A case study for a psychographic-behavioral segmentation approach for targeted demand generation in voluntary medical male circumcision
- Surgo Foundation, United States
- Harvard T.H. Chan School of Public Health, United States
- University of Washington, United States
- Cello Health Insight, United Kingdom
- Ministry of Health and Child Care, Zimbabwe
- Ministry of Community Development, Zambia
- Ipsos Healthcare, United Kingdom
- Ahimsa Group LLC, Kenya
- London School of Hygiene and Tropical Medicine, United Kingdom
Figures
Figure 1 with 2 supplements
Segmentation questionnaire design construct.
https://doi.org/10.7554/eLife.25923.003
Figure 1—figure supplement 1
Demographic and cultural characteristics of the sample population in Zambia and Zimbabwe.
https://doi.org/10.7554/eLife.25923.004
Figure 1—figure supplement 2
Social acceptability of VMMC and perceived risk of HIV/STIs in the sample population in Zambia and Zimbabwe.
https://doi.org/10.7554/eLife.25923.005
Figure 2 with 1 supplement
Distribution of males by segment.
https://doi.org/10.7554/eLife.25923.006
Figure 2—figure supplement 1
Distribution of men in each stage of the decision-making journey within each segment.
% represents the proportion of men in that journey stage within the segment.
Figure 3
Estimated vs. perceived HIV infection risk by segment.
https://doi.org/10.7554/eLife.25923.010
Figure 4
Segment typing tool-decision tree for Zimbabwe.
Scale #1 (7-point scale): 7 = 'Strongly agree'; 4 = 'Neither agree nor disagree'; 1 = 'Strongly disagree'. Scale #2 (7-point scale): 7 = 'Would definitely encourage'; 4 = 'Would neither encourage nor discourage'; 1 = 'Would definitely NOT encourage'. Scale #3 (7-point scale): 7 = 'They think I definitely should get circumcised'; 4 = 'They don't have any particular opinion'; 1 = 'They think I definitely should NOT get circumcised'.
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Figure 4—source data 1
Segment typing tool questions.
- https://doi.org/10.7554/eLife.25923.012
Tables
Table 1
(A) Factors deriving segments and segment profile summaries (Zimbabwe). (B) factors deriving segments and segment profile summaries (Zambia).
https://doi.org/10.7554/eLife.25923.008| Table 1A – Factors deriving segments and segment profile summaries (Zimbabwe) | |||||||
|---|---|---|---|---|---|---|---|
| Country | Segment | Key factors defining segment profiles | Summary of differences among segments | ||||
| Zimbabwe | Motivation/need for VMMC | Rejection due to cognitive dissonance | Perceived lack of ability | Acceptance of social support | Personal constraints | ||
| Enthusiasts | Strong motivation | Neutral | Average ability | Highly socially driven | Some fears | Believe in all benefits of VMMC (including benefits related to sexual life); emotionally associate VMMC with a sense of achievement; relatively high level of risky sexual behavior; very socially driven and supported by social environment; require support to overcome some fears and cognitive dissonance, and strengthen ability to go for VMMC. | |
| Champions | Strong motivation | No rejection | Strong ability | Highly independent | Some fears | Have positive attitudes to VMMC; believe in benefits; much more socially independent (going for VMMC is their own decision, not driven by social environment); feel strong ability to go for VMMC; despite presence of some fears, don’t experience serious cognitive dissonance. | |
| Neophytes | Neutral motivation | Strong rejection | Lack of ability | Highly independent | Some fears | More ambivalent attitude to VMMC (have not decided yet whether they need it or not); quite low level of risky sexual behavior; feel lack of control and rejection due to cognitive dissonance; feel lack of knowledge about VMMC (need information); not socially driven. | |
| Scared Rejecters | Neutral motivation | Strong rejection | Strong ability | Highly independent | Strong fears | Weak motivation due to a number of fears; very worried about contraction of infections and need additional sense of protection, but are not able to go for VMMC (due to fears of complications, pain, surgery, healing process, etc.); feel strong ability to go for VMMC (no need in additional information); not socially driven. | |
| Embarrassed Rejecters | Weak motivation | No rejection | Average ability | Highly socially driven | Strong fears | Weakly motivated to go for VMMC; mostly are not concerned about HIV/STI contraction; have mostly negative beliefs about VMMC; due to absence of motivation do not experience cognitive dissonance; have some positive believes (especially, believe in hygiene), but largely don’t consider VMMC for themselves; have fears and concerns; highly socially driven; have mostly no social support for VMMC. | |
