So how do you get these sexually active people, including marginalised groups such as sex workers and men who have sex with men (MSM), to be cognizant of their own sexual health, and even change their practices and adopt a safer, healthier lifestyle? If you are PSI/Caribbean, which created the very popular “Got it? Get it.” condom campaign, then you approach it like a business product - you market it.
“What makes PSI different is that yes we are an NGO but we market health. The same way that Nike would market shoes,” says Kevon Foderingham, PSI Caribbean’s Marketing and communications manager.
He was speaking with Newsday during a recent interview at the NGO’s offices at Connor Street, Woodbrook. He was joined by the vibrant and affable executive director, Marina Hilaire-Bartlett. The staff at the office are all youthful and fresh faced, dressed in brightly coloured T-shirts.
Population Services International (PSI) is a “global health organisation dedicated to improving the health of people in the developing world by focusing on serious challenges like a lack of family planning, Human Immunodeficiency Virus (HIV) and Acquired Immunodeficiency Syndrome (AIDS), barriers to maternal health, and the greatest threats to children under five, including malaria, diarrhoea, pneumonia and malnutrition”. It was founded in 1970, is headquartered in Washington DC, United States, has more than 8,900 staff and has programmes in 69 countries.
Hilaire-Bartlett explains that PSI globally is strong in social marketing.
“Social marketing is essentially how private sector organisations do marketing around their own brand so that you choose them over somebody else. So what we do is do the same thing for health. So we promote a brand of health, a health behaviour or perhaps a product that encourages the user to have a healthy lifestyle as opposed to a non-healthy behaviour,” she said.
She noted they marry with this the process of Behaviour Change Communication (BCC) “which takes the person along a continuum of change”. She gave the example of moving from a person not even thinking about condom use to starting to think they may be somewhat at risk and finally to the point when they believe they need to access condoms. She said there was the same BCC process for sexual health, which encompasses HIV.
PSI Caribbean was founded in 2005 with Trinidad as the head office. As years passed they expanded into other islands: Antigua and Barbuda, Barbados, Belize, Dominica, Grenada, Jamaica, St Kitts and Nevis, St Lucia, St Maarten, St Vincent and the Grenadines and Suriname. Although they operate in 12 Caribbean countries they only have three physical offices — the Trinidad regional headquarters and country offices in Jamaica and Suriname, with the latter two established in 2011.
Beginning with a focus on HIV/AIDS, in 2009 they began work in sexual and reproductive health and got into service delivery such as sexually transmitted infection (STI) screenings and contraception. They work through the International Planned Parenthood Affiliates and they administer the programme across the region.
PSI Caribbean’s “Got it? Get it.” campaign for regular and consistent condom use was launched in 2006 and was spread throughout the region. Foderingham described the campaign as their “greatest accomplishment”. He explained that before PSI Caribbean, condoms were not sold anywhere other than pharmacies. But now, through their efforts, condoms are sold in beauty parlours, corner shops and gas stations with the “Got it? Get it.” sticker as a notification that condoms are available.
He said historically one of PSI’s goals is to open the market to condom use, whether people can afford or not.
Hilaire-Bartlett noted a lot of work goes into a campaign, starting with research and knowing your audience.
“What we focus on is behaviour. So you might be a straight man but you are still having multiple partners, anal sex, what have you. So how we start the development of a campaign is to really digging into those communities, walking through the life of someone,” she said.
She noted after they have a profile they apply another marketing mechanism of the four Ps - Product, Place, Promotion, Price. Then they get the campaign going by digging into those four Ps from the health perspective and looking into communities.
She explained that Got it? Get it focused on young and young at heart; persons aged 16-25 are one of their at risk groups.
“If I were to articulate how Got it? Get it was so powerful was again it started to engage discussions around condom use. It put in a package essentially that it was okay to be speaking about condoms. We need to get the discussions going. It is okay to access it,” she said.
She noted that there were sexually reproductive health advertisements around condom use, celebrity endorsements, and they also had people in the field. She also noted that the campaign was very interactive and has a social media presence which Hilaire-Bartlett believes is one of their great strengths. Their social media office is in touch on a daily basis to get their communities information on HIV, SRH prevention and gender-based violence.
“All the things that are attached to healthy living,” she added.
She said the success of the campaign has been different in different countries for varying reasons. Foderingham noted that it also depends on the culture of the country, as certain things may be more taboo than others. He stressed that though it is a regional campaign they still have to tailor it to each country because every Caribbean country has its own particular landscape.
WORKERS & MSM
Two of the at risk groups that PSI Caribbean focuses on are sex workers and MSM. Foderingham noted they had an active team which would go into brothels and do SRH education and distribute condoms.
“Really get in there with that particular population because they couldn’t come out. So we had to go in,” he explained.
