Matilda Johansson

Institute of social studies, program of social studies with ethical orientation, 240 hp,
Ersta Sköndal University Collage
Scientific theory and method, SEL62, 20 hp, ST 2012
Supervisor: Johan Gärde
Examiner: Julia Grosse

Social Marketing
A way to reach and empower vulnerable people through prevention work against the spread
of HIV/AIDS and Sexually Transmitted Infections in Ethiopia

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Thank you
Writing this essay has been a great experience and adventure for me. I’ve met so many
beautiful people during my stay in Ethiopia and I’m so thankful for all knowledge these
people provided me with, not only knowledge regarding my work, but about Ethiopia and life
there.
Henock, my biggest thank you and all my love to you for have being such a great help and
inspiration! I’m so impressed by you, your energy and spirit!
Thank you dear Jemil, Sunny, Abeje, Solomon, Samrah, Wondy, Fitsum, Etsub, Bezaye,
Aberra, Gelila, Samrawit, Negussie, Kidan, Merakie, Mahlet, Behailu and everyone else at
TLH, DKT and NIKAT. You are all so fantastic, warm and generous people and you made
me feel so welcome during my stay with you! We will meet soon again!
A great thank you to the girls who shared their important words in the focus group
discussions.
Thank you MARIA, my sister and wife during our 14 weeks long stay in Ethiopia and
Senegal. You’ve been such a great help, support and inspiration in so many ways!
Also my biggest thank you to my supervisor Johan Gärde who introduced me to Social
Marketing and who supervised me during this exiting and sometimes hard work. Thank you!
To my friends who also have been away in different countries writing about super important
things, you’re the best!
Family and friends, thank you for all your support, care, inspiration and patience during the
trip and this summer!

/ Matilda
August 2012

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Abstract
Millions of people in the world are infected by HIV/AIDS or/and other Sexually Transmitted
Infections, STIs. Ethiopia is, with its population on almost 94 million people, one of the worst
affected countries.
One of the methods that are used in the prevention work in order to combat the spread of
HIV/AIDS and STIs in Ethiopia is Social Marketing, a concept that adopts traditional
marketing techniques in order to obtain social change.
This inductive study explores how three various Ethiopian organizations are utilizing
Social Marketing in their HIV/AIDS and STI prevention work throughout Ethiopia, how the
concept can be used to achieve attitudinal- and behavioral change by people, as well as if the
organization’s various Social Marketing projects strive to provide vulnerable groups of the
Ethiopian society with empowerment, and if so, in what ways.
The empirical material was collected through six qualitative interviews and two focus
group discussions during an eight-week long stay in Ethiopia during March-May, 2012.
The findings of this study have been analyzed through theories about human behavior with
a focus on behavior change, as well as various definitions and concepts of empowerment.
The study’s result shows that Social Marketing can be utilized in several ways in the
HIV/AIDS and STI prevention work in Ethiopia to obtain attitudinal- and behavior changes,
for instance by using various commercial techniques, street campaigns,
information/education/behavioral change materials, as well as trainings, outreach work and
peer education, which aims to educate people about HIV/AIDS, STIs, condoms and condom
use.
The organization’s joint Social Marketing project “Wise Up-program” includes Drop In
Centers and Cooperative Activity for sex workers. The findings of this essay shows that these
projects do strive to provide vulnerable groups of the Ethiopian society with empowerment,
psychologically as well as economically.

Key words: Ethiopia, Social Marketing, HIV/AIDS, Sexually Transmitted Infections, STIs,
Prevention work, Female sex workers, Condom use, Empowerment

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Outline
The outline for this study is structured as follows,
The preface aims to introduce this essays topic as well as presenting my problem
statement, the purpose of this essay, its questions at issue and delimitations.
Next chapter, previous research, refers to provide an understanding of the concept Social
Marketing, how it can be utilized in the public health field, in developing contexts and in
HIV/AIDS and STI prevention work. This chapter also includes a section, which describes
how Social Marketing can be utilized in HIV/AIDS and STI prevention work targeting sex
workers. The previous research chapter ends with an overview of the HIV/AIDS and STI
situation in Ethiopia as well as some words about the Social Marketing that is being
conducted throughout the country.
This is followed by a presentation of this study’s theoretical framework and the choice of
my theoretical focus, related to the study, is being discussed. After this follows a section
where the various theoretical concepts, terms and definition, which underlies this study’s
analyzing chapters, are presented.
The next chapter describes how this study has been conducted by a presentation of what
various methods that have been used in order to answer this study’s research questions. This
chapter also contains a part of methodological considerations where the study’s validity and
reliability, as well as ethical issues with this study, are being discussed.
The methodology chapter is followed by the essay’s findings and analysis. These are
presented in two themes, which are related to the study’s two research questions.
The first theme aims to give a depiction on how Social Marketing can be used to affect
people's attitudes and behaviors in order to decrease the spread of HIV/AIDS and STIs in
Ethiopia. The empirical material in this section comes from six qualitative interviews, which
have been conducted during the study.
The second theme aims to answer if various Social Marketing projects strive to provide
vulnerable groups of the Ethiopian society with empowerment, and if so, in what ways. The
empirical material that is presented in this section comes from the same qualitative interviews
as in the first theme and two focus group discussions that have been performed during the
work with this essay.
Both themes ends with an analyze section where the findings are analyzed and discussed
under various sub headings based on the study’s theoretical framework.
Finally, this essay’s conclusions is presented and discussed followed by a final discussion,
which aims to summarize and conclude the study.

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Table of contents
Table of contents ............................................................................................................................. 5

Prologue ............................................................................................................................................. 9

Preface ............................................................................................................................................. 10

Problem statement ...................................................................................................................... 12

Purpose ...................................................................................................................................................... 12
Questions at issue................................................................................................................................... 12
Delimitations ........................................................................................................................................... 12

Previous research ........................................................................................................................ 13

Social Marketing ..................................................................................................................................... 13
The marketing mix ................................................................................................................................................ 14
Products..................................................................................................................................................................... 14
Price............................................................................................................................................................................. 15
Place ............................................................................................................................................................................ 15
Promotion ................................................................................................................................................................. 15
Social Marketing in developing countries...................................................................................... 16
Social Marketing in the HIV/AIDS and STI prevention work................................................... 17
Social Marketing targeting sex workers ......................................................................................... 21
The intervention package .................................................................................................................................. 21
Information and behavior change messages ............................................................................................. 22
Sexual health services.......................................................................................................................................... 23
Successful strategies............................................................................................................................................. 23
Use of informal contacts, key informants and “leaders” to access the population.................... 23
Peer health promotion and education.......................................................................................................... 24
Outreach activities ................................................................................................................................................ 24
Condom social marketing versus free condoms ...................................................................................... 24
HIV/AIDS, STIs and Social Marketing in Ethiopia........................................................................ 25

Theoretical framework .............................................................................................................. 26

Behavioral change and empowerment in this study.............................................................................. 26
Theories about human behavior‐ and attitudinal change.................................................................... 27
The eight principles............................................................................................................................... 27
Social cognitive theory.......................................................................................................................... 28
Triadic Reciprocal Determinism ..................................................................................................................... 28
Empowerment ......................................................................................................................................... 29

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 What is empowerment?...................................................................................................................................... 29
Individual empowerment, psychological and political empowerment.......................................... 29
Locus of control ...................................................................................................................................................... 30
Self‐efficacy .............................................................................................................................................................. 30
Empowerment through choice ........................................................................................................................ 31
Empowerment in poor contexts...................................................................................................................... 31

Methodology .................................................................................................................................. 31
Literature search .................................................................................................................................... 32
Research approach ................................................................................................................................ 32
Sampling .................................................................................................................................................... 33
Timret Le Hiwot Ethiopia................................................................................................................................... 34
DKT Ethiopia............................................................................................................................................................ 34
NIKAT Women association................................................................................................................................ 34
Clarification of the relation between the three various organizations .......................................... 34
Interview informants ........................................................................................................................................... 35
Focus groups............................................................................................................................................................ 35
Implementation ...................................................................................................................................... 35
Interview guide establishment ........................................................................................................................ 35
Implementation of interviews.......................................................................................................................... 35
Preparation and implementation of focus groups interviews ........................................................... 36
Methodological considerations ......................................................................................................... 37
Analysis process..................................................................................................................................................... 37
Validity and reliability ......................................................................................................................................... 37
Conducting interviews through interpretation ........................................................................................ 39
Ethical considerations ......................................................................................................................................... 39
Ethical issues with Social Marketing ............................................................................................................. 40
Conducting research in a developing context ........................................................................................... 40

Findings and analysis ................................................................................................................. 41

How the findings will be presented.................................................................................................. 41
Theme one ................................................................................................................................................................ 41
Theme two ................................................................................................................................................................ 42
Findings, theme one............................................................................................................................... 42
What............................................................................................................................................................ 42
Increase awareness about HIV/AIDS, STIs and condom use, to affect people’s attitudes and
behaviors................................................................................................................................................................... 42

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 How ............................................................................................................................................................. 43
Target.......................................................................................................................................................................... 43
WISE UP PROGRAM .............................................................................................................................................. 44
Drop In Centers for female sex workers...................................................................................................... 44
Out reach work, trainings and peer education ......................................................................................... 45
Distribute, sell and avail condoms ................................................................................................................. 47
Information/Education/Communication/Behavioral change accessories – IECB materials
....................................................................................................................................................................................... 48
Edutainment – combining two important incentives ............................................................................ 49
Campaigns, condom demonstration, media and other creative tools ............................................ 49
Analysis, theme one ............................................................................................................................... 51
Promotion of beneficial behavior ................................................................................................................... 52
Provision of knowledge to enable behavioral change ........................................................................... 55
Directly and indirectly environmental impact.......................................................................................... 56
Findings, theme two .............................................................................................................................. 58
Knowledge ................................................................................................................................................ 59
HIV/AIDS, STIs and transmission awareness............................................................................................ 59
Negotiation ‐ client communication techniques and skills for female sex workers ................. 61
Economic empowerment ..................................................................................................................... 62
Sex workers cooperatives .................................................................................................................................. 62
Income generating activities............................................................................................................................. 62
Engaging female sex workers in distributing and selling condoms ................................................ 65
A protecting home ................................................................................................................................................. 66
A voluntarily exit out from sex work and referral activity .................................................................. 66
Analysis, theme two ............................................................................................................................... 67
Influence and control the environment – from a passive to an active state ................................ 68
Ability to achieve increased self‐determintation..................................................................................... 69
Volontarily approach – a way to increase the sense of choice........................................................... 71
Conclusions and discussion ................................................................................................................ 72
Epilogue ..................................................................................................................................................... 76

Reference list................................................................................................................................. 78
Electronic references ........................................................................................................................................... 78
Web pages................................................................................................................................................................. 80
Sections of the Swedish law .............................................................................................................................. 80

Appendix ......................................................................................................................................... 81

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Appendix 1 ‐ Consent form................................................................................................................................ 81
Appendix 2 ‐ Invitation to focus group discussion (English version)............................................. 82
Appendix 3 ‐ Interview guide, qualitative interviews ........................................................................... 83
Appendix 4 ‐ Interview guide, focus group discussions (English version)................................... 88
Appendix 5 ‐ Definition of terms..................................................................................................................... 89

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Prologue
This essay is a Minor Field Study essay, written within the field of development questions
and social work. The work will keep a considerable focus on how the concept Social
Marketing can be used in the prevention work against the spread of HIV/AIDS and Sexually
transmitted infections in Ethiopia, a marketing technique that can be utilized to attain social
change in various ways.
Since marketing and social work can be considered as two very separated and dissimilar
disciplines, I want to define the term social work in order to in the end of this work discuss
how the two disciplines possibly can relate to each other.
According to International Federation of Social Workers, social work is defined as the
following,
The social work profession promotes social change, problem solving in human relationships and
the empowerment and liberation of people to enhance well-being. Utilizing theories of human
behavior and social systems, social work intervenes at the points where people interact with their
environments. Principles of human rights and social justice are fundamental to social work.
Social work in its various forms addresses the multiple, complex transactions between people and
their environments. Its mission is to enable all people to develop their full potential, enrich their
lives, and prevent dysfunction. Professional social work is focused on problem solving and
change. As such, social workers are change agents in society and in the lives of the individuals,
families and communities they serve. Social work is an interrelated system of values, theory and
practice.1

1 http://ifsw.org/policies/definition‐of‐social‐work/

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Preface
In 2000, the United Nations defined eight Millennium Development Goals, MDGs, in order to
within 15 years end poverty, hunger, spread of diseases, get better education for children,
better survival odds for infants and their mothers, equal rights for women and healthier
environments2.
MDG 6 is to “combat HIV/AIDS, malaria and other diseases”. In 2009, 33 million people
in the world were living with HIV (United Nations, 2011, p. 36). According to UNAIDS,
prevention programs for combating HIV do work. Their global AIDS epidemic report from
2010 confirms that the decreasing rates of new HIV infections during the last ten years “is
clearly linked with changes in behavior and social norms together with increased knowledge
of HIV” (UNAIDS, 2010, p. 5). Still, it’s a pressing global health priority to invigorating the
HIV prevention (ibid.).
Of all HIV infected people in the world, 68% are living in Sub-Saharan Africa (Bogale,
Boer & Seydel, 2010, p. 2). The amount of HIV-transmitted in sub-Saharan Africa is
decreasing but the region is still the worst affected (Federal HIV/AIDS Prevention and
Control Office, 2010, p. 2).
Ethiopia is part of Sub-Saharan Africa and it’s located in east Africa with a population of
almost 94 million people.3 The country is divided in nine independent and self-governing
regions and two cities.
Out of the population, 40 to 45 percent are Orthodox Christians and 45 percent are Muslims.
In addition to this there are Jews, Catholics, Animists etcetera (Chakraborty, Taha &
Vaillancourt, 2005, p. 2).
Ethiopia is the oldest independent country of Africa, since it never was colonized, except an
occupation by Italy during 1936-1941.
The Ethiopian society is hierarchical and complex and ethnical deviation and tension has
formed the country’s history and persists to impact politics and the lives of the Ethiopians
(ibid.).
Ethiopia is one of the worst HIV/AIDS affected countries in Africa with a number of
1,116,216 infected persons in 2009 (Federal HIV/AIDS Prevention and Control Office, 2010,
p. 2). Knowledge about reducing risks of getting HIV/AIDS through condom use during

2 http://mdgs.un.org/unsd/mdg/Host.aspx?Content=Indicators/About.htm
3 http://www.indexmundi.com/ethiopia/demographics_profile.html

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sexual intercourse is low, 47% of the women and 66% of the men aged 15-24 (United
Nations, 2011, p. 38).
The first step to avoid the infections is cognizance about how HIV/AIDS and STIs, are
spread (ibid.). One of the interventions for reaching this in Ethiopia is Social Marketing,
which is a marketing technique that adopts traditional commercial techniques to reach social
goals. Social Marketing strives to make needed products, such as contraceptives, affordable
and available for people, as well as promoting healthier behavior (UNAIDS, 1998, p. 3).
Some of the several behavioral risk factors that push the HIV/AIDS and STI epidemic in
Ethiopia are inconsistent and low condom use as well as low care seeking behaviors for STIs
although repeated episodes of infections (Federal HIV/AIDS Prevention and Control Office,
2010, p. 4).
Due to these facts and Ethiopia’s high rates of HIV/AIDS and STIs, as well as the request
of intensified prevention work, it’s of interest to examine how the Social Marketing concept
can be exploited and useful in receiving social change in terms of halting or ending the spread
of these infections.
As a social worker, using the Social Marketing concept with its creative tools within the
HIV/AIDS and STI prevention work in a developing context caught my interest and raised
questions concerning how it can be utilized to affect the prevalence and spread of HIV/AIDS
and STIs.
The main focus for this study is how attitudes and behaviors can be influenced through
Social Marketing and result in positive effects on the HIV/AIDS and STI prevalence and
spread in Ethiopia. Social and behavioral change is central within the field social change work
and social work. Similar theoretical methods and reasoning that exist within social work are
used and conducted also by other professions in various contexts. As well as behavioral
scientists, psychologists and professionals within health care, social marketers are one of the
professions that conduct social change work based on theories from the social work field.
Even though it’s stated that various methods in the prevention work against the spread of
HIV/AIDS and STIs do work, the infections continue to spread. It’s of interest to examine
what methods that are being used in order to create a critical discussion about which
techniques that might be of more or less success in combating the spread of HIV/AIDS and
STIs. This is especially of interest in a country and context as Ethiopia where the HIV/AIDS
and STI rates are high, but where the prevention work also possibly has been of success
according to that the amount of infected is decreasing.

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Problem statement
The prevalence and further spread of HIV/AIDS and other STIs is a global problem,
particularly in developing contexts like Ethiopia, where the transmission rates are high. In
Ethiopia, comprehensive knowledge and awareness about how the infections are transmitted,
as well as how to protect one from getting transmitted, is inadequate in many areas.
There exists uncertainty of what is affecting the efficiency of various prevention methods.
Factors that may have impact on the efficacy and results of the HIV/AIDS and STI prevention
work throughout the country are religious groups and communities, which can hamper some
of the HIV/AIDS prevention work that contradicts with their way of addressing and counter
the HIV/AIDS and STI problem.
Various methods that aim to combat the spread of HIV/AIDS and STIs have been
conducted for years in Ethiopia, still the transmission of the infections proceeds. Research
shows that there is an alarming need of intensifying the prevention work in order to halt and
combat the spread of HIV/AIDS and other STIs.

Purpose
The essay aims to examine how Social Marketing can be utilized in the prevention work
against the spread of HIV/AIDS and STIs in Ethiopia in order to impact people’s attitudes and
behaviors. The study also refers to investigate if various Social Marketing projects related to
the HIV/AIDS and STI prevention work in Ethiopia strive to provide vulnerable people with
empowerment, and if so, in what ways.

Questions at issue
- In what ways can Social Marketing be used to affect people's attitudes and behaviors
in order to halt the spread of HIV/AIDS and Sexually Transmitted Infections in
Ethiopia?
- Do various Social Marketing projects in the prevention work against the spread of
HIV/AIDS and Sexually Transmitted Infections in Ethiopia strive to provide
vulnerable people with empowerment? If so, in what ways?

Delimitations
As a result of the scope of this study, I don’t intend to give a complete picture of how Social
Marketing is being used in the prevention work against the spread of HIV/AIDS and STIs
throughout Ethiopia. This work will keep its focus on how three Ethiopian organizations are
using Social Marketing in their prevention work against the spread of HIV/AIDS and STIs.

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 The study puts it focus on how HIV/AIDS can transmit through sexual intercourse. Other
possible ways that the infection can be spread are not included.
The “various social marketing projects” that I refer to in the second research question of
this essay, are the projects that the organizations that participated in this study conduct in their
work.
There exist various vulnerable groups in the Ethiopian society. This study puts its main
focus at one of these groups, female sex workers.

Previous research
Social Marketing
Marketing and social science are seen as the two parents of Social Marketing. These two
distinct disciplines have converged to inform the 21st century’s Social Marketing. Philip
Kotler and Gerald Zaltman were the ones who first used the term Social Marketing in their
article `Social Marketing: an approach to planned social change´, 1971. They discussed how
commercial marketing principles could be applied in social, health and quality-of-life issues.
The article offered a definition of Social Marketing:
Social Marketing is the design, implementation, and control of programs calculated to influence the
acceptability of social ideas and involving considerations of product planning, pricing, communication,
distribution, and marketing research (French, Blair-Stevens, McVey & Merritt, 2010, pp.20-23).
After this definition of Social Marketing, several additionally definitions have been
formulated. Jeff French et al. (2010) developed a definition saying “Social Marketing is the
systematic application of marketing alongside other concepts and techniques, to achieve
specific behavioral goals for social goods” (French, Merritt & Reynolds, 2011, p. 13).
UNAIDS is writing that,

“Social Marketing” is the adaption of commercial marketing techniques to social goals. Using
traditional commercial marketing techniques, Social Marketing makes needed products available and
affordable to low-income people, while encouraging the adoption of healthier behavior (UNAIDS,
1998, p. 3).

