Marketing techniques from the commercial sector, applied to the promotion of primary
HIV prevention offer an opportunity to improve programme impact and deserve further
exploration. One such technique, market segmentation, divides populations into groups
and designs programmes that respond to groups’ distinct needs 1. Efficient and effective
HIV prevention requires well targeted and well‐designed programmes responding to client
characteristics and needs. Following best practices in commercial marketing would
allow for more refined knowledge of those at risk and enable more tailored prevention
interventions; specifically, the use of market segmentation that measures psychographic
(psychological attributes such as values, attitudes and beliefs) and behavioural factors
that might relate to product use and then describes segments of the population by
their distinct needs, characteristics, or behaviours, facilitates the differentiation
of products and/or marketing approaches by segment 2, 3. Market segmentation has recently
been used in voluntary medical male circumcision (VMMC) programmes, providing a template
worthy of consideration by other HIV prevention interventions 4, 5. This viewpoint
argues that, well done, market segmentation should be an important component in developing
and delivering HIV prevention interventions.
Successful market segmentation is a multi‐stage process, including: (1) qualitative
work exploring the beliefs, attitudes, influences, habits and feelings of a population
sample; (2) quantitatively surveying a representative sample of the population with
questions derived from the qualitative analysis; (3) statistical analysis of survey
data to generate non‐overlapping segments and narrative descriptions to distinguish
how people in a given segment relate to potential products; (4) tailored programmes
that appeal to each segment so they are persuaded to use the product; and (5) monitoring,
rapid evaluation and correction when needed 2, 3, 6. In public health, market segmentation
also considers who can benefit from a product or intervention, and the objective is
not increased sales and profit, but the public good and a healthier population 1.
Segmentation is useful when it groups people according to characteristics that can
be associated with marketing approaches, which in turn drive quantifiable outcomes
6. Segments should be identifiable, substantial, accessible and sustainable. In the
context of HIV prevention, segments would need to be identifiable, discrete groups
of those at risk of HIV, with attributes related to their beliefs, attitudes, influences,
and habits related to HIV risk and HIV prevention. They should be substantial enough
to make investments in products for HIV prevention and their promotion worthwhile.
It should be easy, financially and emotionally, for those in the segment to access
HIV prevention products and services. Finally, the risks of HIV and segment characteristics
should be stable enough to allow for investments that would sustainably provide segment‐specific
HIV prevention.
In our work on market segmentation, we have reviewed applications to public health
and whilst some broad elements of segmentation, such as age and geography, have been
employed, psychographics and behaviour have been less commonly used. This may be because
psychographics, which measure client attitudes and interests, are harder, or more
expensive to identify, and are seen as more subjective, less replicable and more prone
to reporting bias than objective, demographic criteria. However, well‐applied psychographics
provide a deeper understanding of the desires, needs and decision‐making considerations
of a potential user of a product or service 3. Transferring methods and tools from
the commercial to the public sector is likely also hampered by requirements for evidence
by decision makers. In the commercial context, sales and profits provide rapid evidence;
in public health, impact is typically observed in the medium‐ to long‐term.
Successful HIV prevention strategies to date share several features: political leadership,
community engagement, attention to social norms and open communication 7. These successes
have mainly been in key populations who have been engaged communities, highly motivated
by HIV risk, or in more general populations responding to widespread HIV‐associated
mortality 8. The current situation in southern and eastern Africa, where HIV is not
the primary concern of young people may require additional approaches. Here, male
and female condoms, VMMC and oral pre‐exposure prophylaxis (PrEP) are efficacious,
but there are major barriers to uptake 9, 10. Designing social marketing strategies
for these interventions, tailored for groups based on their values, attitudes and
decision‐making creates the greatest likelihood that people will adopt them 5. The
messages for behaviour change reducing numbers of risky sexual partnerships could
also be tailored to specific segments, where the barriers to accessing and adopting
prevention technologies are less, but the social contexts and norms may be challenging.
There is experience of market segmentation in social marketing of condoms 11, but,
to our knowledge, little has been documented and published in the peer‐reviewed literature.
Table 1 describes the labels used to describe segments that have been used to categorize
populations and the proportion of the population they represent in the few published
studies from Malawi, Zimbabwe and Zambia 5, 12, 13. The segments provide information
on the potential for success that interventions targeting particular segments might
have, along with the scale of the benefits to be derived from successful campaigns.
In addition, understanding the motivation of those within a category allows tailored
messaging. For example, “scared rejectors” of circumcision would require interventions
that address their fears, “friends‐driven hesitant” might respond to peer driven interventions.
The studies of men's attitudes towards VMMC in Zambia and Zimbabwe revealed that the
men responded best to information communicated individually rather than collectively,
needed to overcome fear of pain, and needed to be prompted to attend the clinic 4,
13. These insights allowed Population Services International to develop specific VMMC
campaigns through human‐centred design prototyping and testing 13. The approaches
are now being applied across VMMC programmes and used in a cluster‐randomized trial
to test the effectiveness of promotional materials informed by attitudes expressed
by men engaged in the research. Defining the segments is a first step in the process
of developing messages and interventions that need to be designed, trialled and delivered.
Such intervention design should engage local communities to ensure acceptability and
ownership.
Table 1
Examples of segments from HIV prevention studies
Perception of HIV risk and self‐efficacy (Malawi) 5
Condom attitude segments (Zimbabwe) 12
Attitude to VMMC among uncircumcised men (Zambia) 13
Attitude to VMMC amongst uncircumcised men (Zimbabwe) 13
Responsive
35%
Playful
21%
Enthusiasts
21%
Socially supported believer
11%
Avoidance
8%
Caring
12%
Champions
6%
Self‐reliant believer
9%
Proactive
47%
Easy going
10%
Neophytes
19%
Knowledgeable hesitant
10%
Indifference
10%
Daring
17%
Scared rejectors
17%
Friends‐driven hesitant
19%
Statusa
19%
Embarrassed rejectors
16%
Scared rejector
17%
Composed
21%
Highly resistant
21%
Indifferent resistant
27%
Traditional believer
6%
a
People concerned with their status in the community.
John Wiley & Sons, Ltd
Building on work in VMMC, qualitative and quantitative surveys are underway amongst
adolescent girls and young women (AGYW) in South Africa to explore attitudes to HIV
prevention, generally and in terms of oral PrEP, and among young men and their attitudes
around HIV testing 1. Experience shows that HIV prevention products are not automatically
adopted by those at risk of HIV, but we believe that marketing best practices can
increase the likelihood of success. Defining and describing segments is partly objective
analysis and partly a creative narrative, the success of which can be judged by its
utility in designing segment‐specific campaigns, in measuring the cost of those programmes,
and ultimately in the uptake of prevention.
There is a need to study and document the identification of segments, the design of
interventions to reach those segments, and the uptake of HIV prevention interventions
within those segments.
Competing interests
None.
Authors’ contributions
A.G., R.L., A.E.K. and G.P.G. wrote this viewpoint collaboratively. All authors read
and approved the final manuscript.