The team, which included Spanish speakers, focused especially on Spanish-speaking sex workers. Foderingham pointed out that there were also educators who were part of the sex worker population “so they could build that trust”. He noted that with the MSM community they also have educators which are part of that population.
“So they will go to the parties, they will go the house limes. And they would get their trust because it is the same people, it is part of the community,” he said.
He reported that the communities were very receptive to the information.
Hilaire-Bartlett chimed in that there is a level of trust you have to build and this takes time with a relationship. She also pointed out that you have to know boundaries and have agents to enter the field.
The educators, she stressed, are mandated to be responsive with whom they to those engage with and it is not “them and us” but they are in service to people.
“So when we’re programming we’re constantly going back to the drawing board — what are they saying are their needs?” she explained.
She said they may come with a concept or an intervention but the community may say they need something else. She noted PSI has always been responsive to that “so they feel respected and that we really value (their views).”
“I really think that they trust us with that and the individual members of our clientele, even in Suriname, in Jamaica, all of them are very entrenched already in the work,” she said.
She noted that PSI is not government-aligned and does not have certain agendas.
Foderingham noted that some educators are HIV positive and they disclose their status “so it’s real” when they conduct sessions. He explained that these educators do not talk down to them but tell a bit about their lives so it is a lot more relatable. He added that in general their campaigns are relatable and are not “preachy”.
HIV/AIDS STIGMA REMAINS
On HIV/AIDS Hilaire-Bartlett noted that stigma and discrimination remain an issue in Trinidad and Tobago.
“People are still being discriminated against and I’m saying in the workplace, in their homes, people are still being evicted, children are still being expelled from school, you still have scenarios like that (in this country),” she said.
She noted there was a case of an HIV positive woman and her child, were HIV negative, attending school and teachers and parents banded together and called for the child to be removed.
“And these are things that are not spoken of and that don’t make news but that happen to people every day,” she said.
She said in Trinidad people are still walking around with the fear to come out and say you are HIV positive.
She explained that stigma is a mindset and what you conceptualise someone to be, and all persons have a certain level of prejudice. She noted that stigma discrimination is actions taken because of how a person is perceived. She pointed out that an example of discrimination would be firing a person because of stigma of HIV status or sexual orientation.
“I think (stigma is) still quite pervasive. I think certain groups that may not have been as vocal as before, for example the LGBT (Lesbian, Gay, Bisexual and Transgender) community, I think there are forums now where there is a lot more voice and advocacy where there had not been in the past decades,” she said.
Hilaire-Bartlett noted that knowledge about HIV/AIDS remained an issue as well and myths continue to persist.
“Even though we see that knowledge is high there are still a lot of myths that exist around HIV,” she said.
She noted, from the feedback they receive from their field teams, there are people who believe yo can get HIV from mosquitoes, using the same utensils as a from person with HIV or using the same toilets.
She said perceptions is also an issue perceived positive status and actual positive status “can almost end up being the same thing”. She explained that if your sexual partner may have died of AIDS then people believe “of course you have it”.
She noted that PSI Caribbean partner organisation Caribbean Broadcast Media Partnership for HIV and AIDS, headquartered in Barbados, has a stigma unit.
She explained that though PSI Caribbean is not a specific component of their work it is entrenched in what they do and this includes hiring practices. She said in their recruitment process they make it clear that they work with populations who are difficult to reach and some people may have perceptions about, including sex workers and MSM. When they develop campaigns they are very careful about those aspects and they are inclusive and not exclusive.
She also reported that the Pan Caribbean Partnership against HIV and AIDS (PANCAAP), the regional entity that coordinates all the HIV responses to the region, has a dedicated stigma unit that collates information across the region and bring to a national response for strategic plans which every country should have. There is a three to five year plan how a nation should respond to HIV and that includes stigma and discrimination.
Hilaire-Bartlett noted that they have done a lot of work around the region, including in the Eastern Caribbean islands, but in Trinidad the work has been smaller due to donor restrictions.
She explained that, as a global organisation positioned in the Caribbean, when you look at the donor environment and how you implement projects sometimes there is a blanket approach for countries or regions. Because of that blanket approach they do not really reap the benefits or have the impact that you would need.
“But we are very careful to ensure that you’re culturally relevant. And even though we’re the Caribbean across the board every country is different and every community (is different),” she said.
She noted that generally the donor landscape around HIV in the 1980s and 1990s donation funds were “flowing” and “international aid agencies were very generous with HIV because it was the hot topic essentially” but that has since changed.
“Through the years international donors and the donor pot of money has dwindled a bit because of priorities essentially,” she said.
She noted there is a challenge for donor funding for the Caribbean because it is middle income.
“When you are looking, for example, from the donor’s perspective, where is the most need we (in the Caribbean) don’t look like (we have the most need). If you look at GDP and how ‘rich’ we are. And even across the Caribbean and definitely...in Trinidad, we look rich. We have oil, we should be able to handle all this on our own. So there have been some restrictions in how we mobilise resources and how we advocate for our need is really, really important for us nationally to be able to invest in our country,” she said.