Behavioral change is the main focus in defining Social Marketing. Commercial marketing
is measuring success in terms of profitability and sales, while social marketers keep their
concentration on their consumer’s behaviors. Andreasen describes the difference by stating
that for social marketers “consumer behavior is the bottom line” (Hastings, MacFadyen &
Andersson, 2000, p. 47).
This emphasizing on behavior change is also a central component in varied written Social
Marketing definitions. Kirby’s definition of Social Marketing is “a program planning process

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which promotes voluntarily behavior change based on building beneficial exchange
relationships with a target audience for the benefit of society” (ibid.). Schwartz defines Social
Marketing similarly to Kirby, “a large-scale program planning process designed to influence
the voluntary behavior of a specific audience segment to achieve a social rather than a
financial objective…” (ibid.). These behavioral change centered definitions helps to focus the
significance on behavioral change as a way of evaluate whether Social Marketing is bringing
any achievements or not (ibid., pp. 47-48).
The emphasis on influencing human behaviors through Social Marketing comes from the
desire of improving health, protecting the environment, preventing injury etcetera. To achieve
these goals, social marketers tries to sell behaviors, and having the target audience to modify
their behavior in one of the following four alternatives, “(a) accept a new behavior, (b) reject
a potential behavior, (c) modify a current behavior, or (d) abandon an old behavior” (Kotler,
Lee & Roberto, 2002, p. 5). Means of arranging behavioral change is knowledge and beliefs,
which the benchmark might be established for as well (ibid.).

The marketing mix

Using Social Marketing to bring social change requires social marketers to take notice on the
most fundamental principle of marketing, which is the need to conduct costumer orientation.
This is to define and understand what the aimed target know, do and believe. It’s desired to
identify the audience’s wants, needs, problems, believes, behaviors and concerns (ibid., p. 7).
Characterizing these different segments helps the marketer to establish comprehensible goals
and objectives, which is vital for accomplish a successful marketing program.
To influence the identified target, the social marketers use what is referred to as the “4Ps”,
“product, price, place, and promotion” - “The marketing mix” (ibid.). The marketing mix was
identified 1960 by Jerome McCarthy and it might be the most well known phrase within the
marketing field (French, et al., 2010, p. 194). When using the marketing mix it’s significant to
equilibrium all 4Ps (ibid.). Cheng, Kotler and Lee are writing that the 4Ps shouldn’t be seen
as isolated from each other, even though they should be considered as independent, and they
argue that “it is the synergy of the 4Ps that makes a truly successful Social Marketing
campaign possible” (Cheng, Kotler & Lee, 2011, p. 21).

Products
“Your product is what your selling: the desired behavior and the associated benefits of that
behavior” (French et al., 2010, p. 194). Products, by this mean, are generally insubstantial,
rather than physical, like feeling different or changing behavior (ibid.). Tangible products are

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produced to support and ease the behavioral change that the target groups are aimed to go
through (ibid.).
The product-P can be seen as it includes three various parts; core product, actual product
and augmented product. The core product includes the advantage that the targets will
anticipate or experience in return for adopting the behavior that the social marketers promote.
The behavior that is desired in a Social Marketing program is here called the actual product.
The things and/or services that will be promoted and offered the target audience are the
augmented product (Cheng et al., 2011, p. 22).

Price
The price, cost and barriers that the target audience relates with espousing a new behavior, is
the second of the 4Ps. It can be actually monetary costs, but also emotional, physical and time
costs. Changing behavior must have greater profits than costs (French et al., 2010, pp. 195-
196).

Place
This P describes the place where the desired behavior of the target audience will be
performed, but also where the target can obtain and receive related actual objects and services
(ibid., p. 198). French means, “It’s important to consider where the target audience should
receive the product or service and to make this as convenient and pleasant as possible”. (ibid.,
p. 195).

Promotion
Promotion is the way to reach the target audience with information about the product.
Through promotion, the target will be informed about the benefits of the product, its value
and where it’s available (ibid., p. 200).
The information and messages that aims to be promoted determine what the Social
Marketing campaign’s wishes its target to know, believe and do, and this is delivered to the
audience through various communication channels. Examples of diverse communication
channels are personal selling, word of mouth, advertising, public relations and events. Varied
online and offline media channels that can be used for promotion are Web sites, blogs,
podcasts. tweets, newspapers, radio, television, billboards and kiosks (Cheng et al., 2011, p.
23).
Cheng, Kotler and Lee note that the communication with the target audience should be
more interactive. When it comes to what they call creative elements, they write, “Creative
elements translate the content of intended, desired messages info specific communication

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elements, which include copy, graphic images, and typeface for traditional print media, and
interactive features and audio and/or video streams for online media” (ibid.).

Social Marketing in developing countries

“If you talk to a man in a language he understands, that goes to his head. If you talk to him in
his language, that goes to his heart” - Nelson Mandela (French et al., 2010, p. 319)
In the following, a definition of Social Marketing, which includes the context of
developing countries, some history of Social Marketing in developing countries, as well as
stories from the field where Social Marketing interventions have been used with successful
outcomes, will be presented.
Social Marketing is the use of commercial marketing techniques to achieve a social objective. Social
marketers combine product, price, and promotion to maximize product use by specific population
groups. In the health arena, Social Marketing programs in the developing world traditionally have
focused on increasing the availability and use of health products, such as contraceptives or insecticide-
treated nets (Lefebvre, 2011, p. 55).
Over the past 40 years, Social Marketing has evolved on two various autonomous tracks,
which are equivalent to the contexts where Social Marketing was developed. For one, Social
Marketing was primary and in its earliest used to foster the usage of different health-related
services and products in developing countries. Secondly, Social Marketing was used in the
developed context to decrease different disease behavioral risk factors (ibid., p. 54).
Donors and governments have increasingly used Social Marketing as a technique in
approaching reputable health issues in developing countries (UNAIDS, 1998, p. 3).
Today, Social Marketing is the main method that is being utilized by international
organizations to combat various health issues around the globe (Cheng et al., 2011, p. 86).
Social Marketing-styled interventions were actually introduced to developing countries
before Social Marketing as a term was coined. The World Health Organization (WHO) was
sponsoring international development initiatives as early as in the 1960s. The World Bank
brought family-planning projects to Sri Lanka and oral rehydration initiatives were brought to
Africa (French et al., 2010, p. 22). The Nirodh condom project in India, 1967, is seen as the
first trial to “incorporate marketing practices of consumer research and segmentation,
branding, advertising and promotion, pricing and product distribution strategies … to generate
awareness, demand and use of contraceptive products and services “ (Lefebvre, 2011, p. 55).
The early Social Marketing interventions in the developing field partly incurred as a
response to the donor’s frustration about the clinic-based family planning service’s slow
movement (ibid.). Social Marketing was expanding and rapidly adopted of practitioners in the

16
maternal health and child survival field. Social Marketing was seen as a “ready-made tool”
for distributing behavioral change messages as well as being a method to prevent the
transmission of HIV when the epidemic occurred (ibid.).
One of the qualities of the Social Marketing concept is that it designs services and products
in order to meet the particular needs of deprived people. As mentioned above, Social
Marketing keeps a vast focus on selling behavior in order to achieve social change and social
goods. But what Social Marketing also is invented to do is availing various products. William
Smith is writing about the Social Marketing’s potential of accomplish this related to
disadvantaged groups,
• It package them (the products) so poor people can use them
• It distributes them in places so poor people can get them
• It prices them so that poor people can value them
• It advertises and educated poor people about why and how to use them (French et al., 2010, p.
319).
Other issues and difficulties that can occur and make Social Marketing interventions
needed in these areas are that various products can be infrequently and generic supplied,
limited numbers of different clinics but also that it’s often a lack of adequately educated staff
who can explain the proper use of various health products (UNAIDS, 1998, p. 3).

Social Marketing in the HIV/AIDS and STI prevention work

Social Marketing, used in the reproductive health and family planning field, has been major
around the world and the HIV/AIDS prevention is one of the areas, which have been given
significant observance. Social Marketing of products, especially oral rehydration, bed nets for
malaria protection and condoms for HIV prevention and family planning has generally been
conducted by setting heavily subsidized product prices (Lefebvre, 2011, p. 56).
According to The Global HIV Prevention Working Group (2007), people that are most at risk
of HIV infection have “little or no access to basic prevention tools” (ibid., p. 66) despite
obtainable prevention strategies (ibid.). Lefvebre writes in An integrative model for social
marketing that The Global HIV Prevention Working Group is stating the following alarming
information:

Despite what is known about HIV prevention and what works, only 9 per cent of risky sex acts
worldwide are undertaken while using a condom, and the global supply of condoms is millions
short of what is needed. Only 12 per cent of men and 10 per cent of women in the most heavily
affected countries of Sub-Saharan Africa know their HIV status. About 11 per cent of HIV-
infected pregnant women in low- and middle-income countries receive antiretroviral prophylaxis;
and prevention services reach only 9 per cent of men who have sex with men, 8 per cent of
injection drug users and under 20 per cent of sex workers (Lefvebre, 2011, p. 66).

17
Although that these cheerless figures are existent, Social Marketing still is an important
element in the prevention work against the spread of HIV/AIDS. Utilizing the Social
Marketing concept has been, and is, popular among donors and governments in developing
countries in combating the epidemic (UNAIDS, 1998, p. 3).
Social Marketing programs have reached high-risk groups and low-income inhabitants by
making condoms affordable, accessible and acceptable. Social Marketing is important in
contexts where the infrastructure is underfunded and undeveloped, since it is availing health
products as well as it’s striving for sustainable behavioral change (ibid.). Regarding
HIV/AIDS in developing countries, this could be the case in particular since awareness of
transmission and prevention might be low as a consequence of cultural norms, literacy levels,
and geography etcetera (ibid., p. 4).
Health products can often be found in commercial outlets. These products are usually sold
without promotion and for a cost only wealthy people can afford. Therefore, Social Marketing
programs that are availing condoms also for lower-income people are a vital and a central
incentive in the HIV/AIDS prevention work (ibid.).
The products are mainly sold, not given away for free. The motivation for this is that
market research has shown that consumers are valuing purchased products higher than if they
are received free of charge (ibid., p. 5).
Condom Social Marketing, CSM, is one part of the Social Marketing HIV prevention
approaches and its aim is to amplify the condom access and use, through marketing and
promotion against a specific target (USAID, 2011, p. 1).
USAID is stating that few evaluations have been done regarding CSM and its efficiency, as
well as the need of further, more vigorous, evaluation and research concerning CSM’s
effectiveness and impact on peoples behaviors on condom use (ibid., p. 3). Some research has
all though been conducted.
Results from a meta-analysis on condom use during last sex, conducted by USAID in
Mozambique, South Africa, Zambia, Cameroon and India, showed that people who had been
exposed to CSM “were approximately twice as likely to use a condom as those not exposed.
When restricted to those reporting sex with a causal partner, persons exposed to condom
social marketing were approximately three times as likely to report condom use at last sex
compared to those not exposed” (ibid., p. 2). These results were significant when studying the
overall condom use by people who’d been exposed to CSM. In summary, this study showed
that CSM programs made people twice as probable to use condoms in contrast to people who
had not been exposed for the program. All the program interventions that were included in the

18
study used mass media largely and community-based efforts like promotional events. As
supplement, the social marketers used peer education (ibid., p. 3).
A study on CSM and its impact on male worker’s condom use of Social Marketed
condoms in urban Zimbabwe showed that Population Services International’s Social
Marketing program on “Protector Plus” condoms resulted in a high prevalence in using Social
Marketed condoms, compared to commercial brands and free condoms (Meekers, 2001, pp.
1-3).
The Social Marketing initiative “Program H” has been used in the HIV prevention in order
to get young men to question traditional manhood norms and to take responsible for their
behaviors. The program has been utilized in 15 various countries in three different continents.
The initiative was developed to include young women as well, in order to have them taking
control over their reproductive and sexual health.
This Social Marketing program was tested in Mexico. Significant components that were
included in the program were, working with role models, peer support and skill training. Two
different cartoons were developed for the program, one for young men and one for young
women. These were dealing with issues such as challenges in becoming a man, first sexual
experience, intimate relationships and gender roles. In addition to this, various messages were
transmitted through billboards, postcards, posters, dances and radio spots. SSL International,
Durex condoms producers, created a branded condom for this specific Social Marketing
program; “Hora H” and these were distributed in shops and venues where condoms usually
not are found, which became a central element of the campaign. The campaign part of the
“Program H” was named “In the heat of the moment” after hearing young men saying
“Everybody knows you should use a condom, but in the heat of the moment…” This
campaign theme, combined with condom availability and the program’s media mix, passed
powerful messages to young men about respecting their partners, to practice protected, safer
sex and to avoid violence against women.
The evaluation of the “Program H” showed positive results in terms of increased condom
use. In one of the evaluated areas, the condom use, after participating in the “Program H”
changed from 58 % to 87 %. The program evaluation also showed a difference in attitudes
regarding gender roles and responsibility related to sex (Cheng et al., 2011, pp. 83-103).
In 2004, in the Indian state Rajasthan, Population Services International, PSI, lounged a
Social Marketing program in order to increase the use of emergency contraceptives, ECs
(ibid., pp. 330-331). The main target was unsterilized, married women and men, aged 15-34,

19
living in urban areas around Rajasthan that “intentionally or unintentionally” had unprotected
sex (ibid., p. 332).
The aim of the program was to increase the understanding and knowledge about EC pills,
why and when they can be used, where they could be found and that taking EC pills is not the
same thing as doing abortion. These messages where transmitted through print ads, billboards,
TV ads, radio, banners and posters at places where EC pills could be purchased, information
brochures and interpersonal communication etcetera. The various parts of the promotion
followed different themes, like using the same characters in the TV ads and at the printed
materials.
To evaluate this program, a baseline survey was made in the lounging of the project. The
results from this survey were followed up in 2006 in an end line survey, which was conducted
in order to evaluate the success of the program. This showed “a significant increase in EC
awareness and use, and substantial improvement in the key factors influencing the target
group’s ability and motivation to use EC” (Cheng et al., 2011, p. 342). For instance, the
number of people who had ever heard of ECs, increased from 5.9 % to 44.7 %.
One of the lessons that one could learn from this Social Marketing program was the
importance of the interpersonal outreach and communication elements. Having group
meetings for women where different issues about ECs could be discussed, as well as letting
men participate in interactive quizzes and games, created opportunities for the people to talk
and think about ECs and getting support in the various parts of their behavior change
processes (ibid., p. 343).
Another Social Marketing program that has been conducted in India in order to combat
HIV/AIDS was a campaign called BBC World Service Trust HIV/AIDS Campaign. The core
of this program was a concept, which is called edutainment, entertainment combined with
education.
The project was conducted by creating three various “HIV/AIDS-related health campaign
programs” (ibid., p. 344) that was shown on Indian national TV to create “behavioral change
communication” (ibid., p. 343), like promoting sexual health debating, condom use and
reduce of discrimination and stigma of HIV/AIDS infected people. The campaign also aimed
to spread knowledge and information about HIV transmission, how to prevent the infection
and what kind of treatment that is available for infected persons (ibid., p. 345).
The evaluation of these three various edutainment campaigns showed that they all together
had reached more than 200 million people in India between 2002 and 2007. A survey,
conducted to measure changes in attitudes, knowledge and sexually active men’s behaviors,

20
of people who had, and who had not been exposed to the Social Marketing program, showed
that the programs had huge impact on these indicators. “Data showed that a higher percentage
of those exposed to BBC WST programs became aware of different routes of HIV
transmission” (ibid., p. 350).
The assessment also showed that the people who’d been exposed to BBC WEST
campaigns changed their attitudes against people who are living with HIV/AIDS in a positive
way, that they stopped feeling embarrassed of talking about sexual health related problems
and contraceptives like condoms.
The greatest behavioral change that was observed was among sex buyers. The part of this
group that had been exposed to the TV campaign showed a notably high percentage in using
condoms consistently when visiting a sex worker (ibid., pp. 351-352).

Social Marketing targeting sex workers

The intervention package
Sex workers are seen as a high-risk and core group for the HIV/AIDS and STI transmission.
This is mainly because of their vast number of various sexual partners and high rates of
infection. Sex clients that have both commercial and non-commercial sexual partners are also
seen as a significant group in the transmission of HIV and STIs, since they are bringing the
transmission to the general population.
Vuylsteke and Jana write, in HIV/AIDS Prevention and Care in Resource-Constrained
Setting, that it doesn’t exist one, universal HIV prevention model towards sex workers, “The
content of the intervention package itself, and the strategies to deliver that package, have to be
adapted to different situations” (Lamptey & Gayle, 2001, p. 187).
Many HIV prevention projects towards this group discovered that the “intervention
packages” that have been most successful included three different key parts, “Information and
behavioral change messages, Condoms and other barriers methods and Sexual health
services” (ibid.). These intervention packages is best delivered to its target through various
strategies, such as peer education and health promotion, outreach activities, condom
distribution and Social Marketing, use of key informants, “leaders” and informal contacts to
population access, and sexual health service access (ibid., p. 188).
The evidence, regarding successful and effective interventions targeting sex workers are
increasing. These interventions have lead to decreased numbers of transmitted and reduced
the risks of getting transmitted. This was for instance shown in Abidjan, where the condom
use with the previous client increased from 63% to 91% between 1991-1997. In Thailand, the

21
“100 Percent Condom Program” among sex workers increased the condom use from 14% to
94% (ibid., p. 193).
In the following, a more specific overview of Vuylsteke and Jana’s “Intervention package”
and various strategies in working with HIV and STI prevention among sex workers will be
presented.

Information and behavior change messages

The object of HIV/STI prevention targeting sex workers is to decrease the health risk,
especially the risk of getting transmitted of HIV or another STI. Sex workers in developing
countries have regularly high fundamental knowledge about HIV transmission and that
condoms can protect from getting transmitted. Out of this reason, behavior change messages
should focus on,
• Alternative safe sex practices
• Use and conservation of male and female condoms
• Lubricants
• Symptoms of STDs
• Health-seeking issues
• Clarification of misunderstandings about unsafe traditional practices or beliefs (Lamptey &
Gayle, 2001, p.195).
Vuylsteke and Jana claim, “Creative tools can be helpful in conveying information and
behavior change messages”. Various creative tools that can be used in prevention projects
towards sex workers are comic strips, videos, pictorial flip charts and audio etcetera.
In Brazil, female sex worker’s questions regarding HIV and STIs were gathered and
compiled into a brochure, which then was distributed among sex workers (ibid.).
To put various prevention messages into practice, enhancing skills related to partner
negotiation and condom use are necessary. Alternative techniques for putting on condoms and
strategies to decrease unintentional or intentional condom breakage should be included.
Negotiation and communication skills, in order to increase the condom use is also needed, as
well as targeting sex clients with information and behavior change messages with the purpose
on decreasing misinformation, ignorance and condom resistance (ibid.).

Condoms and other barrier methods

Currently, the merely widely available and effective method for HIV/STI prevention is male
condom. To receive a successful preventative behavior among sex workers, condom access
therefore is vital. Yet, the use of condom highly relies on the male sex partner’s collaboration.
On behalf of this reason, methods that are effective and under the woman’s control is

22
desirable, to lessen risks for transmission and give them the ability to protect themselves
(ibid., p. 196).
That providing sex workers with alternative methods to protect themselves can decrease
the STI rate was shown in Thailand when a group of female sex workers were given the
alternative to use female condoms if/when a client declined to use condom. The STI rate in
this group decreased with 24% and the number of unprotected sexual acts decreased with
17%. These results indicate that providing sex workers with alternative protection methods
might bring improved protection from getting transmitted with HIV or other STIs (ibid.).

Sexual health services

The third, and last key part of the intervention package is providing sex workers with sexual
health services. Having a STI increases the risk of getting transmitted of HIV/AIDS. This has
made STI care a significant part of HIV prevention. STI treatment carries the possibility to
decrease the HIV transmission rates as well as bringing health benefits to the target (ibid.).
Vuylsteke and Jana state that using these three components in the HIV and STI prevention
work among sex workers “will result in a better, more effective HIV prevention intervention”
(ibid., p. 198).
Even though a condom Social Marketing program targeting high-risk women were
introduced to a community in South Africa, the sales of condoms remained low. The reason
for this, according to the targeted women, was that they were “tired of receiving condom
messages while other health issues were ignored” (ibid.). When services for STIs were
obtainable, the condom use got intensified (ibid.).
A STI control program in Peru did not include the behavioral and condom use components
adequately and was therefore not insufficient (ibid.). This points out the significance of
combining the three components in prevention programs.

