Will Balbir Pasha Get AIDS?
The ‘Will Balbir Pasha Get AIDS?’ campaign formed part of PSI India’s Operation Lighthouse, an HIV/AIDS prevention programme implemented in 12 major port communities in India. The programme aimed to reduce rates of unsafe sex by motivating people to consistently use condoms, call the confidential HIV/AIDS hotline, and use the Voluntary Counselling and Treatment services.
The campaign was built around a fictional character called Balbir Pasha. It used a storyboard to place him in various high-risk sexual situations, with unknown outcomes. This provided a realistic behavioural model for urban men living in Mumbai. Using a mixture of outdoor communications, television and radio messaging, and comprehensive newspaper exposure, the campaign succeeded in personalising HIV risk and bringing the topic of HIV/AIDS into the public sphere.
- Increase in proportion of individuals reporting last-time condom usage with commercial sex workers from 87 per cent to 92 per cent
- Threefold increase in retail sales of condoms in the red light district
- Increase in Voluntary Counselling and Treatment services usage
India is home to the third largest number of HIV infected people in the world. In 2002 there were an estimated 3.5 to 4 million HIV-positive people living in India (this has since been revised downwards, with an estimated 2.3 million people in India living with HIV in 2009).
Approximately 80 per cent of HIV cases in India have been attributed to heterosexual encounters and are concentrated among high-risk groups including commercial sex workers, men who have sex with men (MSM) and injecting drug users, as well as truck drivers and migrant workers. Staggering misconceptions regarding HIV/AIDS transmission as well as a reluctance to publicly discuss HIV/AIDS has fuelled the spread of HIV across India.
Against this backdrop, Population Services International (PSI) received funding from USAID in 2001 for five years to develop and implement programmes across India aimed at reducing the spread of HIV/AIDS. The subsequent programme, Operation Lighthouse (OPL), was conducted in 12 major port communities across India: Chennai, Goa, Haldia, Kandla, Kochi, Kolkata, Mangalore, Mumbai, Paradip, Tuticorin, Vashi, and Vishakhapatnam. India’s port cities and surrounding communities were the chosen focus of the programmes because these areas serve as points of convergence for people at highest risk of contracting HIV and transmitting it to others. Port communities directly and indirectly employ large numbers of men – formal and informal port workers, truck drivers and their helpers, migrant workers, fishermen, day labourers and others – many of whom spend significant parts of their lives away from their families and who move continuously between urban and rural environments.
Unlike previous programmes, OPL sought to develop public health campaigns that successfully engaged with at-risk individuals and personalised the risks for the individuals. One of the biggest OPL campaigns was conducted in Mumbai and is the focus of this case study. PSI had been conducting work with commercial sex workers in Mumbai’s red light districts since 1991. Mumbai was the home of the largest red light district in India, and so previous work had focused on educating and empowering the 6,000 to 10,000 commercial sex workers operating in the red light district. The work of OPL would instead work to motivate the clients of sex workers to practice safe sex across the city in a sustained and effective manner.
An extensive scoping phase guided the development of the campaign in Mumbai. This included:
PSI segmented the audience according to demographics, socioeconomic and geographic characteristics, as a review of existing research revealed a strong prevalence toward high-risk attitudes and behaviours among these groups:
- Demographic – Men between the ages of 18 and 40, and those at highest risk for HIV infection (such as men who were clients of sex workers)
- Socioeconomic – Men belonging to lower socioeconomic groups, particularly truck drivers
- Geographic – Men living in Mumbai, where India’s urban HIV epidemic is centred
A review was conducted of existing research around high-risk audiences’ attitudes and behaviours around unprotected sex with commercial sex workers. This included a review of studies conducted by the Avert Society in Maharashtra (of which Mumbai is the capital). This was combined with informal discussions with stakeholders to gain understanding of which aspects of previous health communications in India had previously worked well and which had not.
Lifestyle research, including one-to-one interviews with clients in red light districts and focus groups, were conducted to establish patterns of behaviour and relevant communication channels.
