1. Epidemiology and Global Health
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A case study for a psychographic-behavioral segmentation approach for targeted demand generation in voluntary medical male circumcision

  1. Sema K Sgaier  Is a corresponding author
  2. Maria Eletskaya
  3. Elisabeth Engl
  4. Owen Mugurungi
  5. Bushimbwa Tambatamba
  6. Gertrude Ncube
  7. Sinokuthemba Xaba
  8. Alice Nanga
  9. Svetlana Gogolina
  10. Patrick Odawo
  11. Sehlulekile Gumede-Moyo
  12. Steve Kretschmer
  1. Surgo Foundation, United States
  2. Harvard T.H. Chan School of Public Health, United States
  3. University of Washington, United States
  4. Cello Health Insight, United Kingdom
  5. Ministry of Health and Child Care, Zimbabwe
  6. Ministry of Community Development, Zambia
  7. Ipsos Healthcare, United Kingdom
  8. Ahimsa Group LLC, Kenya
  9. London School of Hygiene and Tropical Medicine, United Kingdom
Tools and Resources
Cite this article as: eLife 2017;6:e25923 doi: 10.7554/eLife.25923
4 figures, 3 tables and 1 additional file

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.

https://doi.org/10.7554/eLife.25923.007
Estimated vs. perceived HIV infection risk by segment.
https://doi.org/10.7554/eLife.25923.010
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'.

https://doi.org/10.7554/eLife.25923.011
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)
CountrySegmentKey factors defining segment profilesSummary of differences among segments









Zimbabwe





Motivation/need for VMMCRejection due to cognitive dissonancePerceived lack of abilityAcceptance of social supportPersonal constraints
EnthusiastsStrong motivationNeutralAverage abilityHighly socially drivenSome fearsBelieve 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.
ChampionsStrong motivationNo rejectionStrong abilityHighly independentSome fearsHave 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.
NeophytesNeutral motivationStrong rejectionLack of abilityHighly independentSome fearsMore 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 motivationStrong rejectionStrong abilityHighly independentStrong fearsWeak 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 RejectersWeak motivationNo rejectionAverage abilityHighly socially drivenStrong fearsWeakly 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 ResistantWeak motivationStrong rejectionStrong abilityHighly socially drivenNo fearsWeak 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)
CountrySegmentKey factors defining segment profilesSummary of differences among segments