Successful strategies
As stated above, the intervention package can be delivered to its target through various
strategies. These will be presented in the following.

Use of informal contacts, key informants and “leaders” to access the population
This target, sex workers, can, out of several reasons, be a group that are complicated to reach,
but not impossible. According to Vuylsteke and Jana, the primary entry to the community of
sex workers should be done through key informants and informal contacts and they mention
an example from Family Health International’s AIDS Control and Prevention (AIDSCAP)
Project in Senegal where clandestine sex workers were reached through registered sex

23
workers (ibid.).
Sex worker clients should be reached in ways that are used to reach the general sexual
active male population, which is through billboards, Social Marketing, mass media and health
services (ibid.).

Peer health promotion and education

Using peer educators in order to reach a target audience with messages concerning condoms
and behavioral change has been considered as an effectual method.

Peer education involves the sharing of information about attitudes and behavior among same-
community members. In the context of sex work, peer health educators are persons who have
worked or are still active as sex workers and are thus able to communicate more easily with their
peers (Lamptey & Gayle, 2001, p. 199).
In Zimbabwe, peer educators were requited and trained in HIV and STI information,
condom promotion, community mobilization and in educational- and counseling techniques
during three hours every week for one year.
In Kenya, peer educators got in charge for one group of peers that all became STI and
AIDS educators, distributers and promoters of condoms (ibid.).

Outreach activities
Services and activities that are brought to sex workers and their clients are called outreach
activities. Using outreach activities to spread behavioral change messages can be conducted
through education sessions for groups, or face-to face interviews, in various meeting places,
venues or workplaces.
In Madagascar, a fieldworker team visited a sex worker area twice a week at night in order
to distribute condoms, hand out free tickets for STI testing and discuss HIV prevention.
In the Dominican Republic, provocative theatre was used in one of AIDSCAP’s projects.
The theatre was performed in bars, brothels and active, busy commercial sex areas (ibid.).

Condom social marketing versus free condoms

One of the most victorious parts of HIV prevention in developing countries is Social
Marketing of condoms. Condoms should be accessible, affordable and continuously
promoted. It’s usually more sustainable selling, or Social Marketing, condoms for a
subsidized price, rather than giving them away for free (ibid., p. 200).
By using non-traditional outlets around sex worker areas, the availability of condoms
increases. To achieve the highest condom availability, social marketers should use multiple
approaches such as targeted distribution, community-based distribution programs, village-
stores, pharmacies, commercial outlets and health facilities (ibid.).

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HIV/AIDS, STIs and Social Marketing in Ethiopia
Ethiopia is one of the countries where the HIV/AIDS epidemic is most advanced and the
country is considered as being particularly at risk (Parliamentary Office of Science and
Technology, 2003, p. 2). HIV was recognized at the first time in the mid 1980s and the first
two AIDS cases were reported in 1986. During the mid 1990s the epidemic reached its peak.
Since 2000, the epidemic has stabilized in rural areas and declined in urban areas.
In 2009, 1,116,216 adults were living with HIV/AIDS in Ethiopia, which is a prevalence of
2.3 percent. The same year 44,751 people were reported dead due to AIDS (Federal
HIV/AIDS Prevention and Control Office, 2010, p. 2). In 2009, the HIV prevalence among
men was 1.8%, compared with women, where the prevalence was about 2.8% (ibid., p. 3).
Power imbalance, gender, socio-economic status, rape and early marriage are factors that are
related to the differences in the HIV prevalence between men and women (Bogale, Boer,
Seydel, 2010, p. 2).
The urban areas of Ethiopia have a higher prevalence of HIV, than the rural areas. It has
been observed that the HIV virus is spreading from the urban areas to the rural communities
through visitors who have unsafe sexual contacts while visiting urban parts of the country
(ibid.).
Several studies on Ethiopia and Africa are presenting results saying that the risk of getting
transmitted of HIV and STIs increases if a person has many sexual partners or if the person is
unfaithful to his or her partner. What also has been argued in various studies is that using
condom during sex with a “higher risk-partner” can decrease the risk of getting infected by
HIV (Govindasamy, Hong, Mishra, 2008, p. 1).
The various groups that are considered as “high-risk” or “Most-at-Risk Population
Groups” in Ethiopia are female sex workers, long distance drivers, migrant workers,
discordant couples and uniformed forces (Federal HIV/AIDS Prevention and Control Office,
2010, p. 4).
Some of the several behavioral risk factors that push the HIV/AIDS and STI epidemic in
Ethiopia are inconsistent and low condom use and low care seeking behaviors for STIs
although repeated episodes of infections (ibid.).
According to the Federal HIV/AIDS Prevention and Control Office the vulnerability factors
that drive the epidemic are, “lack of adequate knowledge and skills to protect one-self, socio-
cultural norms, inaccessible and inadequate basic HIV service coverage, including
information and education, poverty and gender inequality” (ibid. p. 5).

25
 The Federal HIV/AIDS Prevention and Control Office states that to be able to reach MDG
6 by 2015, “there is a pressing need to intensify HIV Prevention” (ibid., p. 14).
In 2009, a National Prevention Summit were held for key stakeholders and there was
consensus concerning reinforcing the HIV prevention activities and intensifying efforts and
interventions towards MARPs (Booth & Ghebreyesus, 2010, p. 6).
The main Social Marketing organization in Ethiopia is DKT Ethiopia. The organization
has conducted HIV/AIDS and STI prevention work and family planning through Social
Marketing of contraceptives since 1990.4 In 2010, DKT Ethiopia sold more than 85 million
social marketed condoms for HIV prevention and their family planning reached about 2.5
million couples. DKT Ethiopia is working in close partnership with the Ethiopian government
and of all modern contraceptive methods in the country; DKT Ethiopia provides an estimated
57 percent of them (DKT Annual Report, 2011, p. 4).

Theoretical framework
Behavioral change and empowerment in this study
The theoretical focus for this work is set on theoretical terms and concept within the field
human behavior, but also on various perspectives of empowerment. According to me, these
various terms and concepts could serve as a well foundation to enable a satisfying analysis of
this work’s results.
This study does not offer empirical material of which it’s possible to draw any conclusions
concerning if Social Marketing actually do have an impact on the HIV/AIDS and STI
prevalence in Ethiopia. The collected material do offer a picture of how Social Marketing can
be used in the HIV/AIDS and STI prevention work as a tool to affect people’s attitudes and
behaviors, as well as if various Social Marketing projects strive to provide vulnerable people
with empowerment.
Even though it’s impossible to draw any factual conclusions about if the organizations that
are part of this study causes any changes in attitudes and behaviors, this work’s empirical
material, from its first research question, can be analyzed in terms of how likely it is that the
organizations will achieve attitudinal- and behavior change from their target through their
HIV/AIDS and STI prevention work, based on some of the principles that are written
regarding factors that have impact on human behavior and behavioral change. This issue is of
interest and importance to examine since ”it’s the way to the goal, that causes the goal”,
which in this study means that it’s how the HIV/AIDS and STI prevention work is conducted

4 http://www.dktethiopia.org/index.php?option=com_content&view=frontpage&Itemid=1

26
that impact and affect what various statistics of the transmission prevalence shows. For this
reason, it’s of interest to study how this prevention work can be conducted and implemented.
This study’s second research question refers to examine whether various Social Marketing
projects strive to provide vulnerable people of the Ethiopian society with empowerment, and
if so, in what ways. Since empowerment and a person’s experienced level of empowerment
can be complicated and complex to measure, the intent of this study’s second research
question is to explore if the empirical findings can be explained and understood based on
various theoretical perspective on empowerment. These perspectives are presented in the
second part of this chapter.

Theories about human behavior- and attitudinal change

There exist various theories about why people change behaviors and attitudes and about what
is needed to receive these changes. Social Marketing is developed out from several of these
theories, for instance social learning theory, transtheoretical (stages of change) model, health
believe model and social cognitive theory etcetera (French et al., 2010, p. 53).
These theories are also a central part of the work methodology in social work. One array of
social work theories within the field behavioral impact and change is cognitive behavioral
focused theories. These theories are of individualistic reformist nature and the main
techniques that are used within this area include social learning and “cognitive restructuring
of people’s opinion systems” (Payne, 2008, p. 179). Another part of this social work theory is
social learning techniques, like skill training and self-strengthening work (ibid., p. 180).
The main aim of social work based on behavioral science is that the people the social
workers are working with should exhibit more desired than undesired behaviors, in order to
be able to act in more appropriate ways that increases their ability to live a good life (ibid., pp.
189-190).

The eight principles

Backer writes that eight various principles regarding human behavioral change were
formulated by some of the world’s most famous psychologists during a “Theorist’s
workshop”, sponsored by the National Institute of Mental Health 1992. The eight principles
were developed out from “more than 100 years of behavioral science” (Becker, 2001, p. 2)
and aimed to define when people are more able/likely to change their behavior (ibid.).
As mentioned above, Social Marketing and achieving social change, is developed out from
a variety of psychology and sociology theories. Backer writes that the eight principles was
defined out from four of these behavior change theories; Fishbein’s Theory of Reasoned

27
Action, Bandura’s Social Cognitive Theory, Triandi’s Theory of Subjective Culture and
Interpersonal Relations, and Kanfer’s Theory of Self-Regulation and Self-Control (ibid.).
The eight principles defines various circumstances that have impact on when people are
more likely to change and adopt new behaviors, and they are formulated as the following,
1 - the person forms a strong positive intention, or makes a commitment, to perform the behavior
2 - there are no environmental constraints that make it impossible for the behavior to occur
3 - the person possesses the skills necessary to perform the behavior
4 - the person perceives that the advantages of performing the behavior outweigh the disadvantages
5 - the person perceives more normative pressure to perform the behavior than not to perform it
6 - the person believes that performance of the behavior is more consistent than inconsistent with his or
her self-image or that it does not violate personal standards
7 - the person's emotional reaction to performing the behavior is more positive than negative
8 - the person perceives that he or she has the ability to perform the behavior under a number of
different circumstances (Backer, 2001, p. 2).

Social cognitive theory

Triadic Reciprocal Determinism
Albert Bandura’s theory on behavioral change, called social cognitive theory, aims to explain
human behavior. In contradiction to many other theories where human behavior is
comprehend in terms of one-side determinism, Bandura means that human behavior should be
understood through a “model of causation involving triadic reciprocal determinism” (Vasta,
1992, p. 2). It’s the causational relationship between cognition, personal factors, behavioral
and environmental influences that interact with each other and affect human behavior.
One of the major links between these subsystems is the interplay between thought, affect
and action (ibid. p. 3). Self-perception, believes, intentions, expectations and goals forms and
direct a person’s behavior. Bandura means that people’s behaviors are affected of what they
believe, think and feel.
The interactive link between environmental influences and personal characteristics is
another of the causational relationships in Bandura’s model. This means that social influences
that passes information, which through teaching, modeling and social persuasion, activates
emotional effects, that develop and modify cognitive competencies, beliefs, emotional bents
and expectations, have impact on human behavior (ibid.).
The two-way influence between environment and behavior points out that behavior
changes environmental circumstances, and in turn, the behavior is changed by the
circumstances it creates. According to Bandura, the environment is not a constant essence that
individuals unavoidably are interfered by. He means that a person, through his or her

28
behavior, can affect if that person’s potential environment will become his or hers actual
environment or not. Out of this, a person is both a product and the creator of one’s
environment (ibid., p. 4).

Empowerment
What is empowerment?
‘Empowerment’ is a term that is used in many various contexts and in several fields, for
instance psychology, social work, education, development and feminist organizations. The
idea of empowerment has its roots in the social activist ideology that evolved in the USA
during the 1960s, as well as from the ideas about self-help during the 1970s (Lundberg &
Starrin, 1997, p. 9).
‘Power’ is the term that empowerment has its origin from, which can have the meanings
force or strength. Askheim is writing that empowerment, to gain strength and force, but also
power, can mean that a person or a group, who are powerless, gain strength that can give
them power to leave that powerlessness. This mobilization should give the people power to
counteract with what makes them powerless and through this, gain more influence in their
own lives (Askheim & Starrin, 2007, p. 18).
Starrin mentions a few definitions of empowerment in his attempt of explaining the term.
He writes that empowerment generally is referred to every process, which makes it possible
for people to own their lives, that empowerment refers to a decrease of dominating feelings of
powerlessness, and that a process that enables individuals to achieve self-determination and to
determine their own terms is empowerment (Lundberg & Starrin, 1997, pp. 12-13).

Individual empowerment, psychological and political empowerment

Environmental conditions have important influence on people’s personality structure.
Experiences and opportunities shape a person and of special significance is the capability of
decision-making and ability to take actions to reach goals. This capacity, or the lack of it,
form and impact people’s character and the level of how efficacious actors they will be in
their lives. Elisheva Sadan writes in Empowerment and Community Planning,
Empowerment is an interactive process which occurs between the individual and his environment
… The outcome of the process is skills, based on insights and abilities, the essential features of
which are a critical political consciousness, an ability to participate with others, a capacity to cope
with frustrations and to struggle for influence over the environment (Sadan, 1997, p. 75).
She writes that the process of empowerment is active, that events and circumstances
determines its form and that it’s people’s action from a passive to an active state that is the
essence of the process. Furthermore, the empowerment process provides an integration of
self-confidence and self-acceptance, political and social understanding as well as the

29
capability of taking control over resources in the environment and taking part in decision-
making (ibid., p. 76).
Sadan writes that empowerment is “a process of internal and external change” (ibid.). A
person’s belief in her capability in solving her own problems and making own decisions is the
internal process, while the external process is the ability to take actions and actualize
resources such as practical knowledge, information, capabilities and other skills that has been
received during the empowerment process. The internal change has been called psychological
empowerment and the external change, political empowerment. Pursuant to this,
psychological empowerment is present on a person’s level of perceptions and awareness,
whilst actual changes, which enable people to participate in decisions regarding their lives, is
the political empowerment. A person needs internal strength to achieve psychological
empowerment, but to receive political empowerment, environmental circumstances, which
will make it possible for the person to carry out new abilities, is required (ibid.).

Locus of control
One way of defining self-empowerment have been by means of psychological constructs.
Rotter (1966) aimed to define one of these constructs with his concept Locus of control,
which is a concept with an internal-external coherent unit. This means that a person, whose
locus of control is internal, inside the person, expects strength from him-/herself and
possesses intrinsic motivation. Out of these reasons, this person expects outcomes to be under
his/her own command.
Despite to this, the external person expects external conditions to have reinforcement on
his/her life.
Individual empowerment has been defined by the means of internal locus of control, while
the external locus of control has been defined as further existence of lack of power (ibid., p.
77).
Deci (1981) has written that individuals are trying to validate and exercise control over
external environmental conditions, because of their desire for assurance. Out of this, they are
susceptible to prefer, enjoy and proceed with activities that “provide them with opportunities
to make choices, to control their own outcomes, and to determine their own fates” (Chua &
Iyengar, 2006, p. 44).

Self-efficacy
Self-efficacy is another concept of self-empowerment as a psychological construct, which was
defined by Bandura (1989). It’s a cognitive concept and it’s an individual mechanism that is

30
central and ongoing, and it is affective and motivational processes that operate it. Self-
efficacy is about people’s perceived belief in their ability to change their life aspects and
control occurrences in their lives. Sadan writes the following regarding Bandura’s theory of
self-efficacy,
Studies indicate that a person’s belief in her ability to achieve outcomes is, among other things,
connected to her thinking patterns - to what extent they help or hinder her to realize goals. This
belief determines how a person will judge her situation, and influences the degree of motivation
that people mobilize and sustain in given tasks (Sadan, 1997, pp. 77-78).

Empowerment through choice

According to Chua and Iyengar, people can perceive control and personal agency by be given
the chance to choose. Richard deCharms (1968), an American psychologist, means that it’s
possible to hypostatize that a person will enshrine a behavior and the results of that behavior
if the person experiences that the behavior is derived from the person’s own choice. If a
person’s behavior is performed as an outcome from external factors, and not from own
choices, this behavior will be devalued.
Other psychologists have also claimed that a person’s inner motivation and experience of
personal control increases when that individual is provided with choices (Chua & Iyengar,
2006, pp. 43-44).

Empowerment in poor contexts

The World Bank defines empowerment, when it comes to poor people, as, “the expansion of
assets and capabilities of poor people to participate in, negotiate with, influence, control, and
hold accountable institutions that affect their lives” (Narayan, 2002, p. VI). They write that
empowerment, in its broader sense, is “the expansion of choice and action. It means
increasing one’s authority and control over the resources and decisions that affect one’s life”
(ibid., p.11).

Methodology
This is a Minor Field Study, which is sponsored by SIDA, The Swedish International
Development cooperation Agency. I received a scholarship from them, which enabled an
eight-week stay in Ethiopia, during March, April and May this year, 2012.
This chapter contains a description of how this study has been conducted and
methodological considerations that has been made during the work.

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Literature search
The moment I started to search after information about this work’s topic, Social Marketing
was a brand new phenomenon for me, which made me start from the very basic level in order
to understand the subject and its field.
The literature search for previous research, as well as my theoretical framework, has been
carried out through systematic searches on the Internet and various databases, mainly Google,
but also Google Scholar. The subject words I used to find information on the research field
was Social Marketing, Social Marketing in Ethiopia, Social Marketing in developing
countries, Condom Social Marketing, attitude change, behavioral change, HIV/AIDS and
STI's in Ethiopia, Sub Saharan Africa, social change, community change, empowerment,
Social Marketing and empowerment, Social Marketing and sex workers etcetera. The various
keywords changed during the work, depending on the works development.
In addition to Internet, I’ve used various Social Marketing literatures, as well as other
literature for the work’s methodology and theory parts.
This way of collecting information and facts was very useful for my work. It enabled an
orientation in the Social Marketing field, the work that has been done, research that has been
written etcetera.
The field of current research on Social Marketing in the work with HIV/AIDS and
Sexually Transmitted Infections in Ethiopia is quite limited. This required a broader approach
in my literature search, including other countries and continents as well as different kinds of
Social Marketing projects, which are focused on other aims than HIV/AIDS and STIs.
The literature search attracted interest and ideas for diverse focus in the field, which
influenced the study's focus and direction.

Research approach
This is an inductive study with a qualitative approach. Bryman (2002) means that qualitative
studies often are based on a research approach that keeps its focus on words, rather than
quantifiable figures (Bryman, 2002, p. 249). The purpose of my study was to gain
understanding of how Social Marketing can be used in the prevention work of HIV/AIDS and
STIs in Ethiopia, and if various Social Marketing projects aim to provide vulnerable groups
with empowerment, and if so, in what way. Out of this reason, a qualitative research approach
was more suitable for this study, rather than a quantitative.
In the qualitative research approach, qualitative interviews are used as a method in order to
collect empirical data. Dalen (2007) writes that the qualitative interview is a good method to

32
use when people’s own thoughts, experiences and feelings are desired (Dalen, 2007, p. 9).
This was what I wanted to receive through my empirical data collection; therefore I chose to
use qualitative interviews as my main method in my data collection.
I also wanted to receive experiences and information from the organization’s target,
regarding their perceptions of the organization’s work. Focus groups, or focused interviews,
are interviews where a group of informants get the chance to answer and discuss questions
that are relevant for them (Bryman, 2002, p. 127). Out of this reason, I thought that
conducting two focus group interviews would be a good complement to the qualitative
interviews in order to receive thoughts and experiences from the organization’s target.
The empirical data for the essay was collected in Addis Ababa, Hawassa and Debre Zeit in
Ethiopia, through six semi-structured interviews and two focus group interviews. I’ve also
visited numerous of the organization’s various projects around the country, mainly in Addis
Ababa, participated in a one-week training for the staff at Timret Le Hiwot Ethiopia and
NIKAT Women association, and in the Global congress on Public Health 2012 that was held
in Addis Abeba, which the organizations participated in. Finally I’ve observed the
organization’s Social Marketing work throughout Ethiopia during my stay and trips in the
country.