| Highly Resistant | Weak motivation | Strong rejection | Strong ability | Highly socially driven | No fears | Weak motivation, rejection of VMMC; mostly negative beliefs about VMMC; relatively higher risk of HIV/STI contraction; however, level of concern about HIV/STIs contraction is low; are not open to information and feel that they know all they need about VMMC; claim absence of fear; very socially driven; mostly highly rejecting VMMC social environment. | |
| Table 1B – Factors deriving segments and segment profile summaries (Zambia) | |||||||
|---|---|---|---|---|---|---|---|
| Country | Segment | Key factors defining segment profiles | Summary of differences among segments | ||||
| Zambia | Motivation/need for VMMC | Control overcognitive dissonance | Perceived lack of ability | Self-efficacy against social pressure | Personal constraints | ||
| Socially-supported believers | Strong motivation | Strong confidence | Average ability | Fully independent | Strong fears | Strong motivation for VMMC; high level of concern about contraction of HIV/STIs; believe in majority of benefits, emotionally associate VMMC with sense of belonging feel that they are independent from social environment in their decision to go for VMMC; but are very actively supported by all people around; control cognitive dissonance; have some minor fears. | |
| Self-reliant believers | Strong motivation | Average confidence | Strong ability | Somewhat socially driven | Strong fears | Strong motivation; believe in the benefits of VMMC, tend to value the benefits for sexual relationships; emotionally associate VMMC with a feeling of closeness to their partner; less socially supported, which makes them slightly less confident in themselves; feel some cognitive dissonance, but presence of fears doesn’t make them doubt in necessity of VMMC; feel strong ability to go for VMMC, don’t require additional information. | |
| Knowledgeable Hesitant | Neutral | Strong confidence | Lack of ability | Somewhat socially driven | No fears | Somewhat motivated to go for VMMC, mostly because of HIV/STI protection; also value benefits for sexual life, considering that circumcised men are more desired by women; riskier sexual behavior; quite strong concerns about possible negative consequences of VMMC, which make them hesitate (e.g. safety of the procedure; loss of sensitivity, increase of promiscuity). | |
| Friends-Driven Hesitant | Neutral | Lack of confidence | Lack of ability | Somewhat socially driven | No fears | Ambivalent attitude toward circumcision: not completely rejecting circumcision, but also don't have strong motivation; less risky sexually, mostly focused on hygiene benefit; social environment also has two directions (supporting and inhibiting); lack of assurance in the need of VMMC; however, don’t have any serious personal constraints. | |
| Scared Rejecters | Weak motivation | Average confidence | Lack of ability | Fully independent | Strong fears | Mostly negative attitude to VMMC; negative beliefs in possible complications, doubts in safety of the procedure; experience cognitive dissonance; don’t completely reject the benefits of VMMC, but the protection of infections is less relevant for them; mainly believe in the hygiene benefit and help for sons to be circumcised. | |
| Indifferent Rejecters | Weak motivation | Strong confidence | Strong ability | Somewhat socially driven | Some fears | The least educated and least knowledgeable of VMMC; are generally not concerned about HIV and other infections; attitude to VMMC is ambivalent; relatively socially driven; not strongly supported by social environment. | |
| Traditional Believers | Neutral | Strong confidence | Lack of ability | Very socially driven | Some fears | Mostly circumcised or have a high level of commitment to VMMC; however rather poor knowledge about the benefits and belief in them; the proportion of men circumcised for religious/traditional reasons is the highest; the key benefit of circumcision is maintenance of tradition in the family, helping sons to get circumcised. | |
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The table summarizes the differences among segments based on the key factors identified via canonical correlations analysis. Zambia, 5 key factors, 7 segments; Zimbabwe, 5 key factors, 6 segments.