This research revealed several key reasons why men were having unprotected sex with partners:
- Misconceptions surrounding HIV transmission
- Poor personal risk assessment – Men believed that while commercial sex workers were at high risk of contracting HIV, the men who patronised them were not
- Belief that individuals infected with HIV would appear outwardly ill – One-third of men who visited commercial sex workers were unaware that a healthy looking, asymptomatic individual could potentially be HIV-positive
- A strong relationship between alcohol consumption and high-risk behaviour
- Negative attitudes towards condom use
The research also identified barriers to using Voluntary Counselling and Testing (VCT) services and a HIV/AIDS helpline:
- Individuals are unable to travel to VCT services
- VCT facilities and HIV/AIDS helpline are not available when individuals are able to go, and they have inconvenient opening hours, especially for working men
- Individuals are too busy to travel to VCT sites due to their jobs, especially if the service is hard to get to
- Some lack access to a phone and/or fear that the helpline will show up on telephone bills
- Many worry about the financial costs of phoning the helpline or visiting VCT services
Knowledge and psychosocial barriers
- Fear of being HIV-positive
- Fear that use of the helpline or VCT services will not be confidential
- If positive, fear that HIV status will be made public, or if negative, fear that using services will cause others to speculate about their HIV status
- Fear of oneself or family being judged and ostracised if use of services surfaces
- Stigma or taboo associated with discussing HIV/AIDS and other sex-related matters
- Lack of awareness of helpline or VCT services
- Low personal risk perception
The research identified two main sources of competition for the campaign:
- Apathy of the male target audience towards public health campaigns or health-related messages
- The need to break through the media clutter in an already media-dense Mumbai
Based on all of this research, it was decided that the programme’s overarching behavioural goals would be to:
- Motivate people to access a HIV/AIDS helpline and VCT services
- Generate discussion about HIV/AIDS among the target populations and opinion leaders
The programme would also have awareness and attitudinal goals to:
- Dispel barriers or myths preventing the consistent use of condoms with female sex workers
- Increase perception of risk from unprotected sex with non-regular partners
PSI sought to develop a strong marketing mix – including communications materials and service provision – to elicit the desired behavioural changes in the target population.
A review of behavioural learning theory and the value of behavioural models for the relevant target audience revealed that people learn by observing the behaviour of others (Social Learning Theory). This led to the development of ‘Balbir Pasha’ – a fictional character who acted as a behavioural model for the target audience.
The campaign would be organised into five stages, each of which progressively builds intrigue and 'gossip value', like the plots in a TV soap opera, with Balbir Pasha as the protagonist.
Stage One: The 'teaser' campaign would depict typical Mumbai lower and middle income men asking each other the following question: “Will Balbir Pasha get AIDS?”. During this teaser phase, viewers would encounter people speculating on Balbir's future in a series of scenarios that reflected real-life situations.
After this initial launch, the campaign would unfold to address three different themes. The three selected themes were developed and pretested among sexually active males from low socioeconomic groups to test relevance and appropriateness. The themes intended to address some of the key barriers or myths preventing the consistent use of condoms that had been identified in the scoping phase. These personalised the risks and were developed to make the target audience question their own sexual behaviours and beliefs.
Stage Two: Alcohol
- Issue addressed – ‘I often use condoms, but when I get drunk, I sometimes forget to use them’
- Message – ‘Balbir Pasha sometimes forgets to use condoms when he is drunk. But by not wearing a condom just one time, it is possible to get AIDS’
Stage Three: Non-regular partner
- Issue addressed – 'I only have sex with one person (sex worker or casual partner) and hence I am safe'
- Message – ‘Balbir Pasha only goes to (has sex with) Manjula. But others go to Manjula too’
Stage Four: Healthy looking partner
- Issue addressed – 'If a person looks healthy he/she must be safe from HIV/AIDS'
- Message – ‘Balbir Pasha only has 'relationships' with healthy-looking people. But you can't tell by looking who has AIDS’
- The Saadhan helpline number would finally be revealed in the last phase, and consumers would be directly asked to call this number and to access available HIV/AIDS services
To address competition in the form of apathy to health-related messages and the media-dense environment of Mumbai, the Balbir Pasha materials were developed to be bold, controversial and eye-catching, and deliberately positioned to become a ‘talking point’ or gossip item amongst the target audience. Social interest in the human story of Balbir thus took over the health element of the programme, so that a traditionally hostile target audience became engaged with the materials.