Sampling
In order answer this essay’s research questions I searched for organizations, which are
working with Social Marketing in Ethiopia, through Internet. It was during this part of my
work I chose to focus the essay on how Social Marketing is used in the prevention work
against HIV/AIDS and STIs in Ethiopia, since the organizations that I found clearly focuses
on that type of work.
I sent emails to nearly 25 various organizations, requesting if I could come visit their
activity. I received one answer from a person from an organization called Engender health,
who forwarded me and got me in contact with another organization, Timret Le Hiwot
Ethiopia, TLH Ethiopia, an organization that works with Social Marketing in Ethiopia. This
organization came to be the main, and the most important contact for my work.
TLH Ethiopia has served as my host organization as well as my help in getting in contact with
other relevant organizations for my work, DKT Ethiopia and NIKAT Women association,
organizations that also are using Social Marketing in their work against the spread of
HIV/AIDS and STIs in Ethiopia, which made them all of interest for my essay.

33
 I thought that using the multi stage technique, snowball sampling was the most suitable
technique to find my informants (Neuman, 2011, pp. 268-269). Bryman explains the snowball
sampling as a type of sampling where the scientist initially establish contact with people that
are relevant for her/his study and then uses these contacts to get in contact with other
appropriate informants (Bryman, 2002, p. 115). Since I didn’t have any contacts in Ethiopia,
this was the absolute most adequate way to collect my informants.
In the following, a short presentation of the three organizations, which are the
organizations the informants from the qualitative interviews are working at, will be made.

Timret Le Hiwot Ethiopia

Timret Le Hiwot Ethiopia is a non-governmental and non-profit organization that works
towards decreasing the occurrence of HIV/AIDS as well as lessen the socio-economic impact
of the infection throughout Ethiopia through Social Marketing. “Socio-economic network”,
“Income generating activities” and “Wise Up project” are three interrelated programs, which
are part of the organizations work (Timret Le Hiwot, Ethiopia, 2008, p. 6).

DKT Ethiopia
DKT Ethiopia is part of DKT International, which is a non-for-profit organization working
for providing affordable and safe alternatives for family planning and HIV prevention. DKT
is the leader in expanding and conducting Social Marketing that brings broad and cost-
effective impact. The organization has programs and offices in 18 various developing
countries throughout the world.

NIKAT Women association

NIKAT was established 2006 in Ethiopia by a group of female sex workers. It’s a local non-
governmental organization, which seeks to improve commercial sex worker and low-income
women’s life conditions through projects that aims to empower female sex workers in various
ways.5

Clarification of the relation between the three various organizations

Timret Le Hiwot Ethiopia, DKT Ethiopia and NIKAT Women association are three different
organizations, but they are all connected through various Social Marketing projects. Timret
Le Hiwot Ethiopia and NIKAT Women association are implementers of some of DKT’s
programs and projects and they are distributing and selling DKT’s various contraceptives as
well as using them in their activities.

5 http://www.nikatethiopia.com/

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Interview informants
The selection of all my interview informants at the organizations has been done based on their
professional titles and work areas at the organizations. I chose the persons who I assumed
would be able to provide me with valuable interview material related to my research
questions.
The interview informants in this study are the following,
The Social marketing program manager at Timret Le Hiwot Ethiopia,
The Wise Up program manager at Timret Le Hiwot Ethiopia,
A Drop In Center manager and outreach worker at Timret Le Hiwot Ethiopia,
The Senior Executive at DKT Ethiopia,
The Wise Up program manager at DKT Ethiopia,
The funder of NIKAT Women association.

Focus groups
During the work process I wanted to conduct a focus group interview with people from the
organization’s target. I thought it was of big value to receive the target’s experiences and
perceptions in their own words. Therefore, I organized two focus group discussions with four
women, ex- and current female sex workers, in both groups. One focus group discussion was
conducted in Addis Ababa, and one in Hawassa.

Implementation
Interview guide establishment
Dalen means that it’s needed to use an interview guide when qualitative interviews are about
to be conducted. Questions and themes that aim to answer the study’s research question
should be part of the interview guide (Dalen, 2007, p. 31).
I developed two various interview guides with approximated themes related to the essay’s
research questions. Out from this, I formulated a number of questions in order to obtain
saturation in my data after conducting the interviews. One guide was formulated for the six
qualitative interviews, and one was developed for the two focus group interviews. (See
appendix 9 & 10).

Implementation of interviews
Before I started the actual interviews, the informants were informed about me, the purpose for
my visit in Ethiopia, my study, as well as other important information regarding their
participation. This was done vocally, but also through a letter of consent, which each
informant got the chance to read and sign before the interview started.

35
 The prolonged ethylene of the interviews differed slightly, about one hour, up to one hour
and 45 minutes.
The interview with the funder of NIKAT Women association was conducted through an
interpreter, who translated my questions from English to Amharinya and the respondent’s
answers from Amharinya to English.
The letter of consent was also translated.

Preparation and implementation of focus groups interviews

Before conducting the first focus group interview I wrote an invitation letter, which was
translated from English to Amharinya. The invitation contained information about my study,
that the participation was voluntary, the approximate length of the interview, that the
participators wouldn’t be mentioned by name and that they would receive an amount of
money as a thank you etcetera. This letter was handed out to a number of female sex workers,
and ex sex workers, at one of TLH’s projects. The time and place was decided and
communicated through the same person who handed out the invitation.
The other focus group interview was conducted under more spontaneous circumstances
during my visit at one of TLH’s projects in Hawassa. All though, the participators in this
group were carefully informed about the study and under what conditions they chose to
participate.
Both focus group discussions were conducted through an interpreter in closed rooms,
where only the participators, the interpreter, and I, were present. Before starting the actual
discussion, the participators were given information about me, the reasons for my visit to
Ethiopia and the aim of the study and that the interview would be recorded. The interpreter
read the consent form for the participators in their mother language and after that the
participators were given the chance to give their approval to participate.
The focus group discussions were semi- structured. I asked my questions in English and
then the interpreter translated them to Amharinya. The participators answered and discussed
with each other in Amharinya and then the interpreter translated, what they’ve answered and
said, to me.
I didn’t follow my questionnaire from A to Z, but added and left some questions, depending
on the interviews development.

36
Methodological considerations
Analysis process
Dalen (2007) means that various analyses methods of qualitative data keep an interpretative
approach to the empirical material. One approach of qualitative data analysis, which I chose
to use in the analysis of my empirical material, is phenomenology. Phenomenology is an
approach, which implies that a scientist strives to “see” the same thing as the person the
scientist is trying to understand sees (Dalen, 2007, pp. 14-15).
Giorgi (1992, 1994) has developed a phenomenology analysis process that includes the
following in analyzing the empirical material; attempts to understand the material as whole,
findings of themes, which are being described and interpreted, and finally, a theoretical
interpretation of the material should be conducted (ibid., p. 15).
I chose to use Giorgi’s process in the analyzing of this work’s data. How this was
conducted is described in the following.
After conducting all the interviews and focus group discussions, all recordings from the
interviews were transcribed from the beginning till the end, word by word.
In the interviews where I used an interpreter, I first transcribed the interviews verbatim. In
some cases, some sentences had to be edited in order to make them understandable for the
readers. This was done with a great prudence, in order to not change the original sentences.
I also changed the interpreters interpretation from sayings like “the informant means that…”,
to “I (the informant) mean that”. This was done in order to make the answers sound like they
came directly from the informants.
After transcribing and editing all empirical material, I read through all the data, which was
about 150 written pages, and themed the findings in order to find answers on my research
questions.
Furthermore, I chose what various quotations that should be part of the essay’s result
chapter. Some of these quotations were edited due to language barriers in order to give
fairness to the informants and to facilitate the reading for the reader. The possible outcome
from this editing will be mentioned in the chapter “ethical considerations”.

Validity and reliability

Validity and reliability are two criteria that are used in order to measure the quality of
research. They are mainly used in quantitative research, and the use of them in evaluating
qualitative research has been questioned. Some authors have tried to formulate new criteria

37
that contain the same as validity and reliability, but in a way that are more suitable for
qualitative research (Bryman, 2002, pp. 257-258).
Guba and Lincoln have formulated two basic criteria for this, trustworthiness and
authenticity. Trustworthiness is then divided in to four sub criteria; Credibility, which
represents that the research has been conducted in accordance with exiting rules regarding
how it’s supposed to be done. It also includes that the researcher let the informants verify that
the researcher has understood the respondents correctly. Transferability involves that the
results in the study would be the same if the research were conducted ones again in another
context, another time. Dependability is equivalent to reliability and handles if a study contains
a description of how the study has been conducted. Confirmability means that the researcher
keeps an objective approach in the execution and the conclusions of the research (ibid., pp.
258-261).
In my opinion, this study keeps a high level of trustworthiness. Regarding the credibility,
I’ve followed various rules and guidelines regarding how research on this level is supposed to
be conducted, for instance by following the Swedish ethical council’s various requirements
for research but also by informing all respondents about the aim of the study as well as letting
them sign a consent form in order to confirm their participation.
I’ve only used literature that is written on a professional level, and I’ve kept a critical
approach towards the literature before deciding to use it in the paper.
I haven’t let all informants read the transcriptions from their interviews, which might affect
this essay’s level of trustworthiness. This was a conscious decision, since I considered the
time frame for the work of the essay as to insufficient. I conducted the transcribing of the
interviews very carefully but of course, some informant might think that I misunderstood
her/him and what she/he said.
Transferability is a complex criteria, especially in a qualitative study like mine, where it’s
people that serve as informants. It’s impossible to ensure that other informants in other
contexts would give the same answers as the informants in my study. What possibly could
give similar results, if the study would be conducted in another context, could be if the study
only included this essay’s first research question, since it’s a question of a more narrative
character.
The dependability of this study is ensured in this methodology chapter, where I describe
how this work has been carried out, from the beginning to the end. This is one way of
strengthen the reliability of this essay.

38
 I’ve tried to satisfy the criteria confirmability, through keeping an aware reasoning with
myself throughout the process. This has been a way for me to reveal any prejudices,
perceptions and beliefs about certain issues, but also help in staying objective among my
study during the work.
Guba en Lincoln’s criteria authenticity relates to what research politics consequences the
study might contribute and result in for the participators (ibid., p. 261). I don’t believe that my
essay will lead to any research politics consequences or have any direct impact on the
participators. Although, my essay might raise questions and issues, which possibly can result
in something that will have impact on the participators somehow.

Conducting interviews through interpretation

The two focus group discussions with the female sex workers and ex sex workers as well as
the interview with the funder of NIKAT Women association were as mentioned conducted
with interpreters since the informants don’t speak English.
Using interpreters in interviews can be very complicated, nor the least it can impact the
trustworthiness of the study, which has been discussed above. There are several reasons for
this. Some of the problems I encountered during the focus group discussions were that it
seemed difficult for the interpreter to successfully translate everything everyone said. A
discussion might be less floating if you interrupt those who are discussing, but this was
necessary at times to have translation on what was said in the discussions.
Another problem that I experienced was that the interpreter at times chose to translate what
she considered to be important, although I at several times explained the importance of
getting my questions accurately translated, and that all responses needed to be interpreted
correctly and entirely.

Ethical considerations
There are always ethical risks in conducting research, not least when it’s a qualitative research
that includes qualitative interviews and has its focus on people and their experiences. My
essay addresses a, in many ways, susceptible topic, which holds cultural differences, norms,
different attitudes and diverse perceptions of reality, which has been of paramount importance
to take into account during the entire work.
While this essay is a work that is written within a University College education at basic
level, it doesn’t obey under the Swedish law concerning ethics for science regarding humans,
(2003:460). But, I’ve responded to the Swedish ethical council's consent-, confidentiality-,
use and information requirements by having each interviewee to sign a consent form that

39
described the overall plan for the research, the purpose of the research, the methods that were
aimed to be used, the consequences and risks that the research could bring, who the principal
investigator is, that the participation in the research was voluntary and that the interviewee
had the right at any time to withdraw their participation.
I’ve chose to not write the names of the interview informants, but their professional titles. I
do understand that it will be possible for the readers to look up the names of the informants
that are mentioned by titles and organizations, but the interview informants have not been
promised to be anonymous in the essay, so hopefully that wouldn’t cause any problems.
Concerning the focus groups participators, one group was invited to the discussion through
a written invitation that was translated from English to Amharinya, while the other focus
group discussion was conducted more spontaneous. Yet, information about the essay’s
purpose and the participator’s involvement was very carefully passed through the interpreter.
As mentioned above, using interpreters can be problematic and it has an inevitably impact
on the communication between the scientist and the informants. I put extra time and accuracy
in the preparation with the interpreters, explaining the importance in having the participators
carefully informed about the study and that their participating was voluntarily etcetera, before
conducting the interviews.
As mentioned, some quotations in the essay have been edited in order to facilitate the
reading and to clarify what the informants are saying. There is a risk that this might have
affected the results and analysis of this work. To avoid this, the edits that have been made was
conducted carefully with respect for the informant’s original statements.

Ethical issues with Social Marketing

Social Marketing and its focus on changing attitudes and behaviors to achieve social change
can be seen as a complex concept. Who possesses mandate to define what are right or wrong
attitudes and behaviors? Social Marketing contains parts that somehow need to be raised to
decrease the risk that the use of the concept results in consequences that points out who’s
behaviors are right, and who’s are wrong. This risk is an aspect I’ve tried to take into account
during the work, during interviews and meetings with people as well as how I’ve talked and
written about the subject attitudinal- and behavior change related to Social Marketing.

Conducting research in a developing context

This heading was something I considered very important to add to this work. Coming from a,
what I like to call, well developed country as Sweden, to conduct research in Ethiopia, which
in many ways barely is comparable with Sweden, has been a great challenge in several ways.

40
 It’s needed to adopt a humble and compassionate approach without being disparaging and
assigning those you meet as victims. We, the West, have a lot to learn from developing
countries. This is important to stress and to emphasize. We are not the savior that knows what
are right and wrong, good or bad, for all countries or people. This is one of the things that
have become very clear for me during my time in Ethiopia.

Findings and analysis

In this chapter, the empirical findings that I received from the six conducted qualitative
interviews as well as the two conducted focus group discussions, will be presented and
analyzed.
The informants have been given abbreviations in order to facilitate the reading and will
presented as followed,
The Social marketing program manager at Timret Le Hiwot Ethiopia: TLH-SM.
The Wise Up program manager at Timret Le Hiwot Ethiopia: TLH-WU.
A Drop In Center manager and outreach worker at Timret Le Hiwot Ethiopia: TLH-DIC.
The Senior Executive at DKT Ethiopia: DKT-SE.
The Wise Up program manager at DKT Ethiopia: DKT-WU.
The funder of NIKAT Women association: NIKAT-FUN.
The two focus group discussions have been given the abbreviation FGDs.

How the findings will be presented

The essay’s findings are presented in two chapters, which are called “findings theme one” and
“findings theme two”.

Theme one
Theme one handles this essay’s first question at issue; “In what ways can Social Marketing be
used to affect people's attitudes and behaviors in order to halt the spread of HIV/AIDS and
Sexually Transmitted Infections in Ethiopia?”
The theme’s findings come from material, received from the six conducted interviews. The
informants have not been given equal space in the findings. The essay has taken different
directions and focus during the work, which have affected which respondents who have been
allocated the most space in the results sections.
Theme one is then divided into two new themes, which is called “what” and “how”.
“What” is the heading for the various organization’s aims and purposes, what they want to
receive with their prevention work against the spread of HIV/AIDS and STIs through Social
Marketing.

41
“How” is how and in what ways the organizations try to reach and fulfill their aims and
purposes.

Theme two
The essay’s second question at issue; “Do various Social Marketing projects in the
prevention work against the spread of HIV/AIDS and Sexually Transmitted Infections in
Ethiopia strive to provide vulnerable people with empowerment? If so, in what ways?” is
handled in theme two.
This theme is also divided into two new themes, “Knowledge”, and “Economic
empowerment”. Under these themes, data from all of the six qualitative interviews, including
the two focus group discussions is presented.
My own observations and experiences during my stay in Ethiopia at the organizations are
also part of the findings in both themes.
The two head themes have been be analyzed separately and can be find in the final parts of
the result presentations.

Findings, theme one

Notice; DKT Ethiopia, TLH Ethiopia and NIKAT Women association are connected with
each other through a project, Wise Up, which will be presented below.

What
Increase awareness about HIV/AIDS, STIs and condom use, to affect people’s
attitudes and behaviors
According to several of the informants at the organizations, they are all working towards the
same goal - towards achieving attitudinal- and behavioral change from their target by
promoting safe sex, which means promoting condoms and the habit of condom use, in order
to combat the spread of HIV/AIDS and STIs. The Wise Up Social Marketing program
manager at DKT (DKT-WU) defines DKT’s work with HIV prevention,
We do Social Marketing in a very wide and vast way and we do the promotion of condom use (…)
So, what we do at DKT is promoting HIV prevention methods, mainly C among the ABC, mainly
work with condoms (…) concerning HIV prevention we have condoms of different varieties so we
give the education, we do the promotion and we also have the products. (…) We do the trainings
and interpersonal communication, mass media and we also do some trainings (…) so, it’s like a
package. We do the whole package of Social Marketing.
At Timret Le Hiwot Ethiopia, TLH, the Wise Up program manager (TLH-WU) defines
their work more focused on sex transactions related to HIV transmission, since the
organization is a implementer of DKT’s Social Marketing program “Wise Up” where the
target is sex workers and their clients,

42
 The main message of our work is … like … it’s hundred percent condom use, you know, using
condoms consistently and correctly, in all commercial sex transactions. And that will prevent or
protect “at risk-groups” like sex workers … to prevent their risk of HIV infection. So, there are
messages I mean, promoting condom, condom promotion.
The TLH Social Marketing program manager (TLH-SM) has the similar definition
regarding the organization’s work with Social Marketing, “the main objectives of Social
Marketing in TLH is promoting safe sex, among sex workers and their clients”
This view of the organization’s main aim with their Social Marketing program is also how
the TLH Drop In Center manager/Outreach worker (TLH-DIC) explains their work, “Aim of
Wise Up is promoting condom, using, enhancing proper condom use between sex workers
and their clients. Because we think that sex workers are the most transmitted of AIDS.”
What DKT Ethiopia and TLH Ethiopia mainly are doing is promoting condoms, through
Social marketing, to influence people have safe sex. Condoms need to be used correctly and
consistently to protect from STIs. For this reasons the organizations provide trainings on
condom use, condom client negotiation for female sex workers and education regarding
HIV/AIDS and other STIs.

How
Target
The organizations are working towards specific targets and the informants explain that the
absolute main target of their various interventions are the people that are identified as “most
at risk population” in Ethiopia. One subgroup under this umbrella concept is female sex
workers, who are defined as a high-risk group related to HIV/AIDS and STIs. One of the
reasons for this is that they have multiple sexual partners. Female sex workers are also
considered as “bridging population”, which means that men from the “general population”
might get exposed to HIV/AIDS and/or STIs when they visit sex workers. This motivates the
thought of protecting the society from transmissions through targeting female sex workers in
HIV/AIDS and STI prevention programs. The TLH-WU says,
According to the Ministry of health and the World Health Organization there are targeted groups
put as key populations or at risk, MARPS, most at risk population groups. You know these sex
workers have, they have multiple partners, sexual partners, so, they are vulnerable. So, it’s better
to reach these sex workers as primary targets. (…) It’s because of two reasons, one, the HIV
prevalence is very high among these groups, and the second one is, these groups serves as bridge
to transmit the HIV pandemic to the general population. And this is the rationally behind you
know making our primary target group sex workers, because of the fact that they are vulnerable.
And they are also, they have the potential to transmit this diseases to the general population. And
if we, I mean, protect, if we hamper the prevalence the HIV pandemic among the sex workers, the
general public will be safe.
Other targets are the clients of the sex workers, gatekeepers and stakeholders, who are bar
owners, hotel staff and the police etcetera. Students are a big target group since plenty of the

43
schools in Ethiopia include HIV/AIDS knowledge in their teaching, as well as organizing
various campaigns, sport- and music events in order to spread information about HIV/AIDS
and influence the behaviors of the students.

