the impact of an intervention. Future public health strategies should therefore heed both the diversity of messaging and channels required to target different segments, but also consider prioritizing some segments over others depending on the likely impact and ease of conversion. If interventions are targeted to resonate with segments found through accurate field-based typing, HIV transmission rates in Zimbabwe and Zambia could decrease as the spread of HIV in men is reduced. Beyond the HIV application introduced here, behavioral-psychographic segmentation is likely to be a valuable tool whenever a group of stakeholders is diversified in their beliefs, emotions, and attitudes towards a target behavior.

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Author details

1. Sema K Sgaier

   1. Surgo Foundation, Seattle, United States
   2. Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, United States
   3. Department of Global Health, University of Washington, Seattle, United States

   Contribution

   Conceptualization, Resources, Data curation, Software, Formal analysis, Supervision, Funding acquisition, Validation, Investigation, Visualization, Methodology, Writing—original draft, Project administration, Writing—review and editing

   For correspondence

   semasgaier@surgo-foundation.org

   Competing interests

   No competing interests declared

   "This ORCID iD identifies the author of this article:" 0000-0002-8311-2686

2. Maria Eletskaya

   Cello Health Insight, London, United Kingdom

   Contribution

   Data curation, Formal analysis, Supervision, Investigation, Visualization, Methodology, Writing—original draft, Writing—review and editing

   Competing interests

   No competing interests declared

3. Elisabeth Engl

   Surgo Foundation, Seattle, United States

   Contribution

   Formal analysis, Validation, Visualization, Methodology, Writing—review and editing

   Competing interests

   No competing interests declared

4. Owen Mugurungi

   Ministry of Health and Child Care, Harare, Zimbabwe

   Contribution

   Resources, Investigation, Project administration, Writing—review and editing

   Competing interests

   No competing interests declared

5. Bushimbwa Tambatamba

   Mother and Child Health, Ministry of Community Development, Lusaka, Zambia

   Contribution

   Resources, Investigation, Project administration, Writing—review and editing

   Competing interests

   No competing interests declared

6. Gertrude Ncube

   Ministry of Health and Child Care, Harare, Zimbabwe

   Contribution

   Conceptualization, Resources, Supervision, Investigation, Project administration, Writing—review and editing

   Competing interests

   No competing interests declared

7. Sinokuthemba Xaba

   Ministry of Health and Child Care, Harare, Zimbabwe

   Contribution

   Conceptualization, Resources, Supervision, Investigation, Project administration, Writing—review and editing

   Competing interests

   No competing interests declared

8. Alice Nanga

   Ipsos Healthcare, London, United Kingdom

   Contribution

   Resources, Formal analysis, Supervision, Investigation, Methodology, Project administration, Writing—review and editing

   Competing interests

   No competing interests declared

9. Svetlana Gogolina

   Ipsos Healthcare, London, United Kingdom

   Contribution

   Data curation, Formal analysis, Investigation, Methodology, Writing—review and editing

   Competing interests

   No competing interests declared

10. Patrick Odawo

    Ahimsa Group LLC, Nairobi, Kenya

    Contribution

    Conceptualization, Resources, Supervision, Funding acquisition, Investigation, Project administration, Writing—review and editing

    Competing interests

    No competing interests declared

11. Sehlulekile Gumede-Moyo

    1. Ipsos Healthcare, London, United Kingdom
    2. Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom

    Contribution

    Conceptualization, Resources, Data curation, Software, Formal analysis, Supervision, Funding acquisition, Validation, Investigation, Visualization, Methodology, Writing—original draft, Project administration, Writing—review and editing

    Competing interests

    No competing interests declared

12. Steve Kretschmer

    Surgo Foundation, Seattle, United States

    Contribution

    Conceptualization, Resources, Data curation, Software, Formal analysis, Supervision, Funding acquisition, Validation, Investigation, Visualization, Methodology, Writing—original draft, Project administration, Writing—review and editing

    Competing interests

    No competing interests declared

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