Table 2
Circumcision levels and commitment for MC, by segment.
https://doi.org/10.7554/eLife.25923.009| Country | Segment | All men in segment* | Uncircumcised men in segment† | ||
|---|---|---|---|---|---|
| Circumcised % (n) | Uncircumcised % (n) | Not committed % (n) | Committed % (n) | ||
| Zimbabwe | Enthusiasts | 42.6 (211) | 57.4 (284) | 15.5 (44) | 84.5 (240) |
| Champions | 76.2 (269) | 23.8 (84) | 8.3 (7) | 91.7 (77) | |
| Neophytes | 6.1 (17) | 93.9 (260) | 43.1 (112) | 56.9 (148) | |
| Scared rejecters | 2.6 (6) | 97.4 (228) | 78.1 (178) | 21.9 (50) | |
| Embarrassed rejecters | 32.7 (112) | 67.3 (230) | 56.1 (129) | 43.9 (101) | |
| Highly resistant | 0.7 (2) | 99.3 (298) | 92.6 (276) | 7.4 (22) | |
| Zambia | Socially-supported believers | 56.1 (160) | 43.9 (125) | 20.0 (25) | 80.0 (100) |
| Self-reliant believers | 71.2 (272) | 28.8 (110) | 14.5 (16) | 85.5 (94) | |
| Knowledgeable hesitant | 49.8 (119) | 50.2 (120) | 41.7 (50) | 58.3 (70) | |
| Friends-driven hesitant | 14.1 (38) | 85.9 (231) | 29.0 (67) | 71.0 (164) | |
| Scared rejecters | 9.7 (22) | 90.3 (204) | 62.7 (128) | 37.3 (76) | |
| Indifferent resisters | 5.5 (19) | 94.5 (325) | 79.4 (258) | 20.6 (67) | |
| Traditional believers | 70.6 (180) | 29.4 (75) | 16.0 (12) | 84.0 (63) | |
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*No. of circumcised OR uncircumcised men in segment/no. total men in segment; Zambia, N = 2000; Zimbabwe, N = 2001
†uncircumcised committed OR not-committed men in segment/all uncircumcised men in segment; Zimbabwe, N = 1384; Zambia, N = 1189
Table 3
Segment targeting recommendations
https://doi.org/10.7554/eLife.25923.013| Country | Targeting priority | Rationale for targeting priority | Key messages | Use of mass media | Use of IPCs | Use of advocates |
|---|---|---|---|---|---|---|
| Zimbabwe | Enthusiasts | Large potential (21% of uncircumcised men) with 85% of segment committed; high risk behavior, but likely to advocate | Detailed info on procedure and healing process; pain management; improved relationship with partner | Not a target | Clarify pain during healing, time off work/school; counsel on potential increase in promiscuity | Engage as advocates |
| Champions | Low potential (6% of uncircumcised men), but easy conversion (92% committed) and highly likely to advocate | Address uncertainty on healing process and pain during healing and procedure | Not a target | Address uncertainty on healing and pain; identify a friend-advocate to go with them for the VMMC | Engage as advocates | |
| Neophytes | Large potential (19% of uncircumcised men), and 57% committed; knowledge needed to inform commitment for rest | Full info on benefits and risks; clarify safe, skill of surgeon, healing process; where to get info and service | Personalize benefits, pain – how to manage it, accomplishment | Communicate full info on benefits, risks, safety, procedure and healing process | Use advocates to allay fears, share process, accompany | |
| Embarrassed Rejecters | Moderate potential (16% of uncircumcised men) but commitment low (22%) and embarrassment, fears high | VMMC becoming norm – be part of it; VMMC + condom use benefit; safe; how to manage pain, abstinence | VMMC norm, where service, reality of pain and how to manage it | VMMC norm, how to manage abstinence, reasons for pride, address myths believed | Provide community network of advocate support – VMMC as social norm | |
| Scared Rejecters | Moderate potential (17% of uncircumcised men) but commitment very low and fears/dissonance are strong | Safe procedure, low risk of complications; pain mgmt. during healing; improved relationship with partner | Not a target | Safe, low risk, expert service, pain real but manageable, involve partners | Use advocates to allay fears, share experience, accompany | |