WISE UP PROGRAM
In order to reach the target female sex workers, and to advance the condom promotion in the
combat of HIV/AIDS and STIs through Social Marketing, DKT Ethiopia launched a program
called Wise Up in 2007.
TLH Ethiopia is an implementer of DKT’s Wise Up program and the TLH-WU defines it
like, “Wise Up is a nationwide HIV prevention program, targeting sex workers and their
clients and advocates for 100% condom use, or to use condom consistently and correctly as a
HIV prevention mechanism”
One of the things that makes the Social Marketing part of the Wise Up program differ from
DKT’s other Social Marketing of contraceptives is the generic promotion of the condoms.
Other promotion that DKT conduct is branded, which means that they promote their own
contraceptive brands. The DKT-WU explains the reason for this generic promotion towards
female sex workers by saying that the use of condom, by this target, is more important to
focus on initially, than having them choosing DKT’s contraceptive brands.
What we’re trying to do is to get people to the habit of using condoms first. Choosing brands can
come later (…) it’s really important that they use condoms. These are high risk groups, most at
risk population, we call them MARPS, and these people are in danger of being infected everyday,
every minute, so, it’s very important that they know to use condoms, then they can choose their
brand.
The Wise Up program is now working in 18 cities throughout Ethiopia and the program
includes Social Marketing of condoms and other contraceptives as well as activities that are
called Drop In Centers and cooperative activity for sex workers. These are found at 21
various places throughout the country.

Drop In Centers for female sex workers

The Wise Up program includes Drop In Centers, DICs, for female sex workers. These are
venues that are opened for all female sex workers. They are located in various areas
throughout the country, mostly around “hot spots” where many female sex workers are found.
The centers provide the female sex workers with resting rooms, showers, kitchens, social
activities, counseling, and trainings on HIV/STI prevention etcetera. They are opened
everyday, daytime. There are outreach workers and nurses working at the DICs. The centers
are drug and tobacco free spots and the female sex workers need to respect these conditions in
order to be welcomed at the DICs.

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 Inside the DICs a lot of information regarding condoms, oral contraceptives, HIV/AIDS
and STIs are found and passed in diverse ways. The information is showed and presented in
several ways. There are banners, photographs, posters, boards, postcards, sun umbrellas, table
cloths, curtains, pillows, mirrors, bottle openers, towels, blankets, slippers, t-shirts, condoms,
stickers, cars, tricycles, wall paintings and bags etcetera, with different information, slogans
and quotes about condoms, condom use and HIV/STIs. For instance, “Using condoms is
smart”, “100% condom use”, “Condomize, don’t compromise”.
In addition to this, various printed materials, like comic books that tell stories about female
sex workers and their clients, can be found inside the DICs. It can be about how a female sex
worker negotiates condom use with her client, or how a female sex worker tells other female
sex workers that she got a STI test.
There are also flip-cards showing pictures, symptoms and information about various STIs,
how to prevent them and how to recover from them.
These different materials try to spread information and knowledge about HIV/AIDS, STIs
and condoms and they are used for promotion and distribution as well as educational material
during various sessions, such as “training sessions” for various target groups and “peer
education”, which are conducted at the DICs.

Out reach work, trainings and peer education

The organizations are not only stationed at these various “Wise Up-venues”. They are
conducting Social Marketing in further ways in order to sell condoms, spread knowledge
about HIV/AIDS, STIs and condom use, to reach a larger amount of female sex workers.
Some of these things are outreach work, trainings and peer education.
The TLH-SM is talking about these parts of their work as something that comes together;
outreach work to find and recruit female sex workers, so they can come to the organization’s
training sessions about HIV/AIDS, STIs, condoms and condom use, so that they, after
attending this training, can teach their peers what they’ve learned.
So, the outreach coordinators in different operational areas they go and recruit sex workers from
streets, from hotels or something, and they will be provided with different kinds of training, so
they will be graduated as peer educators so they can teach their peers.
The TLH-DIC, is one of TLH’s outreach workers and he emphasizes one perspective of
the outreach work by talking about being resembling to the female sex workers to reach them
with the organizations message.
We’re going to outreach and enter to every venues and local drinking houses, where we’re able to
find girls, you know. And we just caring to them, maybe we’re gonna have some drink, to be
similar with them and to start a conversation to them.

45
 Just like the previous two informants, the TLH-WU also mentions bars and venues as
places where they recruit female sex workers to get them to come to the organization's
trainings. He also mentions what are included in the organization’s trainings,
These sex workers are recruited from the bars or from the venues and they come to the trainings
session and they get trainings on HIV, STIs, condom use, condom negotiation and so on and so
forth. And then, after having that knowledge, they will go to the bar and they will educate their
peers, you know, their friend, and their clients too.
He continues,
… there are trainings organized for sex workers on condom use and this condom negotiation, life
skills trainings and so on and so forth, you know. So, first we just you know make them free, sex
workers, to express their thoughts, to share ideas and so on and so forth. After creating that good
environment, you know, they are free to express their own ideas and thoughts and so on and so
forth, we can, actually we don’t force them, we just let them to know the risks and how to avoid
the risks. So, that’s based on I mean, mutual understanding that we are forwarding our message
and trying to create awareness and so on and so forth. We are not forcing them to, to accept each
and everything but we guide them you know (…) if you use a condom, you can, protect yourself
from HIV/STIs and among pregnancy and so on and so forth. So, you have to use condom, for
your own sake. To be safe you have to use a condom is our, we just advocate for this. And, you
know since for, to protect themselves from HIV and STIs and related problems so they are very
happy to except that and they are also forwarding there own experiences…
The informants tell stories from the trainings, how people get the chance to try to turn on
condoms on plastic penises and that they hire experts to come and answer the female sex
worker’s questions about condom use and how to negotiate condoms in certain situations.
Peer education is when someone teaches his or her peer about something, in this case about
HIV/AIDS, STIs and condom use. When the informants talk about the peer education part of
their work, they highlight the importance of being equal with the one that passes a message,
to have people listen and to change their thinking and acting.
This seems to be particularly the case in their work with female sex workers. The DKT-
WU says, “You are more likely to respond to somebody who’s like you than to somebody
who’s way far up there. (…) The fact that we use sex workers (…) has helped us a lot, really.
(…) They go and they invite them, it’s easier for them you know. They trust them”
The NIKAT-FUN also emphasis the importance and function of using peers,
they are the same group, groups of people like, not like a doctor and sex worker together so they
educate themselves and they tell everything they know and go through to each other cause you tell
me your story I’ll tell you mine, they know each other, the same things happened to them, so, they
have better way of communicating with each other.
The TLH-DIC raises the possibilities in using the function of peers in order to reach female
sex workers,
we just handle these issues by peer conversation. (…) “please try to tell her, try to convince her
please”, because it’s very easy to hear her rather than me, to listen to her, because I mean she’s her
friend, she knows what quality she possess and what witness she have so she’s gonna tell them
properly, rather than me.

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Distribute, sell and avail condoms
The head organization of the contraceptives that the organizations are distributing and selling
is DKT Ethiopia. DKT Ethiopia is developing the brands and the various Social Marketing
campaigns that all three organizations implement. When the DKT-WU is talking about the
organization’s work with condoms, she stresses the significance of making condoms available
and accessible by having condoms at a numerous places and by selling them to a subsidized
price,
We provide these condoms under cost. They are really, really highly subsidized. (…) The cost is
not a barrier at all. You can’t say “I can’t afford to buy condoms” (…), money cannot be a reason
(…). And we’re trying to make it accessible for everybody. (…) The main channel for DKT
distribution is the kiosks, pharmacies and drug stores. And the sex workers (…) mainly distribute
condoms to hotels and bars and clubs and pensions. So, this way we’re trying to ensure that
condoms are available, we don’t want availability to be a problem as well, so we’re trying to make
them available everywhere. They are affordable and available.
The DKT-SE is also emphasizing the importance of making condoms available so people
are given the best opportunities to access them,
for the prevention of HIV/AIDS (…) the method that we use are availing condoms, promoting
condoms, education about condom. So, we just provide … the outlets which are the pharmacists,
the clinics the kiosk, with condom, so that whenever people come they can buy it at a very low
price, or affordable price.
He says that it’s important how the condoms are packed, the look of the condoms should
attract the target and he also stresses that the suspender, or box, the condoms come in have to
include information about how the condoms should be used.
He continues by claiming that people are more likely to use something they’ve paid for,
“when they pay for a thing they are really more you know strong to use this one than throw it
away because they have paid it”.
This is also mentioned by the DKT-WU. She means that people value what they have paid
for, compared to something they get for free, “We want people to pay, if they don’t we can’t
even say they used it. (…) You value what you pay for, so, that’s one of our principles”.
The TLH-WU also stresses the importance of making condoms available and affordable
through Social Marketing as a significant part of HIV prevention,
This Social Marketing has its own (…) strength (…) because Social Marketing (…) is availing
condoms and other reproductive accessories with a very subsidized manner to the community. So
if we socially market condoms or other reproductive accessories, the society will use it and (…)
can protect herself or himself from HIV/AIDS. If I get a condom in a very subsidized way I can
purchase the condom and use it, protect myself from HIV and AIDS. So this Social Marketing has
a very significant role in HIV prevention.
From my observations during my stay in Ethiopia I’ve seen numerous of venues that are
providing social marketed condoms and other contraceptives for sale, places you might not
expect doing that. The majority of the places I saw in various Ethiopian cities were outlets

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disposed everywhere, and nowhere, from big supermarkets to sheds along the roads, in larger
cities and in smaller villages.
Outside of these places one of DKT’s Social Marketing advertising sign was placed to
indicate that condoms were available at that outlet.

Information/Education/Communication/Behavioral change accessories – IECB

materials
The organizations are striving to be visible at a lot of places for instance by using billboard
commercials about condoms and contraceptives but also by distributing a lot of
“Information/Education/Communication/Behavioral change accessories”, IECB materials,
materials that in various ways passes information about condoms and condom use. They want
people to start, and never stop, thinking about condoms and that it’s wise to use them. These
IECB materials can be clothes, diverse accessories, and interior items etcetera.
The DKT-WU is talking about their various IECB materials and explains that different
materials are developed for their targets,
So, when we develop our materials we develop them different, in different ways. For sex workers
we have tank tops, we have earrings, we have slippers, we have the towels. We have a lot of things
for sex workers. And when you go to the bar owner we have bottle openers, we have table
umbrellas that everybody can see. We have trays, (…) we have mirrors for their bathrooms, you
know, all these things that can be put inside the venues as reminders. For, the clients we have these
things like the t-shirts, key-chains, the hats, you know, this is for the general population.
She continues and explains the wished outcome from distributing various IECB materials,
These are reminders, we want people to think condoms all the time, that’s what we’re trying to do.
When you wear a t-shirt it’s a lot of people looking at your t-shirt and they are thinking about
condoms, whether they like it or not, in a good way, or in a negative way. They have to think
about condoms (…) this takes away the stigma, the shame that people have.
Using the IECB materials as reminders is something the TLH-SM also reasons about and
he raises the organization’s main commercial icon, “Mr. Condom”, as the symbol that should
remind people in their daily lives to use condoms, “if you’re having coffee or some beer in a
certain café under the umbrella (IECB material), you might see that more than ten times, oh,
umbrella, Mr. Condom, use condom, use condom, use condom, always”
The TLH-WU also talks about the IECB materials as reminders and states that people will
start think and act as an outcome from seeing and get reminded of the materials,
If these reminder materials are there, they will see it, and they will think of it, and they will act,
you know. Whenever they see this condom man, the condom man, oh use condom, ok. This
condom will be in their mind so this has really a very great impact on this condom use.
These IECB materials could be seen and located at the most unpredictable places over the
country. In Addis Ababa I passed shoe shine boys sitting under “Mr. Condom sun umbrellas”,
women and men working in sun-bleeched condom t-shirts and homeless people sitting under

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Mr. Condom umbrellas on the street. In Hawassa, south of Addis Ababa, a women served fish
under a Mr. Condom sun umbrella and another umbrella could be seen at one of the markets.

Edutainment – combining two important incentives

“If you don’t tell the person in a way that he or she should understand it then they’ll not
understand it”
One of the incentives the organizations are using in their HIV/AIDS and STI prevention work
through Social Marketing is Edutainment, education and entertainment combined. Several
informants are mentioning the importance of having fun as a component to receive attention
and attitudinal- and behavioral change from the target as well as the general population. They
highlight that people easily get bored of listening to information about HIV/AIDS and STIs
and mean that one way to reach the target without boring them is through edutainment. The
TLH-SM says,

You know, peoples by nature are getting bored within very short period of time, so when there is
fun, there is music, when there is kind of drama or, they will be always watching, they will be
always … getting the awareness, so, if you’re going to sit down and just be very sweet and say
“Ok let’s talk about … and so on”, they loose their concentrate in a short period of time you know,
but, so, I think it’s better to use different kinds of campaigns. Because, they think that they are
enjoying, but they are also getting education.
The DKT-SE states that one way to reach the public is by passing information to the target
once you got their attention, “You know people they get easily bored, (…), and they don’t
want to stay with you. So, you need to have different methods so that they can stay with you,
and pass your key message during those sessions”. He thinks that the various methods that
ought to be used should be entertaining.
He continues and reasons about that edutainment is a good way to communicate with the
public since HIV/AIDS has been a taboo topic not so long ago, and that this way makes it
easier to talk about it,
It should be this way, to communicate people. Now people are not afraid of condom and
HIV/AIDS. Now we have like condom fashion shop, people they just wear it, but few years ago
you don’t not talk about condom in public rooms, so it should be this way.

Campaigns, condom demonstration, media and other creative tools

The edutainment part of the organization’s work is represented in numerous ways; campaigns,
condom demonstration, radio and dramas, billboards etcetera. This part of their Social
Marketing projects are the parts that have the most possibility to be available for the largest
number of people and to reach the general public, for one reason by being visible at a lot of
places.

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 During my first days in Addis Ababa I saw a couple of condom commercial billboards.
These giant billboards were placed downtown along the roads where plenty of cars are
driving. Later I would come to discover that these billboards were not only located
downtown, but throughout the city.
Another tool that is used to reach the general public is the organization’s cars and busses.
These are advertisers on wheels, with their various contraceptives commercials and condom
use messages.
The TLH-WU are talking about the creative parts of their Social Marketing work as a way
to reach the general public in Ethiopia,
… we have to reach the general public, through different, condom promotional events, maybe road
shows and also you know like this music and drama, football tournaments, and different sport
competitions, quiz competitions and also these talk shows and debates or panel discussions for the
university student and so on and so forth. So these are our strategies to reach the general
population, general public.
The TLH-SM means that these ways of working can give people awareness about
HIV/AIDS and STIs, even if their intention just were to go out and have fun,
they are not going there most of the time to attend our programs (…) but they might be going to
watch a movie for example, or to watch football or to see a bowling tournament, a pool
tournament for example. But when they go there, they will hear about, they will take any kind of
information about HIV and AIDS… about condom.
Another technique to reach people in this way is mentioned by the TLH-WU and he calls it
“invisible dramas”. These dramas are performed out on bars and other venues by a group of
actors that perform a scene without that the people around them know that they are acting.
The aim of this technique is to bring a hot topic to a place in order to get people to start
discuss the subject. In this case, the subject can be condoms and condom use. The TLH-WU
is talking about the aim of the invisible dramas,
They just you know brought a very, you know, hot, I mean, scenario, hot, setting or condition to
that, so people were discussing about condom (…) But nobody knows whether that was drama or
not, that’s invisible performance, to reach the clients, you know what I’m saying? So, these, I
mean, eh, performances, these campaigns, these creative, you know, stuff, are really very
wonderful in reaching this.. (…) in creating the awareness of people and in changing the attitudes
(…) So, we want people to discuss in that specific event, specific campaign and you know share
their own ideas.
The TLH-SM gives an example from one of the organization’s campaigns, the “Safer life
campaign”, and how the organization’s campaigns and demonstrations can look like,
In the Safer Life campaign, it’s a one month long campaign and in that campaign we have
different kinds of activities. For example we have the launching. In the launching ceremony we
will have a march band, so Mr Condom will be there, so, we gonna have booths, booths means
some kind of tent. So in the tents there will be condom demonstration. So peoples will wear the t-
shirt, “I will use condom, 100% condom use”, so they will walk from Arat Kilo to Sedest Kilo
(…) the march band will be in the front so we’re going in the back and wearing the t-shirts or
something so, peoples: “what’s going on”, oh the people are promoting condoms you know. So
after that there will be condom demonstration in the booths, you have to use condom and.. We’re

50
 going to teach them how to use condoms. (…) outreach workers, some voluntaries or something,
they will teach you how to use condom. Ok, so it will just initiate people to think about condoms,
The DKT-WU means that these campaigns catch people’s attention and that they get
curious and attracted to it, which make them show interest, which thereby can result in
knowledge,
People are attracted to this, whether they like it or not. We reach a lot of audiences by doing this.
We get a lot of attention, (…), people really wants to know what’s going on. And, that’s what we
want. We want attention from the general public. (…) Most people get curious, but in the end they
know something about condoms.
When I ask if it is difficult to perform campaigns of this kind out on open streets in a
society as Ethiopia, she replies,
Actually when DKT started 20 years ago I heard the sells people where being chased by a lot of
people, by, people were throwing stones at them, they were chasing them around, so you know …
they didn’t like it. But now we don’t have all that, we’ve come a long way from that so people
they are proud to wear a condom t-shirt, that’s huge.
She continues,
Every year it’s getting easier and easier to get people to talk about condoms, every year.
Especially in the small regions, Addis is a big city, but in the small regions, people are like coming
and doing the condom demonstration from the public. That wasn’t easy, but now people do that,
they don’t care anymore.
The DKT-WU means that performing these types of campaigns and demonstrations over
and over again can help to normalize the HIV/AIDS, STIs and condom topic and also reduce
stigma related to this. She highlights the significance of that their work is visible to the
community,
The more you do it, the more you get rid of the stigma, that is for sure. If you see it every day, if
you hear about it every day, (…) you may not do it but you don’t mind people are doing it, (…)
you can’t because we’re so visible, (…) everything is so visible.

Analysis, theme one

In the following, the findings in theme one will be analyzed and discussed based on Backer’s
eight principles on behavioral change and Bandura’s social cognitive theory, as well as parts
of this work’s previous research. The theme’s analysis chapter will keep a discussing
approach in terms of how likely it is that the organization’s HIV/AIDS and STI prevention
work with Social Marketing could result in attitudinal- and behavioral change regarding
HIV/AIDS/STIs, condoms and condom use by their target audiences.
The informants describe several ways of using Social Marketing in the HIV/AIDS and STI
prevention work in Ethiopia, from huge commercial billboards that are communicating
advertising for condoms, to paper flyers and t-shirts that communicate messages that are
trying to attract increased condom use. Their work with Social Marketing is primarily focused
on the program DKT chosen to call Wise Up, targeting sex workers and their clients.
Although, the program seems to put more focus on the female sex workers rather than the

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clients. The Wise Up program includes various incentives of Social Marketing and projects
that somehow are related to it. Various IECB materials, condom distribution, but also
outreach work, trainings and peer education, to name a few.
The organization’s trials to increase awareness about HIV/AIDS and STIs, to impact
people’s attitudes and behaviors, as well impacting people in protecting themselves from
HIV/AIDS and STIs by using condoms consistently and correctly, are their way of trying to
halt and end the spread of HIV/AIDS and STIs throughout Ethiopia.
I have chosen to divide this analysis chapter into three sections, which I think represents
the results from the essay’s first research question well; promotion of beneficial behavior,
provision of knowledge to enable behavioral change and finally, directly and indirectly
environmental impact.