She noted that for health financing and national budgeting around HIV and other health related areas the development community is becoming more aware of the fact that it has to be an integrated approach.
“Generally the donor landscape we have to know how to manoeuvre it well and to really be able to speak to what is best for our nations,” she said.
For PSI Caribbean two of their major donors are international agencies. They do get “small pots of funding” for training and the Ministry of Labour under their HIV/AIDS Advocacy and Sustainability Center (HASC), has subcontracted them to do training for their members. She noted how they mobilise resources with the ministries and the Government is important even if it is a matter of cost sharing.
She also noted that they do partner in some ways, and in that partnership may receive things in kind and different contributions. They do not, however, receive a large pot of money coming from the local Government. She noted that there are multiple players locally in the HIV/AIDS response and PSI has a great benefit being a global organisation. She said there are others that may need funding in a different way “and we understand there is a kind of pull and tug and governments have to prioritise as well”.
On the positive side, Bartlett noted the world has advanced in the HIV response in a number of regards. In the Caribbean, for example, prevention of mother to child transmission “has almost been eliminated which is really a powerful advancement”.
In the area of stigma and discrimination Bartlett said a number of communities that did not have a voice were now able to access services, there are free anti-retroviral drugs and HIV testing done widely. She noted that the incidence of HIV has been reducing to an extent but higher rates are being seen among young women.
On the impact of the efforts of PSI Hilaire-Bartlett explained that their marketing aspects are measurable; the PSI slogan is “healthy lives, measurable results”.
“At the end of the day we have to know the impact that we’ve made. So you can’t know your impact unless you know where you’ve come from. You have to be able to measure it,” she said.
She noted that they utilise “disability adjusted life years “ to check how your intervention has made an impact and would save lives, and the amount of years that are added to a life. They also mesure the positive changes in the community due to their interventions.
Foderingham said that, like any organisation selling a product, they operate by targets and have to reach those targets. If they have to reach 100,000 people, for example, they will have to record how many they have reached and if they are going to reach that benchmark they will need to beef up their efforts.
He explained that educators go prepared with forms and tools and materials and capture all the information. They record what they did and these are sent back to PSI headquarters and they upload the information to their online system. They have a data warehouse that helps to guide all of their marketing efforts. On a monthly basis every country and every intervention has to report to PSI global.
EXCITING NEW FRONTIERS
With their work in HIV/AIDS and SRH, PSI Caribbean will be adding in the next couple of years Non-Communicable Diseases (NCDs) and gender-based violence. The mortality rates for chronic NCDs in the Caribbean are among the highest in the world. In Trinidad and Tobago, which has one the highest diabetes rates in the Caribbean, Health Minister Dr Fuad Khan has cited NCDs as one of the major health issues facing this country.
Hilaire-Bartlett noted that when looking at burden of disease and mortality rates by country and age, health and development, there must be a response to NCDs. She also noted that the donor landscape is currently focused on NCDs.
As they venture in this issue she explained that the prevention of NCDs is a lot about lifestyle choices. They will be returning to BCC and will try to articulate with clients the question -“what are the choices you are making that are not giving you the healthiest results?”.
“We focused on that with HIV; to the same extent we are going to focus on it with non- communicable diseases,” she said.
She noted it is an “exciting territory” for them because it is a public health response when look at social determinants of health.
“If you have all of the services, if you have all of the hospitals and the clinics, what is it that’s happening in the community and in people’s lives that prevent (healthy behaviour),” she said.
She recalled that the Pan American Health Organisation hosted a virtual consultation for the region where all CARICOM countries came together to state their response to NCDs, what they need and how they can support each other.
“Trinidad and Tobago is really making a lot of progress,” she recalled.
She said the intention for this country is to have an NCD Unit and PSI wants to offer their services.
“Our social marketing expertise and our behaviour change successes can really support this national response,” she said.
They are currently developing proposals at this point and reaching out and are hoping for 2015 to “really dig into it”.
She noted they are also entering into a gender-based violence prevention project, which is linked to HIV, SRH and STI prevention “because they are all so intertwined”. The project was introduced to them by a Specific donor interested in the field.
This country has been granted one million dollars to do work here and it will run for three years; a similar project is being conducted in India.
Hilaire-Bartlett noted there are other players in the field and doing work for many years. They have been working with the Coalition Against Domestic Violence, headed by Diana Mahabir- Wyatt. She said they are focusing on healthy relationships and gender dynamics. Their target group will be young women between the ages of 18-30, though it will not exclude the engagement of men and boys,
“Over the next three years you are really going to be seeing PSI much more visible around (gender-based violence,” she said.
She noted that their work will be married with intervention in SRH and HIV. Work on this project begins this year.
“So it’s exciting ground,” she added.