| Highly Resistant | Large potential (21% of uncircumcised men), but hard to crack; knowledgeable, little fear; don’t recognize need despite high-risk behavior | VMMC becoming social norm; address safety, service quality, privacy; pain management | Not a target | Acceptance of VMMC by wider community and advocacy from leaders; address fears with full info | Need advocates, communicating pride in VMMC and allaying fears |
| Country | Targeting priority | Rationale for targeting priority | Key messages | Use of mass media | Use of IPCs | Use of advocates |
|---|---|---|---|---|---|---|
| Zambia | Socially-supported Believers | Moderate potential (11% of uncircumcised men), high commitment (80%); likely advocate to broad audience, but dissonance | Address uncertainty on healing process and pain during healing and procedure | Not a target | Address uncertainty on healing and pain; identify non-circumcised friends to go together for VMMC | Engage as advocates |
| Self-reliant Believers | Moderate potential (9% of uncircumcised men), high commitment (86%), easy conversion to action; likely advocate for friends | Address questions about pain during procedure and healing process | Not a target | Address uncertainty on healing and pain; identify non-circumcised friends to go together for VMMC | Engage as advocates | |
| Knowledgeable Hesitants | Moderate potential (10% of uncircumcised men) and commitment (58%); key concern is safety | Protection benefits, VMMC + condom use benefit; safety, low risk of complications; pain management | Not a target | Safety - low risk (esp. for sexual life); pain is real, but manageable; expert service; involve partners | Use advocates to allay fears, share experience | |
| Friends-Driven Hesitants | Large potential (19% of uncircumcised men); 71% of segment committed; need add’l assurance, but relatively easily converted | VMMC social norm – be part of it; emotional benefits; detailed info on procedure and healing process | Personalized benefits; sense of accomplishment; low risk | VMMC norm, manage healing, clarify pain, service quality, availability; reasons for pride | Provide community network of support – social norm | |
| Scared Rejecters | Large potential (17% of uncircumcised men) but low commitment (37%) and strong concerns - fears and embarrassment | Safety, low risk of complications; pain management during healing; emphasize protection benefits | Not a target | Safety – credible info on low risk, expert service; pain is real, but manageable | Use advocates to allay fears, share experience, accompany them | |
| Zambia | Indifferent Rejecters | Large potential (27% of uncircumcised men), low commitment (21%); hard to crack; absence of motivation, while almost no concerns or fears | Full benefits and risks, HIV/STIs protection; clarify safety; address myths believed; where to get info and service | Full benefits, process, reality of pain and how to manage it; sense of accomplishment | Full benefits and risks; acceptance of VMMC by wider community and advocacy from leaders; dispel myths | Need a lot of advocates around, communicating pride in VMMC and allay fears |
| Traditional Believers | Small potential (6% of uncircumcised men), but no need for support; high commitment (84%) driven by tradition - will get MC | Information on benefits and risks; where to get info and service | Not a target | Will benefit from short communication on benefits and risks; info on service/clinics | Not applicable |
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- https://doi.org/10.7554/eLife.25923.014
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A case study for a psychographic-behavioral segmentation approach for targeted demand generation in voluntary medical male circumcision
eLife 6:e25923.
https://doi.org/10.7554/eLife.25923