Promotion of beneficial behavior

Social Marketing is about selling behaviors. DKT, TLH and NIKAT are all working towards
increasing condom use by their target, mainly sex workers and their clients. The behavior the
organizations are selling is the habit of consistently condom use during sex. The reason for
this is that people can protect themselves from HIV/AIDS and STIs by using condoms.
Of McCarthy’s “4Ps”, this can be understood as the first P, which is the product, what the
organizations are trying to “sell”. According to French, the “product is what you’re selling:
the desired behavior and the associated benefits of that behavior” (French et al., 2010, p. 194).
The desired behavior here is as mentioned, condom use, while the benefits are the increased
chance to stay safe from transmissions like HIV/AIDS or other STIs, compared to having
unsafe sex.
This can also be explained with two of Cheng, Lee and Kotler’s three parts of McCarthy’s
Product-P. The part that they call the actual product, is the requested behavior from the
target. This correspond with French statement that the product is the desired behavior from
the target.
Another part of Cheng, Lee and Kotler’s division of McCarthy’s P:s is the core product,
which here is what benefits the organization’s target audience can expect by protecting
themselves from various transmissions by using condoms. This, the expected outcomes from
performing the desired behavior, is also part of French definition of the product-P of the 4Ps.
The organizations are using various slogans to communicate the positive outcomes of
using condoms. To start with, the chosen name of their biggest program - Wise Up and the
“Mr. Condom-icon”, which is present on the majority of their various materials indicates on

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something positive. The “condom man” points at his head with one finger, and the other hand
is doing thumb up, it’s wise, and it’s good to use condoms!
Not the least, DKT's largest condom brand is called "Sensation" and the slogan that can be
seen at various billboards and advertising boards for the condom is "Make your life
sensational".
One of Backer’s principles for behavioral change is that a person is more likely to change
if “the person perceives that the advantages of performing the behavior outweigh the
disadvantages” (Backer, 2001, p. 2). Related to what just have been written, it is likely that
this principle is met by the organizations through their way to promote the behavior they want
the audience to embrace. The message, that condom use is a good thing compared to not
using condoms can be considered quite clearly communicated to the target audience, which
should allow a motivation for people to create an impression that it is more favorable for them
to adopt the behavior than not to.
If a person choose to adopt a behavior, which the person experience has a advantageous
impact on one, then one can assume that the chances that this person experiences a positive
emotion of performing the behavior is higher than the risks that the person perceives a
negative feeling. This, that a “person's emotional reaction to performing the behavior is more
positive than negative” is another of Backer’s principles and this indicates that if the
organization’s target experience that type of positive emotions DKT, TLH and NIKAT are
trying to convince that condom use may contribute, possible attitude and behavior changes
may occur.
The organization’s work towards their target can be viewed from a perspective that they’re
keeping a positive approach in how they choose to communicate their messages to reach their
target to achieve attitudinal- and behavior change. Instead of formulating urging slogans,
which aim to have people not behave in a certain ways, the organizations use slogans, which
encourage people to behave in particularly ways. They exhort “do’s”, rather than “don’ts”.
For instance, they are working towards that people should use condoms, not towards that
people should stop having sex.
What the organizations also do is that they use fun and easygoing methods to catch their
public’s attention and to reach them with information. The informants examples of how they
use edutainment in their work points out how Social Marketing can provide the organizations
to handle a in many way tabooed topic like HIV/AIDS, but also how it enables to reach
numerous of people, for instance people who perhaps did not intend to attend a certain event

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to learn about HIV. Campaigns, tournaments, and marching bands etcetera - the informants
think that having fun is a significant part in trying to reach the target.
One part of Backer’s first principle on behavioral change is that a person who forms a
strong positive intention to perform a behavior is more likely to change (ibid., p. 2). The
organization’s positive approach towards condom use and its benefits, as well as their various
events, which are conducted in a lively and energetic way to reach the public, seem to aim to
attain this.
Furthermore, Backer’s sixth principle states that behavioral change can occur if a “person
believes that performance of the behavior is more consistent than inconsistent with his or her
self-image or that it does not violate personal standards” (ibid., p. 2). The organization’s work
with peer education could be seen as one way of trying to achieve this from their target.
Informants at both NIKAT and DKT emphasis the advantages with using peers in their work
and they especially stress that people find it easier to assimilate what communicates from a
peer.
If a person who is similar to you adopt a certain behavior that should ease the process for
this person to adopt the same behavior if the person is able to reflect her- or himself in the
peer. If a female sex worker tells her friend, who is also a female sex worker, that she always
tries to have condoms available during work and that she took a training on condom use, this
may affect the other female sex worker’s perception of whether a particular behavior is going
well or less well with the her self-image. This type of process is the one the informants
mention when they say that people are more likely to respond to a peer.
What also can be understood as a way of reaching the sixth of Backer’s principles are the
way the organizations choose to arrange their Drop In Centers, DICs. The various educational
materials they develop and provide the female sex workers with, for instance the comic strips,
can be seen as a way of using roll models to influence the girl’s attitudes and behaviors.
Showing how a female sex worker negotiate condoms with a client can somehow pass a
message to the reader that this is something this person also can do, which can enable an
identification. The norm that prevails in the DICs is that you should use condoms. When a
new visitor comes to a DIC, this person can meet and talk with other female sex workers who
use condoms. This may affect the person’s attitude towards condom use and contribute to
some behavioral impact of the new visitor.
What has been written above can also be understood through the first interactive link in
Albert Bandura’s (1989) causation model on behavioral change, the relationship between
thought, affect and action (Vasta, 1992, p. 3). If the target creates the thought that using

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condoms are beneficial for them, and if they experience that it is, if they create positive
emotions and if they feel that the desired behavior is consistent with their self-image, it’s,
according to Bandura’s social cognitive theory, likely that the target group will change or
proceed their behavior since people's behavior is influenced by what they think and feel.
Bandura’s theory of that a person’s believes, intentions and expectations forms how a
person behaves are in accordance with Backer’s principle regarding that people are more
likely to change if they perceive that the advantages of performing a behavior outweigh the
disadvantages (ibid.).

Provision of knowledge to enable behavioral change

According to the organizations, it’s not enough only using condoms; they need to be used
correctly and consistently. To achieve this, information and education is needed to provide the
target with knowledge and skills to perform the desired behavior – condom use. Backer’s
third principle says that if “the person possesses the skills necessary to perform the behavior”,
behavioral change can happen (Backer, 2001, p. 2). The targets are provided with practical
skills during the organization’s trainings. In addition to knowledge about HIV/AIDS and
STIs, they get trainings on condom use, how to use condoms properly, which is the primary
skill to be able to perform the desired behavior, condom use, correctly.
Another way to provide the targets with enough skills to be able to use condoms is through
the information that can be found inside the boxes, which the condoms are sold in. The work
the organizations are doing in order to provide their target with skills on condom use
corresponds with one of William Smith’s points regarding how Social Marketing can avail
various products to poor people, namely that "it advertises and educate poor people about why
and how to use them" (French et al., p. 319).
When the organization’s targets are provided with actual skills on condom use, one can
assume that they develop a feeling concerning that they are able to perform the behavior.
Backer means that a person is more likely to change if “the person perceives that he or she
has the ability to perform the behavior under a number of different circumstances” (Backer,
2001, p. 2). According to the informants, the female sex workers get trainings on condom use
and negotiation not only by “one-way-teaching”. The female sex workers can also ask
questions about these things, which can result in help in how to use condoms as frequently as
possible. The animated books for the female sex workers can also be considered as one way
of reinforcing the female sex worker’s feelings of having the ability to negotiate condom use
in various situations.

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 If you look at this in the light of Bandura’s second causational link, the relationship
between environmental influences and human characteristics, it’s possible to understand the
information and skills the organizations are trying to provide their target with, as what
Bandura calls “social influences that passes information” (Vasta, 1992, p. 3). Bandura would
say that this type of teaching, skill training, could activate affective reactions by the target,
which develop and form cognitive competences that impact people’s behaviors. (ibid.).

Directly and indirectly environmental impact

The most fundamental in enabling condom use by people in order to halt or end the spread of
HIV/AIDS and STIs, is that people need to have, own, condoms, to be able to use them.
Backer’s second principle states that a behavior can occur if there are no “environmental
constraints that make it impossible”. Working towards this, seems to be one of the most
important parts of the organization’s work. The informants emphasis the significance of
availing condoms by making them accessible at a number of various places. The outlets that
store condoms are plenty and this increases the possibility for people to have access to
condoms. They can be found in kiosks, pharmacies but also in hotels and bars.
This direct environmental impact complies with McCarthy’s third marketing P, the Place-
P. French writes that it’s important to make the access of the products; here it’s the condoms,
convenient and easy for the target to obtain, in order to enable the desired behavior – condom
use (French et al., 2010, p. 195).
Furthermore, McCarthy’s promotion-P defines that the organization’s target needs to be
informed where condoms are available. One way that the organizations are trying to do this
are through the advertising signs that they place outside the outlets where condoms are
available.
Just like Smith’s words about that social marketed condoms should be priced “so that poor
people can value them”, the informants stresses that they provide their condoms under cost, to
a highly subsidized price, for the reason that cost never should be a reason for not using
condoms (ibid., p. 319). This is an important contribution in making condoms accessible for
all people, especially poor people. If this wouldn’t be done, the habit of condom use could be
more of a class issue and the amount of people that could afford them would decrease.
Using Bandura’s idea concerning that a person is both a product and a producer of her/his
environment, this could be understood in terms of that the targets are products of their
environment by the means that they somehow are dependent on that the organizations provide
them with condoms by making these accessible and affordable, but, once they get access to

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the contraceptive, they are given the opportunity to be creators of their environment by
choosing to, or not to, use condoms. This interactive relationship between people’s
environment and their behavior is Bandura’s third, and last, link in his triadic reciprocal
determinism model on human behavior and it states that a person can affect once environment
by her/his behavior, since the environment’s not a fixed, constant essence (Vasta, 1992, p. 3).
However, this is, for the people in this case, fairly dependent on the organization’s action to
enable the target’s ability to act.
The organizations are doing various things that can be seen as having indirectly
environmental impact on people and the society, things that somehow might affect people’s
attitudes, but also behaviors. The informants mention IECB materials as one way of reaching
people and that one of the aims with using these in their work is that they want people to think
about condoms as often as possible. Condoms and condom use should be active and ongoing
thinking processes in people’s heads.
The organizations are affecting the Ethiopian environment, not only by placing out various
interior things with condoms and slogans on them, but also by placing out billboards and
advertising signs that pass commercial and information about condoms, condom use and
where these can be found. What also can be seen as environmental impact are the campaigns
and the demonstrations that the informants mention. These events can be observed of
numerous people and affect these people even though these individuals perhaps didn’t have
the intention to see and hear about condoms and condom use when they went out that day.
The organizations are somehow conducting a normalization process of HIV/AIDS, STIs,
condoms and the use of these. They challenge traditional structures and norms in a
conservative society like Ethiopia. This is probably necessary for the organizations to do, to
be able to make direct environmental impact like availing condoms at all the various outlets
that they do.
People don’t have to use condoms just because the organization’s billboards and
commercial signs exist, but the fact that these billboards and signs can be found in the
environment affect the actual environment. This can result in a normalization of condoms and
condom use, since people can see the advertising, but also, the organization’s campaigns that
are conducted out on open streets.
Backer writes that if a “person perceives more normative pressure to perform the behavior
than not to perform it” behavioral change is more likely to happen (Backer, 2001, p. 2). In a
future perspective, this normative pressure might be able to occur within people in the
Ethiopian society as a whole. If the organizations continue to conduct their work in the same

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way as they do today, the chances for this can be good. One informant mentioned that 20
years ago, DKT people got chased with stones because of their work. That’s not the case
today, so, something have most likely happened in the normalization of condoms and condom
use.
The normative pressure that is part of Backer’s principles might also occur for the female
sex workers in the organization’s DICs. In these there are condoms everywhere, from the
floor to the roof in some of the places, even at the pillows in the resting rooms for the female
sex workers and there are slogans on the walls saying that condom use is smart. I’d say that
it’s impossible to not be affected of the mass existence of the “Mr. Condom man” and the
condoms inside the DICs. This can cause the type of normative pressure that Backer mentions
as a cause for behavioral change for the female sex workers, since it’s very obvious that the
organizations and their projects are completely contained on condom use.

Findings, theme two

Theme two focus on whether the organization’s Social Marketing projects strive to provide
vulnerable groups of the Ethiopian society with empowerment, and if so, in what ways. As
acknowledged, DKT’s Wise Up program, mainly targeting female sex workers, has been
given an immense focus in this study. Therefore, that program and its target has been the
object for this theme. The following results are from the six qualitative interviews with the
informants that all are connected with the Wise Up project in one-way or another. This
chapter also includes data from the two conducted focus group discussions with female sex
workers and ex female sex workers.
Empowerment is a term that can be defined and understood in numerous possible ways.
The informants were somewhat analogous in their definition of the word when it’s exploit in
their work. They are talking about building up the female sex worker’s own capacity in order
to be able to decide over their own lives, as well as be given the strength and ability to be able
to chose to leave sex working. They are somehow dividing empowerment into two broad
divisions, knowledge and economic/financial empowerment.
Empowerment, as empowerment seems to be seen and understood at DKT, TLH and
NIKAT, is a multidimensional phenomenon. The informants say that they are trying to
empower the female sex workers in several ways, psychological, for instance by trying on
working with their self confidence and self-esteem, as well as practical, by giving them
knowledge about contraceptives, transmissions, STI testing and negotiation with sex clients.
The practical part of their empowerment work also includes fractions like sewing,

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embroidery, food preparation and pure theoretical education as reading, writing and computer
skills. In addition to this, the organizations provide them with knowledge in handling money
and they are also assisting and guiding the female sex workers in creating legally registered
cooperatives in order to be able to earn money in additional ways than sex work.
The following part of the findings from this theme will present the various parts of
empowerment that the informants, and most important, the female sex workers, raised as vital
in the work/in their lives.

Knowledge
HIV/AIDS, STIs and transmission awareness
One of the Wise Up project’s main aim is to create and transmit information, knowledge and
awareness about HIV/AIDS and STIs. This is in order to let female sex workers know about
various risks and how to protect them selves from getting different infections by having safe
sex via using condoms correctly and consistently. The informants are talking about that
having knowledge about these things is a way of valuing life, since if you know about the
risks and possible consequences with having unsafe sex, you’ll be more likely to say no to
that.
In the FGDs, the girls are mentioning the things they’ve learned about HIV/AIDS, STIs
and condoms as the most important things they’ve learned at the organization’s DICs.
What also is brought up for discussion is that the Wise Up program is the only place of its
kind, that this activity was a surprise for them and that there are no other places like the DICs
where you can get this kind of training, especially about STIs. One girl is saying, “Nobody
tell you about STIs if you don’t come to a place like this”.

Condom use expertise

The Wise Up program is not working on having people not having sex, but having protected
sex. They are only working among the “C” in the HIV/AIDS prevention work’s ABC’s. A is
for abstinence, B is for being faithful and C is for using condoms. The A and B is what some
other organizations and the churches usually are concentrating on. The Wise Up trainings are
including condom demonstrations and chats about condoms. This is to clear out diverse
possible existing misconceptions about condoms, how and when they should be used etcetera.
The TLH-DIC is claiming that the trainings on condom use are empowering the female sex
workers.
Most of our targets who took peer education training, and who uses DIC services are empowered
not to have sex without condom. They have a full knowledge, full understanding you know, full
understanding of using condoms. They say “no sex without condom”.

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 All informants had the same view regarding the outcome from these condom use trainings
– the female sex workers have full knowledge and they won’t have sex with clients without
condoms. The TLH-SM claims, “They wont have sex without condom, even if you pay them
extra. Because you know, we are just teaching and teaching and teaching them”.
When this was brought up for discussion in one of the FGDs, similar responses occurred.
The girls were saying that they wont agree to sex without condom. They were all very
determined concerning always protecting themselves with condoms and various strategies of
doing this was presented,

I’ll be wearing the Wise Up-things, condom all over, so I will tell him that I work on that place,
(the cooperative), and for his sake and for my sake that we should wear the condom and I always
have a pack in my bag, so I try my best to convince the guy (…) But usually it needs a bit of
haggling (…)
She continues,
I try to put on the gear, the Wise Up gear with Mr. Condom on my ears and bag and my umbrella,
my shoes, everything, (…) I know everything about the condom use so I try to spread it out. The
clients would look at me and think like, “ok she’s really in to this thing” and put on the condom.
Cause, you know, I somehow know the use of it.
One girl is telling a story about a client who tried to have sex with her by taking off the
condom just before putting in his penis in to her and that she put on a new condom twice, and
tried to get him to understand that she wouldn’t agree on unsafe sex. The client was very
affected of alcohol and fell a sleep, so the girl left and went to a clinic to get tested for her STI
status, since she knew about the possibly risks with unprotected sex.
Another girl is saying that before she came to the DIC she’d only heard about condoms,
but that she didn’t use them. “I think I come here, understand more. I always use safe sex.
Before I know only condom, about condom, understand condom. But don’t use. But I use
now”.
The girls from one of the FGDs are lifting one perspective of how the knowledge they
achieved through Wise Up’s trainings is useful for them in their work. One of them says,
There are guys who are so scared about everything that before he even takes of his clothes he puts
on a condom and there are guys who’d even put on two condoms and I tell them it wouldn’t work
that way cause of the friction of the two robbers would make it brake, so I tell him to put on only
one condom.
Having the female sex workers always carrying their own condoms is a key principle in
what the training is supposed to give the girls knowledge about. The reason for this is to
secure that condoms are available when it’s needed, and that the condoms are safe and of
good quality. The NIKAT-FUN reason about it,
… she has to protect herself so, we tell her to carry the condom, always. She’s supposed to have
that, unless certain circumstances made her not. She should always have a condom to protect
herself, much better than expect the guy to have a condom every time. Just always for her

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 protection. She’d be ready all the time with here condoms. (…)The guy might bring a condom, it
might not be right, it might be put in his pocket or it might be spoiled, or there are people out there
who’d hamper, destroy, put holes in it, to make it not work.
This issue was mentioned in one of the FGDs, and it was clear that the different costs that
exist on condoms in various outlets might have impact on the possibility of always having
condoms available in your pocket. The girls said that they at the moment have to walk a long
way to get cheap condoms in a outlet that always are open, “We’d love to have 24 h condom
shop like NIKAT, (…), because we have to go all the way to NIKAT to buy the cheap, for
cheaper price, like for two bucks. Other than that we will have to buy it for five bucks”.

Negotiation - client communication techniques and skills for female sex workers
A word and phrases that came up numerous times during each interview was “negotiation”,
“client negotiation” and “condom negotiation”. The informants were all explaining the aim of
teaching the female sex workers various ways of negotiation. One important aim intends is to
be to provide the female sex workers with diverse techniques in convincing their clients to use
condoms during sex.
The major motive on training the female sex workers in negotiating condoms is to
minimize the risk of them being exposed to HIV/AIDS or other STIs. But it’s also on the
basis for having them taking control over the situation. The DKT-WU says,

We’re trying to empower the girls to negotiate condoms with their clients. Since the client is the
payer, everything’s in his term, he sets everything. (…) But we want the woman to have power to
negotiate, condoms and other things. They don’t have to do what they want to. (…) Part of our
training is like “if you don’t want something you can say no”. (…) We want the girls to be in
charge (…) We want them to be empowered to, we want them to be confident enough to say that
they want to use condoms.
The negotiation is supposed to be in a kindly, friendly and non-confrontational manner.
Some informants, for instance the TLH-WU, spoke about negotiation also in a more
educating way,
… he might also like “I want to have sex without condom”, and then she has not to be offended
“Go out! I don’t…” you know. This is not a good way of (…) negotiate with customers or clients.
You know “please, have a seat first. HIV is a very you know killer disease, it’s a killer pandemic
so you better keep yourself very safe. (…) If you are safe, I am safe. And also if I am safe you are
safe and others will be safe (…) so it’s for both of us, it’s for the sake of me and you. So you better
use condom”. This is a very diplomatic way of negotiating with clients.
The DKT-WU expressed that mentioning HIV, while negotiating with the client, is not
always very prudent. She spoke about condom negotiating as something that can be done in a
sensual way,
We have experts to train them this, how to negotiate condoms. (…) “I want to use condom because
I don’t wanna get HIV”, that’s not a good strategy. He could say “Who said I’ve got HIV?!” (…)
there are ways they can negotiate with them and it doesn’t have to be confrontational. It could be,
you know, they are men, they know how to handle them in other ways you know. So, you know,
they can be nice, and how they can put on the condom themselves and you know, they can make it

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 a very attractive.. (…) So, that’s part of their training, how to negotiate condom with the client
without offending him, without causing violence.
Even though the female sex workers learn how to use these miscellaneous negotiation
techniques, there are clients who refuse to use condom during the sex. One girl is telling
stories from her reality, “There are guys who force you, for example, the negotiation. We go
in to the room and he’d say like “I’m not going to put on a condom and I want to do this
without a condom”. If I say no, there are guys who’d force me”
This scenario was brought up in the interviews, in order to explore what the organizations
train the female sex workers to do in situations when clients refuse using condoms or get
violent. All informants that were asked responded in ways that was about telling the female
sex workers to leave the place if a client doesn’t want to use condom or if the client uses
violence. The female sex workers should not hesitate on their lives. The NIKAT-FUN says,
“We always teach them they have to look, like the room they go in, always they have to have
an exit strategy, you don’t know what kind of customer you’ll get. We teach them you have to
always know where the door is, the windows is and stuff.”
When I asked the girls in one of the FGDs about how they act if/when a client refuses to
use condom one girl answered that she would leave, “completely”.