Zambia
Motivation/need for VMMCControl overcognitive dissonancePerceived lack of abilitySelf-efficacy against social pressurePersonal constraints
Socially-supported believersStrong motivationStrong confidenceAverage abilityFully independentStrong fearsStrong 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 believersStrong motivationAverage confidenceStrong abilitySomewhat socially drivenStrong fearsStrong 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 HesitantNeutralStrong confidenceLack of abilitySomewhat socially drivenNo fearsSomewhat 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 HesitantNeutralLack of confidenceLack of abilitySomewhat socially drivenNo fearsAmbivalent 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 RejectersWeak motivationAverage confidenceLack of abilityFully independentStrong fearsMostly 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 RejectersWeak motivationStrong confidenceStrong abilitySomewhat socially drivenSome fearsThe 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 BelieversNeutralStrong confidenceLack of abilityVery socially drivenSome fearsMostly 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.
  1. 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
CountrySegmentAll men in segment*Uncircumcised men in segment
Circumcised
% (n)
Uncircumcised % (n)Not committed
% (n)
Committed
% (n)
ZimbabweEnthusiasts42.6 (211)57.4 (284)15.5 (44)84.5 (240)
Champions76.2 (269)23.8 (84)8.3 (7)91.7 (77)
Neophytes6.1 (17)93.9 (260)43.1 (112)56.9 (148)
Scared rejecters2.6 (6)97.4 (228)78.1 (178)21.9 (50)
Embarrassed rejecters32.7 (112)67.3 (230)56.1 (129)43.9 (101)
Highly resistant0.7 (2)99.3 (298)92.6 (276)7.4 (22)
ZambiaSocially-supported believers56.1 (160)43.9 (125)20.0 (25)80.0 (100)
Self-reliant believers71.2 (272)28.8 (110)14.5 (16)85.5 (94)
Knowledgeable hesitant49.8 (119)50.2 (120)41.7 (50)58.3 (70)
Friends-driven hesitant14.1 (38)85.9 (231)29.0 (67)71.0 (164)
Scared rejecters9.7 (22)90.3 (204)62.7 (128)37.3 (76)
Indifferent resisters5.5 (19)94.5 (325)79.4 (258)20.6 (67)
Traditional believers70.6 (180)29.4 (75)16.0 (12)84.0 (63)
  1. *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
CountryTargeting priorityRationale for targeting priorityKey messagesUse of mass mediaUse of IPCsUse of advocates
ZimbabweEnthusiastsLarge potential (21% of uncircumcised men) with 85% of segment committed; high risk behavior, but likely to advocateDetailed info on procedure and healing process; pain management; improved relationship with partnerNot a targetClarify pain during healing, time off work/school; counsel on potential increase in promiscuityEngage as advocates
ChampionsLow potential (6% of uncircumcised men), but easy conversion (92% committed) and highly likely to advocateAddress uncertainty on healing process and pain during healing and procedureNot a targetAddress uncertainty on healing and pain; identify a friend-advocate to go with them for the VMMCEngage as advocates
NeophytesLarge potential (19% of uncircumcised men), and 57% committed; knowledge needed to inform commitment for restFull info on benefits and risks; clarify safe, skill of surgeon, healing process; where to get info and servicePersonalize benefits, pain – how to manage it, accomplishmentCommunicate full info on benefits, risks, safety, procedure and healing processUse advocates to allay fears, share process, accompany
Embarrassed RejectersModerate potential (16% of uncircumcised men) but commitment low (22%) and embarrassment, fears highVMMC becoming norm – be part of it; VMMC + condom use benefit; safe; how to manage pain, abstinenceVMMC norm, where service, reality of pain and how to manage itVMMC norm, how to manage abstinence, reasons for pride, address myths believedProvide community network of advocate support – VMMC as social norm
Scared RejectersModerate potential (17% of uncircumcised men) but commitment very low and fears/dissonance are strongSafe procedure, low risk of complications; pain mgmt. during healing; improved relationship with partnerNot a targetSafe, low risk, expert service, pain real but manageable, involve partnersUse advocates to allay fears, share experience, accompany
Highly ResistantLarge potential (21% of uncircumcised men), but hard to crack; knowledgeable, little fear; don’t recognize need despite high-risk behaviorVMMC becoming social norm; address safety, service quality, privacy; pain managementNot a targetAcceptance of VMMC by wider community and advocacy from leaders; address fears with full infoNeed advocates, communicating pride in VMMC and allaying fears
CountryTargeting priorityRationale for targeting priorityKey messagesUse of mass mediaUse of IPCsUse of advocates
ZambiaSocially-supported BelieversModerate potential (11% of uncircumcised men), high commitment (80%); likely advocate to broad audience, but dissonanceAddress uncertainty on healing process and pain during healing and procedureNot a targetAddress uncertainty on healing and pain; identify non-circumcised friends to go together for VMMCEngage as advocates
Self-reliant BelieversModerate potential (9% of uncircumcised men), high commitment (86%), easy conversion to action; likely advocate for friendsAddress questions about pain during procedure and healing processNot a targetAddress uncertainty on healing and pain; identify non-circumcised friends to go together for VMMCEngage as advocates
Knowledgeable HesitantsModerate potential (10% of uncircumcised men) and commitment (58%); key concern is safetyProtection benefits, VMMC + condom use benefit; safety, low risk of complications; pain managementNot a targetSafety - low risk (esp. for sexual life); pain is real, but manageable; expert service; involve partnersUse advocates to allay fears, share experience
Friends-Driven HesitantsLarge potential (19% of uncircumcised men); 71% of segment committed; need add’l assurance, but relatively easily convertedVMMC social norm – be part of it; emotional benefits; detailed info on procedure and healing processPersonalized benefits; sense of accomplishment; low riskVMMC norm, manage healing, clarify pain, service quality, availability; reasons for prideProvide community network of support – social norm
Scared RejectersLarge potential (17% of uncircumcised men) but low commitment (37%) and strong concerns - fears and embarrassmentSafety, low risk of complications; pain management during healing; emphasize protection benefitsNot a targetSafety – credible info on low risk, expert service; pain is real, but manageableUse advocates to allay fears, share experience, accompany them
Zambia Indifferent RejectersLarge potential (27% of uncircumcised men), low commitment (21%); hard to crack; absence of motivation, while almost no concerns or fearsFull benefits and risks, HIV/STIs protection; clarify safety; address myths believed; where to get info and serviceFull benefits, process, reality of pain and how to manage it; sense of accomplishmentFull benefits and risks; acceptance of VMMC by wider community and advocacy from leaders; dispel mythsNeed a lot of advocates around, communicating pride in VMMC and allay fears
Traditional BelieversSmall potential (6% of uncircumcised men), but no need for support; high commitment (84%) driven by tradition - will get MCInformation on benefits and risks; where to get info and serviceNot a targetWill benefit from short communication on benefits and risks; info on service/clinicsNot applicable

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