In order to disseminate these messages, appropriate media channels were identified based on the research conducted, which identified areas often frequented by the target population. These included: billboards and posters in the red light area; posters on trains and at train stations to reach the four million people travelling on the Mumbai train network each day and to create a conversation buzz; use of cinema halls to capitalise on the popularity of Hindi and Marathi films, communicate complex ideas to a captive audience, and use the many B and C grade cinema halls located in areas where the target population lives; hard-hitting television and radio adverts across a broad mix of networks; ubiquitous print advertisements and comprehensive newspaper exposure, with Balbir Pasha featuring in the major language papers (Hindi/Marathi) available in Mumbai. PSI negotiated on average a 40 per cent discount on media space in newspapers, the radio and outside advertising (from CBS outdoor).
This awareness-raising work would be integrated with on-the-ground activities and services, which were implemented in all of OPL programmes, including:
Voluntary Counselling and Testing (VCT) services
VCT services would be endorsed on the ground to ensure saturation of behaviour change messages from all possible angles.
Saadhan telephone hotline
Research showed that telephones are widely accessible in Mumbai (cellular phones, landlines or public phones, which are available at almost every 100 meters). This easy accessibility made the development of an HIV/AIDS helpline particularly appropriate for Mumbai. The helpline would be staffed from 10am to 9pm, Monday to Saturday, providing confidential HIV/AIDS information and counselling to callers. PSI would provide training to ensure that all telephone counsellors could address the issues raised by the Balbir Pasha campaign and make the appropriate referrals to various local VCT services. To overcome the barriers to using a helpline identified during the research, the helpline would be low-cost, anonymous and confidential, and the long opening hours would make it accessible for most working men.
Interpersonal Communication Workers
PSI had teams of Interpersonal Communication Workers to work in and around the brothels of Southern Mumbai, educating both commercial sex workers and their clients about HIV risk behaviours. The Balbir Pasha themes would be used as a way of starting discussions with these target audiences.
Each of OPL’s 12 sites, including Mumbai, had 3 units that oversaw the implementation of the work: a marketing team that worked on the sale and distribution of condoms; a communications team that managed the interpersonal communicators and any mass media campaigns; and a medical services team that oversaw the VCT services and helpline.
In Mumbai, the Balbir Pasha mass media campaign (Phase One) ran from November 2002 to February 2003:
- Stage One – Teaser (ran for three weeks in November 2002)
- Stage Two – Alcohol (ran for three weeks in December 2002)
- Stage Three – Non-regular partner (ran for three weeks in December 2002 to January 2003)
- Stage Four – Healthy looking partner (ran for three weeks in January 2003)
- Stage Five – The Saadhan Helpline (ran for three weeks in January 2003 to February 2003)
“I think we did something special with this mass media campaign, simply because it broke the mould in how advertising and communications were done in India with respect to public service announcements. Even today it’s referenced to. What was unique with that was it used great consumer insight, and secondly it spoke in a manner that was natural and not didactic as typical health communications tend to be.” (Sanjay Chaganti, Programme Director)
The Balbir Pasha mass media campaign received great attention and successfully got people discussing HIV/AIDS, but importantly was supported by work on the ground through the Interpersonal Communication Workers to educate commercial sex workers and their clients. However, when the research was conducted to inform the programme, there were very clearly defined red light districts around Mumbai.
Subsequently it was initially very easy to identify where the Interpersonal Communication Workers needed to operate. Then because of an increase in awareness of HIV, men were less interested in coming to a brothel but were looking for sex in places outside brothels. This meant that the Interpersonal Communication Workers had to be flexible and operate in numerous locations around the city where commercial sex workers were now working, and had to be adaptable to further changes in these locations.