Economic empowerment
“It’s not only enough to give them some kinds of information about HIV/AIDS you know.
We should also participate in changing the lives of the sex workers”

Sex workers cooperatives

Some years ago, the activity at the DICs was criticized by some female sex workers for being
too much about the condom education, and too little about the organizations being engaged in
changing the lives of the female sex workers. Out of this reason, a “female sex worker
cooperative concept” was developed, in order to create an activity that could bring the female
sex workers various types of education and an alternative income, which could be a way for
the female sex workers to change their lives.

Income generating activities

“You educate us, use a condom, and then you just let us go”
The above words are coming from NIKAT-FUN when she’s talking about one of the reasons
for creating the female sex workers cooperatives. The cooperative idea with its income
generating activities came from the funder of the organization, as a response of the female sex
worker’s critique, after she’d been to Cambodia and seen that type of cooperative activity

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there.
The organizations mean that it’s needed to provide the female sex workers with something
more than just knowledge about HIV/AIDS, STIs and contraceptives, something that can
support them in changing their lives, through earning some extra money. The cooperative
concept and its income generating activities, IGAs, is now part of the whole Wise Up
program. Some of the miscellaneous IGAs that the female sex workers are provided with are
food preparation, café activity, beauty saloon work, clay work, sewing and embroidery
etcetera.
The informants mentioned the reasons for adapting and conducting the IGA concept in
various ways. The overall reason that was mentioned during most of the interviews was to
provide the female sex workers with alternatives and choices, through getting an alternative
income, in order to give them a chance to be able to change their lives. Identical to what the
NIKAT-FUN said regarding the female sex worker’s feelings about the Wise Up program,
before they added the cooperative concept, the TLH-SM expressed something similar, “It’s
not only enough to give them some kinds of information about HIV/AIDS you know. We
should also participate in changing the lives of the sex workers”
The main aim of stepping up the DIC activity by creating female sex worker cooperatives
was explained like the following by the TLH-DIC,
The main goal is to let them explore an alternative income, an alternative livelihood income rather
than sex working, like empowering on economic empowerment, empowering them on economic
status. Forget this work and try to start another work (…) rather than sex working.
For three of the girls in one of the FGDs this had become reality. They all had quit sex
work and were now supported through the cooperative’s IGAs. In addition to this they were
now “trying to work something out to succeed on their own” by opening their own café
business.
Despite these possible opportunities of earning money in other ways, rather then selling
sex, only a few female sex workers leave their jobs as sex workers. The sex work generates
more money than the IGAs do, which make it tough for many of the female sex workers to be
able to quit selling sex.
Even though this is the case, the DKT-WU emphasized an important perspective of having
the IGAs for the female sex workers, “These cooperatives (…) supplement their incomes. For
one thing, that gives them the power to say no to clients who say they don’t want to use
condoms” She means that if the female sex workers can get some extra money, in other ways
than sex work, they will be more capable of saying no to unsafe sex, because they’re not only
dependent of the money they earn from selling sex.

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 It’s very common that sex clients offer more money to have unprotected sex. A lot of sex
workers agree on this, partly because they are economically weak and in the need of all
money they can get. According to the DKT-WU the IGAs can strengthen the girls in saying
no.
This was also expressed from a girl during one of the FGDs, “Last night somebody come
for me (…) without condom. (…) I pay you 600 Birr you know, and I said that no, I don’t
care about your money (…) I only use safe sex (…)”.
The DKT-WU continues about the possible outcomes from the IGAs,
It also helps for partner reduction. (…) They are at risk because they have a lot of partners so, if
you have less partners. You’re less at risk. So, if you have little money and they don’t have to go
out every night, maybe she’s tired tonight and she doesn’t want to go out, maybe she has her
period and she doesn’t want to go out, she has that option, she has a little bit of supplement
income.
The NIKAT-FUN raised a further side of getting the female sex workers in to various
IGAs and says that it’s needed to work on the female sex worker’s self-images before doing
anything else, “Just first to make them come here, to get them to listen and to change their
thoughts about themselves, all this is about some kind of empowerment, they should be able
to see that it’s possible to change, I can change, I can do my own life…”
She’s talking about working on their self-confidence and have them internalize a new view of
themselves “I can do it, I’m a sex worker but I can be somebody. (…) They are smart people,
just that nobody told them”.
Several informants mentioned that it’s common that the female sex workers think that they
are doomed to sell sex, that it’s their destiny and the plan of God. The TLH-DIC is saying,
they thought that sex working is my destiny, you know. There is nothing else for me, there is
nothing else for me. This is what God gives me to live with. They’re just thinking like that you
know. (…) It’s my destiny. When God created me he just let me be a sex worker.
This way of thinking about destiny is also something that can have an impact on the female
sex worker’s motivation of changing their thinking and behaviors. The TLH-DIC goes on,
“It’s preprogrammed, they think that… It’s preprogrammed. If God let me be sick, I’m gonna
be sick. If God let me be with HIV, I’m gonna be with HIV, so what’s the need for my care?”
What also is frequent is that the female sex workers don’t even know that there are other
works for them. This was mentioned in one of the FGDs and one of the girls, who quit sex
work said,
I never thought that I could get money in any other way except do sex work (…) after I came to
this place, I got training for four days, and then found out that we can get money in other ways too.
(…) so that’s why I stopped. Now I’m at the cooperative, I’m a member of the cooperative. I had
no idea that I could get money other than doing sex work.

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 All the girls in one of the FGDs wanted to start earning money in other ways than selling
sex. One girl is saying, “I have no money now. I have to get the money. I don’t want to do
the work. It’s money you know. (…) If I had money, if I get the money. I need learn
hairdressing style. I need training (…) I hate this job”. Another girl from the same FGD says,
“I need only money and change my life”.
If, or once the female sex workers start to earn money, there is a need of teaching them
how to handle that money, as well as the money they earn from selling sex. The female sex
workers are taught business skills and how to look after their money. This part of the activity
seems to have vital meanings in the female sex worker’s lives. One girl in one of the FGDs is
saying that she got help to put “money in the bank” and that the DIC helps her to have
“money in her pocket”.

Engaging female sex workers in distributing and selling condoms

The female sex workers from the DICs and cooperatives are participating in different
campaigns and events, where condoms and other contraceptives are being distributed,
demonstrated and sold etcetera.
They are also part of making condoms available at diverse venues like bars and hotels, so
these spots can stalk and have condoms accessible at all time.
The female sex workers also get the opportunity to enter the selling of contraceptives in a
business called “24 hour condom shops”, as another IGA.
In Ethiopia, the cost for condoms changes after midnight, the cost gets higher. This causes
less buying and use, which may result in an increase in transmission of different infections.
For this reason, DKT launched this “24 hour condom shop” project in order to make
contraceptives available at all time, for a fixed and constant cost.
DKT argue for having female sex workers selling condoms in these shops by saying that
this serves as an alternative IGA for the women. The DKT-WU calls it a “win-win for all of
us”, condoms will be available for a cheap and fixed price and the female sex workers will be
offered an alternative way of earning money.
The TLH-DIC is talking about selling condoms as the best way of getting money instead of
selling sex.
Most of the females are the most vulnerable or the marginalized section of the society, so, this is
the best way for them to earn other means of income, you know. (…) DKT is benefitting from the
sells of condom, and (…) the females are also benefitting from the condom sales (…). It’s another
means of, an extra means of income. You know, rather than sex working. (…) No one is forcing
them to sell the condom, you know. If they want, they do it. It’s based on a mutual agreement
between DKT and the sex workers. (…). So it’s based on their free choice.

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A protecting home
“This is just like a home, the DIC. In the hotel places, the sex workers are fighting, chewing
khat and abused to alcohols (…) The DIC is my home, this is a free place. I’m happy.”
The DICs, seem to be the absolute most important part of the Wise Up project for the female
sex workers. A significant number of them are homeless or staying in small rooms together
with plenty other people. The informants are stating several parts of the DICs that have
positive and important impact in the female sex worker’s lives and daily living, everything
from taking showers and sleep, to a more social dimension like watching movies, drinking
coffee and talking about life together.
The DKT-WU about the DICs, “The Drop In Centers are supposed to be sanctuaries for
the sex workers (…) and they enjoy being there. But if they also have questions, there are
answers right there”.
In one of the FGDs the girls were asked why they enjoy coming to the DIC and they all
said that the main reason for coming, and coming back, is because they feel free at the DIC
and that, compared to other places, the DIC is a calm and safe place where they can rest, take
showers, watch movies and wash their clothes without having to worry about thieves or
fights.
Another thing that the girls refer to as important and good for them is that it’s forbidden to
smoke, drink alcohol or use drugs at the DIC and that this makes the DIC a place where they
can stay safe from getting exposed to that. The alcohol- and drug prohibition was also
mentioned by the girls in one of the FGDs, as a way of saving money. Staying at the DIC
during the days are helping them not buying alcohol, cigarettes, khat or other drugs for their
money.

A voluntarily exit out from sex work and referral activity

The final findings of theme two is sometime that was highlighted in numerous of the
interviews. This was that all the activity that the female sex workers are provided with are
voluntarily. No one is being forced or pushed in to doing certain things or making certain
decisions. The TLH-WU expresses it like,
You know, we just put alternatives, we don’t force them you know, it’s based on their willing,
that’s all. (…) The decision is up to them, we just make them free and they decide. We don’t force
them to be engaged in other alternatives, income generation skims or what ever (…) it’s up to
them to decide. After all, we’re helping them to help themselves.
TLH-SM has the same perception, “So, we’re not just influencing “you should do this”,
you know, we’re not obligating them, we’re just introducing the concept. (…) So it’s up to the
person to choose the kind of life that she wants to live, but we’re going to offer the choices”.

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 Their hope is to empower the female sex workers, so they can decide to leave the sex work
and begin another life. The TLH-WU continues,
Our hope is (…), of course the projects goal is to reduce (…) the HIV prevalence. But you know,
at the end of the day, when these sex workers are empowered, economically and socially
empowered, they will leave that job and then they will start their own very safe way of life. They
will not be exposed to HIV or AIDS or other STIs or other related problems.
The DKT-WU is also talking about their activity as a possible exit out from sex work as
well as the voluntarily part of it,
(…) for those who wants to quit sex work, this is an exit, a strategy. If they want to quit, there is
an option, of course they may not make as much as they make in sex work, but if that’s what they
want they will take this. (…) some of them say “I don’t want to be sex worker, it’s because I have
no other option”. And we, actually we don’t (…) ask them to quit or anything, but if they want to,
here is an option.
If a female sex worker wants to quit sex work, the DICs will help that person by referring
the person to the accurate place for doing that. This is also how it works if someone needs
assistance in receiving HIV- or STI testing etcetera. The DKT-WU says,
If you need, we have assistance, this is where to go. If you need HIV testing, this is where you can
go. If you need STI testing, you can go here. If you need to quit sex work, here are organizations
that work with that. Because we don’t work with that, we just work on their safety.
This part of the Wise Up program’s DIC activity seemed to be requested in one of the
FGDs. The girls in this group clearly expressed their feelings about their lives and that a
change is needed for them. “I hate the prostitution life so hard you know, it’s my hard life, so,
I need to change my life” Another girl says, “I’m afraid for the work, the sex work. I’m afraid
and I’m new for the working… so hard.” A third girl concludes this section of the FGD by
saying,
I don’t expect… I don’t feel… I have no dream you know… so hard. I can’t say you nothing, I just
live day-to-day life you know… I need get out, I need out of this work. I need to get out this work
and I need to live with my family… I’m 19 years old.

Analysis, theme two

The organizations say that they strive to provide their main target, female sex workers, with
empowerment in various ways. I’ve divided the findings from theme two under three
headings that I think serve as good headings in understanding what the informants are saying,
influence and control the environment – from a passive to an active state, ability to achieve
increased self-determination and finally, voluntarily approach – a way to increase the sense
of choice. The findings will be analyzed and discussed based on the empowerment chapter of
this essay’s theoretical framework.
When I write “the informants”, I refer to the informants from the six qualitative interviews.
When I refer to the participators in the focus group discussions, the FGDs, this will be
announced.

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Influence and control the environment – from a passive to an active state
The organizations are keeping a great focus on the condom negotiation that they teach the
female sex workers in. They teach them various techniques in negotiating condoms with their
clients, but they are also teaching the female sex workers about condoms and the use of using
them correctly and consistently. One of the reasons for this is to minimize the risks for the
female sex workers of getting exposed to HIV/AIDS or other STIs, but the main reason for
training the girls in condom negotiation seems to be to increase the girl’s abilities in taking
control over diverse situations. Not only should the girls learn to negotiate condom use, they
should also adapt the habit of always carrying own, safe, condoms as well as learn how to act
in various possible situations that can occur in their work.
These things can all have impact on the female sex worker’s environment. Negotiate
condoms with clients affect the communication with the clients, but most important, it might
affect the client’s attitudes towards using condom or not during sex.
This focus on the organization’s trials in increasing the female sex worker’s control can be
seen as a way of provide the female sex workers with empowerment by impact the external
part of their empowerment processes. Sadan means that empowerment is “an interactive
process which occurs between the individual and his environment” (Sadan, 1997, p. 75) and
that being able to act and actualize various skills, like condom negotiation, is something that
can enable people, female sex workers, to take part in decisions concerning their lives. Out
from Sadan’s words about the external part of the empowerment process, it’s possible to say
that the organizations do strive to provide the female sex workers with what Sadan calls the
external part of the empowerment process, namely political empowerment (ibid., p. 76).
Another part of Sadan’s political empowerment is the “capability of taking control over
resources in the environment and taking part in decision making” (ibid.). The organizations
work with influencing the female sex workers to always, no matter what, carrying their own
condoms during work, can be seen as one way of striving to attain this type of empowerment.
If the female sex workers always have condoms available, and if they possess skills in
negotiating the use of these, the chances of that the condoms are being used increase, and the
risk that the female sex workers are being exposed to any kind of infection decreases.
Sadan means that it’s people’s action from a passive to an active state that is the essence of
the empowerment process (ibid.). The female sex workers get education and trainings on
condom use. One of the informants in one of the FGDs states an example from when she
refuses to have sex with a client when he tries to have unprotected sex with her and that she
put on new condoms on his penis repeatedly. She had condoms available, she knew how to

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use them and the use of using them – she was not passive but active in this situation as a
result from her knowledge.

Ability to achieve increased self-determintation

A prerequisite that may be necessary to be able to act in certain ways is that the person
feels that she/he has the ability and the skills to act. The informants say that they are trying to
empower the female sex workers psychological, for instance by working on their self-esteem
and their self-images. The NIKAT-FUN says that the female sex workers need to hear that
they are smart and capable and that this could be something they’ve never heard before. They
want the female sex workers to internalize a new view of themselves as persons that can
change and manage on their own in other ways rather than sex work.
Of Sadan’s empowerment process this part of the organization’s work can be seen as a way
of influencing the female sex worker’s internal parts of their empowerment processes. She
means that a person’s belief in her capability in solving her own problems and making own
decisions is the internal part of the empowerment process and she calls it psychological
empowerment (ibid.).
The organizations are trying to provide the female sex workers with psychological
empowerment not only by working on their self-esteem but also by providing them with
opportunities to be engaged in various IGAs. They work towards changing some of the
female sex worker’s perceptions, for instance that it’s their destinies to become sex workers,
and they present other alternatives that can generate money for them, but also generate more
power over their lives.
One informant in one of the FGDs said that she didn’t even know about other ways she
could earn money than sex work before she heard about it at one of the organization’s DICs.
Some informants from one of the FGDs spoke in terms of that if they had money, they
could change their lives and that they need the education they can get through the
organization’s cooperatives to receive this.
This can be understood with Bandura’s term self-efficacy. He means that a person can
attain this type of self-empowerment if the person perceives a belief in her/his ability to
change ones life aspects and control occurrences in her/his life (ibid., pp. 77-78).
One example from the organization’s work that might be a result out of perceptions of self-
efficacy by the female sex workers are the informants from one of the FGDs that now are ex
female sex workers who are supplying themselves through the organization’s cooperative
activity. It is likely that this change was preceded by changes in the person’s feelings and

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believes in themselves and their ability to have influence in their own lives - a sense of self-
efficacy was developed.
The organizations are somehow striving to provide the female sex workers with tools that
can be useful for them in various situations. Carrying condoms, possess knowledge of how
they should be used correctly, negotiating condoms etcetera, can be seen as ways for the
female sex workers to protect themselves from getting transmitted of HIV/AIDS or/and other
STIs. By receiving information and education, as well as various skills, they also get the
opportunity to increase their chances of staying safe from infections. This is important of
several reasons, not the least that they are considered as a population group that are most at
risk and the fact that they, just as the DKT-WU said, are exposed to risks day and night.
The informants emphases that the female sex workers that took their trainings on
HIV/AIDS, STIs and condom use negotiation are empowered to say no to unsafe sex. The
informants in the FGDs also confirm this - they wont agree to unprotected sex even if they get
extra money. It’s clear that they have received knowledge about the risks in not using
condoms and various techniques in influencing their clients in using condoms.
One example on this is from the informant in one of the FGDs who says that she knows
everything about condom use, that she always has condoms available and that one of her
ways of getting her clients to understand that she wont agree to unsafe sex is by wearing
clothes and accessories with “Mr. Condom” on that she received from the organizations.
Other informants in the FGDs also mentioned the use they have from the organizations
trainings on condoms and negotiation, they now know more about condoms and they use
them. They also told stories about when they teach their clients in how to use condoms
correctly.
These things can be understood through Rotter’s concept Locus of control, a psychological
construct of self-empowerment (ibid., p. 77). The female sex workers get the chance to
develop qualities that can strengthen their expectations in their abilities to control and
command outcomes in their lives, which is the internal locus of control – the female sex
workers can in some ways impact what happens in their lives, by negotiating condoms and
having condoms available etcetera. If the female sex workers were completely out of
possibilities in having impact on their environment and the outcomes in their lives, they
wouldn’t possess what Rotter call individual empowerment through internal locus of control;
they would stay in an existence of lack of power, since they then would believe that it’s only
external factors that have impact on their lives (ibid.).

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Volontarily approach – a way to increase the sense of choice
The informants stresses that the activity they offer female sex workers at their DICs and sex
workers cooperatives is on voluntarily basis. They mean that they don’t force anyone to adopt
any kind of behavior or act in certain ways. They don’t tell the female sex workers they meet
what to do, or not to do, they say that they provide them with choices and alternatives that
they are free to respond to if they prefer.
The DICs are places that are open for all female sex workers that wish to visit them. The
informants in one of the FGDs said that they feel free at the DIC and that the DIC is one way
to stay away from drugs, alcohol and fights. The DICs are places that provide the female sex
workers with a decent and safe environment where they can meet people who say that they
want their best by offering them support in various ways.
This approach of volunteerism that the organizations are keeping towards the female sex
workers can be one way of providing them with empowerment in terms of perceived feelings
of control and personal agency. According to DeCharms (1968) a person is more likely to
establish a behavior if the person feels that the behavior comes from ones own choice (Chua
& Iyengar, 2006, pp. 43-44). The organizations provide the female sex workers with
alternatives, for instance by letting them know the possible benefits in always having
condoms available. They’re not using phrases of forcing character, but formulate their
messages in ways that open up alternatives for the female sex workers.
This can be understood as a way of working to attain that the female sex workers not only
shall experience a sense of that they make own decisions in their lives but that they actually
do chose how to act based on their own decisions. DeCharms means that persons who
experience that their behavior is a result from that person’s own choice, and not from external
factors, will value this behavior (ibid.). In this case it could be the habit of carrying condoms
or negotiating condoms or even quit sex work, if other circumstances contribute to that
ability.
This can also be seen through Deci’s (1981) words regarding that people are more likely to
appreciate and continue with activities that gives them the opportunity to make choices to
determine and control their own fates (ibid., p. 44). That the informants in one of the FGDs
said that they feel free at the DIC and that it’s like a home for them is something that indicates
on that it’s a non-forcing atmosphere at the organization’s activities, which can result in
Deci’s thoughts on self-empowerment.

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 According to Starrin, empowerment is every process where people get the chance to own
their own lives. He means that a person can achieve empowerment when the person
experience decreased feelings of powerlessness (Lundberg & Starrin, 1997, pp. 12-13).
The organizations division of the empowerment they wish to provide the female sex workers
with, knowledge and economical empowerment, are both possible ways to provide vulnerable
people with empowerment. By giving the female sex workers the chance to get knowledge
and awareness about how they best can try to protect themselves from getting transmitted of
HIV/AIDS and STIs, the organizations are providing the female sex workers with alternatives
that can result in feelings of control and power.
The organizations work with helping the female sex workers to register cooperatives as
well as engaging them in various IGAs as an alternative income to the money they earn
through selling sex can somehow be explained with Askheim’s means that people can get
empowered when they get strength to leave a state of powerlessness and get more influence in
their lives (Askheim & Starrin, 2007, p. 18).
The World Banks definition of empowerment can summarize what has been mentioned
above. According to them, empowerment is “the expansion of choice and action” by the
means that if people get increased control over decisions and means that have impact in their
lives, they get empowered (Narayan, 2002, p. 39). The female sex worker’s opportunity to
influence and control their environment, their increased ability to achieve increased self-
determination as well as the choices and alternatives they are provided with, can be
understood as a way of receiving empowerment related to The World Bank’s definition of the
concept.

Conclusions and discussion

The aim with this study was to examine how Social Marketing can be utilized in the
prevention work against the spread of HIV/AIDS and STIs in Ethiopia in order to impact
people’s attitudes and behaviors. The study also referred to explore whether various Social
Marketing projects strive to provide vulnerable groups of the Ethiopian society with
empowerment, and if so, in what ways.
In summary it’s possible to conclude that Social Marketing can, and is, being utilized in
several various ways in the HIV/AIDS and STI prevention work in Ethiopia. The concept is
used in larger and smaller occasions at more or less visible locations. The main aim in the
organization’s work with Social Marketing is to utilize it as a tool to communicate various
messages that aim to affect the prevalence of HIV/AIDS and STIs in Ethiopia by impacting

72
people’s attitudes and behaviors when it comes to knowledge and awareness about HIV/AIDS
and STIs, as well as sexual behavior. Through a tenaciously work with spreading information
about HIV/AIDS and STIs, condoms and condom use, by using billboards and IECB
materials etcetera, the organizations strive to make people think about condoms and condom
use as frequently as possible, of the reason that they believe that this can increase the habit of
using condoms.
Out from this essay’s theoretical framework and analysis chapter it’s possible to conclude
that the way the organizations are conducting their work with Social Marketing, which in this
case is selling the behavior “condom use”, might result in behavioral changes by their target
group out from what has been written about human behavior.
Conducting Social Marketing of condoms and condom use in a society like Ethiopia is not
simply an uncomplicated activity. The majority of the Ethiopian society is conservative
religious, which is one of the contributing factors to that speaking openly about condoms, sex
and sex work can be seen as something very controversial.
The organizations are brave and norm breaking with the work they are conducting. They
are challenging prevailing norms and patterns that exist in the Ethiopian society. Their work
is an innovative and an important contribution to the HIV/AIDS and STI prevention work that
are being conducted throughout the country.
The way they use Social Marketing to spread knowledge and awareness about HIV/AIDS,
STIs, condoms and condom use is communicated in an including way, by means that
numerous of people have the chance to take part of and understand the organization’s
messages since they are conveyed in simple and understandable ways.
The organizations work with availing condoms at numerous of places to affordable prices
is also having an in including and important effect of the HIV/AIDS and STI prevention
work, since it facilitates the access of condoms, which can increase that they are being used.
The fact that they are sold for a highly subsidized price increases the opportunities for more
people to be able to afford condoms.
One part of the organization’s work that has been given a great focus in this study is the
Wise Up program. This program has served as the Social Marketing project, which I referred
to explore in this essay’s second research question. My question was if these kinds of
projects, like the Wise Up program with its Drop In Centers and Sex worker cooperatives,
strive to provide vulnerable people with empowerment, and if so, in what ways.
Out from my empirical material and the analyze that’s been made in this study based on
various definitions and perspectives on empowerment, it’s possible to answer yes on this

73
question. The Wise Up program do strive to provide vulnerable people, female sex workers,
with empowerment and they strive to do it in various ways, psychologically as well as
economically.
This study’s findings show that DKT Ethiopia, TLH Ethiopia and NIKAT Women
association’s activities Drop In Centers and Sex workers cooperatives are unique. These types
of places are not many and number, but their existence seems to play a fundamental role in
their female sex worker visitor’s lives.
That the organizations are putting their absolute main focus on their HIV/AIDS and STI
prevention work on female sex workers is because they are considered as one of Ethiopia’s
most at risk population groups. One of the arguments for this is that female sex workers are
considered as a bridging group, by the means that people from the “general population” that
buy sex from sex workers might get transmitted of some STI since numerous sex workers are
infected with STIs.
This way of focusing on the female sex workers rather that the once that buy sex, as well
as prostitution as a phenomenon, need to be problematized in some ways.
In Ethiopia, sex work is considered as something shame- and sinful and sex workers have
very low social status. Yet, prostitution and buying sex from a sex worker is very common
and normalized in Ethiopia, although barely no focus or responsibility are put on the sex
buyers in comparison to the sex workers.
That the organizations chose female sex workers as their absolute main target is something
that of course can, and do, help and strengthen numerous female sex workers in protecting
themselves from getting transmitted with HIV/AIDS and/or other STIs, since they are
frequently exposed of getting infected. What is at risk of becoming complicated is that a lot of
responsibility is put on the female sex workers, rather then the men that are buying sex, when
it comes to condom use and knowledge about how and why condoms should be used
properly. Obviously, the chances that a condom will be used during sex increases if condoms
are available, which the female sex workers are urged to ensure. This is something good, but
in my opinion it’s desirable that a further, more focused discussion concerning the buyer's
knowledge, behavior and responsibility is being pursued and given a greater focus in the
HIV/AIDS and STI prevention work.
Another part of this study, which I want to raise in this discussion, is the indwelling ethical
issues in speaking in terms of “providing someone with empowerment”, since talking in terms
about providing another human with empowerment somehow runs against the empowerment
concept. It’s of importance to not adopt a “top-down“ perspective by defining and

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formulating other peoples needs and interests, but to embrace an approach where the
organization’s main target – female sex workers, are given opportunities to be heard and able
to set their own needs and wishes.
Using the term empowerment in this context can be very hard and complicated, if not in
some ways impossible. These women, female sex workers in Ethiopia, are living in a
multidimensional pattern of inequality. They are not only living in a society, which contains
structural inequalities and subordination for women, they also work with selling their bodies,
which often contributes that these women get stigmatized. Numerous of the women are
homeless and very poor. This is yet another condition that contributes to that it’s in one
perspective even may seem bizarre to speak about empowerment for female sex workers in
Ethiopia. They are in many ways very dependent on earning the money they do from sex
work in order to survive every day. This is an important perspective to take into account when
understanding the sex worker’s motivation in adopting the behaviors the organizations want
them to adopt.
Conducting trainings on condom negotiation for female sex workers is a significant
activity and it most probably contributes to an increased level of condom use. But, once
again, the sex buyer’s part of it needs to be reviewed. The female sex workers are
”empowered to use condoms”, yes, but when it all comes around, it’s the men, not the female
sex workers who decides if the condom will, or not will be used. The female sex workers are
trained in saying no to unprotected sex and leave if a client disagrees to use condoms.
Encouraging the female sex workers in saying no, and leave, is good and important, but it also
needs to be understood through the perspective that it may involve risks, such as violence and
threats, for sex workers that choose to leave their clients.
It’s also the sex clients who have the money, money the female sex workers need, in many
cases just to survive. This means that it’s the clients who set the terms, for instance by
offering more money to have unprotected sex. For a person who doesn’t have any money, or a
home, it can be hard to not agree to such an offer/requirement. This contributes to difficulties
in talking in terms of that the female sex workers have true opportunities to “choose” in
various situations.
For these and several other reasons, it’s of great importance to continue the work towards
increasing female sex worker’s empowerment in Ethiopia. But as long as strong, traditional
structures exists, this work is at risk of focusing too much on how these women, female sex
workers, should gain strength and power to control or/and change their life situations, rather

75
than aspects that contributes to that women end up and have difficulties in leaving the
situations they gotten in to.

Epilogue
Social Marketing offers various methods and techniques that somehow are more inventive
and innovative than traditional ways of reaching people with information and knowledge that
could be of interest and inspiration for social work. Its broad concept opens up for new,
creative ways of communicating and spreading various messages in order to attain social
change.
Social Marketing’s entertaining elements helps social marketers to attract and get contact
with a vast number of people by making them curious and interested of things they otherwise
maybe never would have known of.
The technique is also a way of publicize information and awareness concerning
phenomena that are complex to reach the society with because of their controversial
characteristics.
Out of these and further more reasons, using Social Marketing in the prevention work
against the spread of HIV/AIDS and STIs can be an important tool to efficiency the
possibilities in attaining contact with people in order to achieve attitudinal- and behavioral
change, for instance towards HIV/AIDS, STIs, condoms and condom use.
The organizations DKT Ethiopia, TLH Ethiopia and NIKAT Women association are not
social work organizations, and they are not claiming that they conduct social work. Yet, they
are conducting social change work that in many ways relates to existing social work methods
and theories.
According to the definition of social work that was presented in this work’s prologue, the
social work profession encourages social change and empowerment of people in order to
increase well-being. Social work do also strive to “enable all people to develop their full
potential, enrich their lives, and prevent dysfunction”6 Out from this it’s possible to reason
about whether DKT Ethiopia, TLH Ethiopia and NIKAT women association’s work can be
linked or/and be defined as social work.
According to this work’s findings and to the definition of social work, I’d say it’s fully
possible to claim that the work the organizations are conducting can be liked and even defined
as social work. The fact that the Social Marketing they use in their work is based on the same

6
http://ifsw.org/policies/definition-of-social-work/

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theories on human behavior as social work is, and that they also developed projects that aim
to strengthen individuals in ways that relate to the core of social work, contributes to this
conclusion that the organization’s work can state an example of social work that are being
conducted by non professional-social workers, but social marketers.

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Web pages
http://ifsw.org/policies/definition-of-social-work/

http://mdgs.un.org/unsd/mdg/Host.aspx?Content=Indicators/About.htm

http://www.indexmundi.com/ethiopia/demographics_profile.html

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http://www.nikatethiopia.com/

Sections of the Swedish law

Law (2003:460)
http://www.notisum.se/rnp/sls/lag/20030460.htm

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Appendix
Appendix 1 - Consent form
Consent form
This is a consent form for participating interview respondents for my bachelor essay, which
addresses the issue of preventive work against the spread of HIV and STIs through Social
Marketing in Ethiopia. The purpose of this paper is to obtain an overview of how Social
Marketing is used as a utility in the prevention of the spread of HIV and STIs.
The study will be conducted through semi-structured interviews and focus group discussions
with people working on different organizations, which are working against the spread of HIV
and STIs in Ethiopia. These interviews will be recorded and transcribed. It can also apply
spontaneous interviews with people who work in the field and/or with people living in
vulnerable areas.
I will use previous studies and current research on the topic to accomplish the study.
Data collection takes place during eight weeks in Addis Ababa and in areas around the city.
After this, I will finish my writing. The essay is planned to be presented and examined by
Ersta Sköndal University College in August 2012.
The research will not present any risks for the participating informants. The interview
material will not be accessible by anyone other than me during the paper writing and after the
study is completed, all recordings and notes from the interviews will be discarded.
Ersta Sköndal University Collage, Stockholm, is the responsible principal for this research.

All participation in this research is voluntary and you have the right to withdraw your
participation at any time.
As a thank you, you may if you wish, get a copy of the finished work.

I have read and understood the above and I accept that what I say during the interview can be
used in the essay.

_____________________________
Signature (please print)
Thank you for your participation!
Matilda Johansson
Ersta Sköndal University Collage, Institution of social work, Stockholm

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Appendix 2 - Invitation to focus group discussion (English version)

2012-04-19

Invite to take part in a chat about the WISE UP programʼs Drop In Center and
cooperative activity
My name is Matilda Johansson and Iʼd like to invite you to participate in a one-hour
chat about the WISE UP programʼs Drop In Centers and cooperatives, if and how
these activities might affect your life and daily living.
The reason for this is that Iʼm in Addis Ababa to write an essay about Social
Marketing in Ethiopia.
No names will be mentioned in the paper, it is completely confidential. You wonʼt be
forced to answer any questions, itʼs totally voluntary, and you decide what you want
or not want to respond to.

The discussion will take place Friday April 20th at Bole/Yeka DIC, at 10.30-11.30.

You will be offered 30 Birr in compensation for your participation.

Your thoughts and knowledge are very important!

Hope to meet you!

Warm regards,

Matilda Johansson

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Appendix 3 - Interview guide, qualitative interviews
INTERVIEW GUIDE
Theme one:
Questions:
• How do you define Social Marketing?
• What different kinds of projects are there in the prevention work against the
spread of HIV and STIs, in Ethiopia in general?
• Why did TLH start working with SM? What’s the story?
• Who educated people at TLH in SM?
• What is the main message for your work?
• How do the SM projects at TLH look like? Why do they look like they do? How
did the organization think and argue when different SM projects were
developed?
• What priors have been done in ways of working? Why?
• Does the work differ from how it was “supposed” to look like, if so, in what
ways?
• If you got the chance to change anything about the work/projects, what would
that be, and why?
• What groups of people does the work focus at? Why?
• MARPs, Most at risk population, could you please define who these people
are?

• Why did you choose to work with MARPs?

• In what ways does your work with SM affect the spread of HIV and STIs?
• What is needed to make the prevention work act preventative?
• How can SM change/affect attitudes?
• Ethical dilemmas with working with behavioral change?
• Do the different SM projects in your different regions differ from each other? If
yes, why do you think that is?
• How do you measure if social marketing has an affect in the HIV prevention
work?

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Theme two:
Questions:
• How do you define empower when the term is used in your work?

• Do you strive to empower your target groups? If yes, how, in what way and for
what purpose?

• Do you work with some projects that includes education about HIV, STIs, how
the infections are transmitted, how different contraceptives are used etc.?
How? Why?

• Can you please define your peer education project and it’s aim?

• Can you please define what your outreach coordinators are doing and why?

• What is the aim of your sex worker cooperatives?

• What is the aim of you Drop In Centers?

• Are you working with male sex workers? If yes or no, why?

• Do you help your target groups getting educated in reading, writing etc.? If
yes, no, why?

• Are you discussing poverty and it’s possible consequences for people’s life
and behavior?

• How do you try to get people to join/come to the cooperatives and DICs?

• Do you think the poverty, many of the people you’re working with are living in,
affects their interest in your organization?

• What are the goals for getting people to come to your different activities?

• How do you talk about prostitution with your target group “sex workers”?

• How do you argue about your way of talking or not talking about some certain
things? Ex, prostitution, poverty, violence, education.

• How come you provide counseling for your target groups? Aim of the
counseling?

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 • Social marketing often includes a strive to change peoples behavior and
attitudes, is that focus included in your work? How? How do you think about
ethics related to this?

• Do you think your target groups are having a free choice how to live their life?
If yes, in what way, if no, explain.

• Are there any financially interests in the organization? From who, in what
way?

Theme three:
Questions:
• Do you face any difficulties in your work?

• How do you get people to change thinking and attitudes?

• How do you achieve this without making them feel forced?

• What are the different perceptions about how HIV and STIs are transmitted?
(Lack of education/knowledge, taboos etc.)

• Can you define any patterns in how different groups receive, or not receive
your messages and what are your explanations for it?

• Is your work mainly about having people changing attitudes or giving them
knowledge?

• Would you define your work as norm breaking and controversial? (Does it
goes against social norms?) If yes, in what way? Does it affect the work?

• Is it OK to speak openly about HIV, the amount transmitted, the seriousness of

the virus and contraceptives etc. in all social contexts in Ethiopia?

• Do you face any cultural barriers in your work? (Religion, people with different
education, people from different areas, age differences etc.)

• What respond do your organization and your work get by different groups in
society? Are there any taboos about this phenomenon in the Ethiopian
society? Ex. Orthodox Church, Islam, etc.? How do you cope/face their

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 response? Is their any difference in how the different religious groups respond
to your work?

• WISE UP project’s target group is sex workers, their clients and gatekeepers.
Talking openly about specific groups like that, confirms that prostitution occurs
in Ethiopia, how is that received and how do different groups in the society
react on that?

• In what ways does the government help/hinder your work?

• MSM is a group where HIV and STIs occur, how do you think this target
should be faced in Ethiopia?

• How/do you think TLH should work with it?

• Have you experienced any contradictions within the organization in terms of

how the organization should or should not work? If yes, what kind? How did
the organization cope with them?

• Was their any difficulties in the organization’s work before that the
organization’s not dealing with any longer?

Theme four:
Questions:
• Can alternative, creative methods of working develop the work with HIV and
STI prevention? In what ways and why?

• Do you think the creative parts of the SM technique affect your ability to reach
and work with people? If yes, how and why?

• Do you think your different creative activities affects your target groups and
how they are doing and feeling? If yes, how and why?

• Do you think the creative parts of your activity develop your work? In what
ways and how?

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• What are the thoughts behind the creative parts of your work? For example,
what is the idea with the condom man? Is he supposed to be funny,
controversial, uncontroversial or provocative?

• How do you want people to react on your different creative campaigns and
messages? What reactions do you want?

• Why do think the different creative incentives appeals the organization’s target
groups?

• What results does the organization want from the creative campaigns?
Manifest? Create interest? Spread knowledge?

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Appendix 4 - Interview guide, focus group discussions (English version)

• How did you get to know about this DIC?

• How come you got interested in visiting the activity?
• What is the best thing about having a DIC to visit?
• Have this opportunity, to come to this DIC, changed your life in any kind of way?
• Are you learning something here? (Practical – Theoretical)
• Do you know something about HIV/STIs that you didn’t know before you came to the
Wise Up program? (Same question about contraceptives)
• Do you feel that this activity has impact on your life?
• When it comes to negotiating with your clients about condom use, do you thing the
Wise Up program helped you with that? In what way?
• What are you doing if a client refuses to use a condom?
• Do you think the Wise Up program’s ways of trying to get people to use condoms is
working? Why? Why not?
• What do you think about having condom pictures everywhere?
• How is your peer education working?
• Do you feel that the Wise Up project gave you opportunities to make different choices
in your lives?
• Is it something you feel that you need that you’re not getting here today?

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Appendix 5 - Definition of terms

Social marketing
Adjustment of traditional marketing techniques to social goals. (UNAIDS, 1998, p. 3)

HIV
Human Immunodeficiency Virus. (Merritt, 2010, p. 216)

AIDS
Acquired Immune Deficiency Syndrome. (Merritt, 2010, p. 216)

STI
Sexually transmitted infection (Federal HIV/AIDS Prevention and Control Office, 2010, p. ii)

MARP’s
Most At Risk Population (Federal HIV/AIDS Prevention and Control Office, 2010, p. ix)

Vulnerable people
People that are exposed or at risk in various ways.

Condom
When the word condom is used in this essay, it refers to male condoms.

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