“Brothels had suddenly become blacklisted as the bedrock of infection, so they started moving out of the brothels and into lodges and small hotels. So we went from operating in 2 red light areas of Mumbai, to working in 10 to 15 different locations across the city. That posed considerable challenges. It’s a big city. That was something we had to be flexible with and ensure our programme implementation was in alignment with the needs.” (Sanjay Chaganti, Programme Director)
Despite the successes of Phase One of the mass media campaign, it also came under criticism from some non-governmental organisations (NGOs) in Mumbai. The NGOs felt that the focus of the campaign was too narrow as it focused only on heterosexual transmission, that it was too frank, and that it was not gender sensitive (many believed the campaign was anti-women, as it implied HIV was passed from women to men only).
For the second phase of the campaign, PSI worked with the Mumbai District Aids Control Society (MDACS) to obtain stronger NGO buy-in. All messages and concepts were tested with NGOs to ensure messages were deemed acceptable. The messages were adapted to ask ‘Who will become Balbir Pasha?’. Three themes were used to address issues agreed with stakeholders:
- Issue addressed – Married men and the risk they put their families at when they indulge in extra-marital affairs
- Message – ‘Will Hariya’s wife and his to-be-born child become Balbir Pasha? Away from his wife, Hariya fulfils his needs elsewhere. It’s men like these who often infect their wives and children with HIV/AIDS’
- Issue addressed – Not wearing a condom is a misplaced sign of being macho
- Message – ‘Will Rocky become Balbir Pasha? Rocky has many girlfriends and he never wears condoms. This sense of bravado has left many men infected with HIV/AIDS’
- Issue addressed – Sexual relationships with any non-spousal partner put one at risk of contracting HIV
- Message – ‘Will Manu and his ‘date’ become Balbir Pasha? Manu and his date know each other. But both of them could have other relationships too’
These new messages formed Phase Two of the mass media campaign, which ran from November 2004 until February 2005. All materials contained a tagline: ‘Brought to you by PSI in partnership with MDACS’ to highlight the NGO endorsement.
While the second phase of the campaign built on the successes of the first phase, it did not appear to have the impact and resonate with the target audience in the same way Phase One of the campaign had done. While Phase Two had obtained the key stakeholder buy-in from the NGO sector which Phase One had failed to achieve, it is thought that Phase Two did not reach the target audience as successfully because the message had weakened.
“HIV is not just a very sensitive topic but it is also a very politically charged topic. The data at that point in India showed that something akin to 80 per cent of new infections were happening because of men having unprotected sex with commercial sex workers, so therefore we focused on that behaviour. However there were many vocal groups, which said: ‘Why are you only focusing on this behaviour? What about mother to child transmission? What about men having sex with men? What about intravenous drug usage?’ Therefore, various groups who very justifiably sometimes feel marginalised can often influence the agenda by speaking up the loudest, and I think that was the mistake we made the second time around, because it meant we lost focus and diluted the message.” (Sanjay Chaganti, Programme Director)
An independent research agency (Mode) conducted a post-campaign impact evaluation following the first phase of the campaign (November 2002 to March 2003). Results revealed that campaign messages and services were well received and effective.
1,500 interviews were carried out. The street intercepts focused on the awareness, attitude and behaviour of men visiting commercial sex workers.
- Increase in number of calls to the Saadhan HIV/AIDS hotline, and a shift in types of queries from superficial to more invasive and informed
- Increase in proportion of individuals reporting last-time condom usage with commercial sex workers, from 87 per cent to 92 per cent
- Retail sales of condoms in the red light district tripled after the launch of the campaign
- 54 per cent of the target audience reported having discussed the campaign with someone
Risk perception changes
- Increased proportion of those who feel at high risk of HIV from unprotected sex with a non-commercial partner, from 17 per cent to 43 per cent
- The percentage of those who believed that using condoms all the time reduces HIV/AIDS risk increased from 80 per cent to 86 per cent
- An increasing proportion realised using condoms half the time did not reduce risk at all (from 43 per cent to 53 per cent)
- Respondents showed an increase in risk perception regarding healthy looking and more expensive commercial sex workers
- Over a third stated that one should not engage in sexual intercourse with non-regular partners without a condom
Creation of an icon
One of the most striking aspects of the Balbir Pasha campaign was its assimilation into popular culture.
Amul, one of India’s leading dairy cooperatives mimicked the idea of a 'regular partner' in a billboard advertisement which featured the caption: ‘Who does Balbir Pasha wake up with every morning? Amul Butter. Regular Item.’
According to the 14 January 2003 issue of Mumbai’s Economic Times, ‘To qualify for an execution in Amul’s long-standing series of satirical topical ads, a campaign must have really made it into the city’s everyday talk.’ This and other spin-offs and parodies reflect the status of Balbir Pasha as a cultural icon.
Phase Two of the Balbir Pasha campaign (2004 to 2005) was evaluated as part of the wider OPL programme. The programme saw an increase in men in the 12 port cities reporting condom use with non-spousal partners, from an average of 57 per cent in 2002 to 75 per cent in 2006 among truckers, and from 45 per cent to 71 per cent among other men.
As with many programmes in developing countries and elsewhere, the Balbir Pasha campaign and the OPL work has had to contend with finite funding cycles from donors. As a fairly large organisation, PSI received five-year funding for the OPL work, whereas often funding only lasts two to three years. These funding cycles mean that there are periodic problems with sourcing funding. Because of this, while aspects of the OPL work continue today, the scale of this work has been reduced.
The VCT services continue to run, alongside the Saadhan helpline. The helpline has been expanded to cover a wider range of reproduction health issues and is being supported by a private foundation based in the US. The outreach workers who formed the interpersonal communications part of the campaign continue to operate, however their numbers have been reduced to approximately one-third of the levels during the OPL work because of reduced funding.
The lessons learned from the Balbir Pasha campaign have been used to influence numerous HIV/AIDS campaigns run by PSI and others. The mass media campaign was later used by PSI in Tamil Nadu and Andhra Pradesh with the character Puli Raja (a name more appropriate for these states) replacing Balbir Pasha.
Several criticisms arose as a result of Phase One of the campaign:
- The campaign was too frank – 'Bringing the bedroom into the living room'
- The campaign promoted 'anti-women' messages because of the implication that HIV is passed on from women to men
- It only focused on heterosexual transmission – It did not address the behaviour of MSM, intravenous drug use or pre-natal HIV testing
In response to these criticisms, campaign strategists consulted more closely with key stakeholders during the development of the second phase of the campaign. However this created further challenges. Having to incorporate the opinions and needs of multiple stakeholders can water down the final message – this was found to be the case for Phase Two of the campaign, which did not have as great an impact with the target audience as Phase One, despite being more preferable to the numerous stakeholders involved. Any programme thus needs to strike the delicate balance between having broad stakeholder input and buy-in and ensuring that this input does not dilute the message to the target audience.
Lessons were also learned about the Saadhan telephone hotline:
Monitoring and evaluation – Continuous and regular monitoring of the helpline is imperative to ensure that operations are running optimally and that the helpline’s objectives are being met. It is also important to develop a means to evaluate the helpline’s impact on the target audience, as well as a baseline survey to do so.
Flexibility – As it is virtually impossible to anticipate and forecast all helpline related issues, it is vital that helplines remain flexible and are able to adapt quickly to meet the needs of the programme and target audience. Consequently, the Saadhan Helpline in Mumbai has adapted its programme in several areas and capacities to improve services.
Counsellors were trained in MSM sexuality and related sexual issues, the helpline’s hours of operation were extended when trends showed an increase in evening calls, and methods were developed to manage prank calls and even turn them into counselling sessions.
Despite these challenges, the programme was deemed successful at combining a mass media campaign with interpersonal communications (face-to-face communications on the ground).
“Interpersonal communications and mass media can work wonders, if used synergistically. Often people compare the two, and that’s like comparing a hammer and a screwdriver. They have different uses, they should be thought about differently, but they can be used synergistically to be very useful.” (Sanjay Chaganti, Programme Director)