1. Introduction

Emergency Contraceptive Pill (ECP), also known as ‘morning after pill’ is a form of birth control that can be used shortly after sexual intercourse to prevent unintended pregnancy as opposed to the conventional oral contraceptive pill (OCP) which is used before sexual intercourse (Dailard, 2005), ECP can be used in the event of sexual assault / rape, if intercourse occurred without the use of birth control, or partners found that a condom broke during sex or some other methods such as an intra-uterine contraceptive device (IUCD) failed.

ECP are among the 13 essential commodities in the framework for action established by the UN Commission on life-saving commodities for women and children (Dawson A, et al 2014). ECP has been available for more than 30 years, however many women across the globe have been unaware of its existence as an option for unprotected sex and where to obtain it, thus leading to poor accessibility and lack of correct information on how to use it effectively. This scenario is particularly true in developing countries including Malaysia.

Literature review indicates that ECP in relation to its demand and supply has not been extensively studied. Specifically, based on literature review there has been no studies on the effect of 4Ps (Product, Promotion, Price and Place) on the target group for intention to purchase ECP, although there are numerous studies on the effect of 4Ps on other products. This study therefore sheds light on the consumer perspective of the 4Ps and how it affects their purchase intention.

The practical contribution of the study is to enable policy makers and suppliers to re-strategies and redefine the roles of the suppliers based on the responses of the target group, particularly to re-strategies the sales and marketing strategies to upscale supply and improve access to ECP. As for theoretical contribution, the study applies Theory of Reasoned Action and explores the relationship between the 4Ps and purchase intention of ECP.

2. Literature Review

Literature review reveals gap in information on the effect of all 4Ps on the intention to purchase ECP, although a number of studies have highlighted on the effect of promotion on demand (Dixit A. et al., 2015; Rogan et al., 2010). This review therefore explores studies that are closely related to the issue. The fundamental marketing framework of the 4Ps and 4Cs has great potential for success if incorporated into the family planning programme (Harrison et. al., 2016).

The 4Ps (Product, price, Placement and Promotion) and the 4Cs (Customer, Cost, Convenience and Communication) encapsulates the commonly accepted framework through which the market dynamics are analyzed. Although successful business strategies addresses profit and loss, it cannot be negated that a strong marketing mix framework that focuses on the 4Ps and 4Cs as drivers of a healthy market has to be developed (Harrison et al 2016). The article indicate that developing and developed countries can benefit by defining the global contraceptive market to include the public, non-governmental, social marketing and commercial organization as a “Total Market Approach” to optimize the use of public and private resources.

A global review on current evidence in low and middle income countries on improving access to ECP indicate very little research on the commercial sectors important role in the distribution of ECP. Therefore, research that could provide evidence-based guidance for decision makers to best engage with the private sectors to improve access to ECP is necessary (Dawson et al, 2014). Similarly, Rogan et al, 2010 asserts that there has been considerably little attention to the influence of the markets, commercial interests and regulatory structures on the supply and promotion of emergency contraception. This could possibly be due to the erratic demand for emergency contraception which have an impact on the supply.

There has been considerable research on the potential consumer of ECP in terms of knowledge, attitude, practice among women who sought abortions regularly at abortion clinics and those who visit family planning and reproductive health clinics for their regular supply of contraceptives (Antenah et al, 2009; Eugene J.K et al, 2007; Farhana I et al, 2009; Nausheen F et al 2004; Myer L. et al, 2007; Maharaj P, et al, 2011; Mathew S. et al, 2005; Tajure N. 2010; Sandra G, et al 2008; Tesfaye T. et al 2012). These studies focused on the consumers’ perspective and sought their views on why women who needed ECP did not use them. The findings are almost uniformly consistent that women did not use ECP for various reasons which include lack of knowledge on its availability and usage patterns as well as where to buy them and misconceptions on the side-effects, including religious and cultural barriers. This is only one dimension of the equation in terms of the demand factors for the low uptake of emergency contraception. The other dimension of the equation being the supply factors in terms of the marketing mix of the 4Ps / 4Cs which need to be explored.

3. Promotion

Promotion is one of the key elements of the marketing mix and refers to either one or two way communication with the consumer using advertising and other ‘pull’ tactics. The promotion strategy involves key decisions such as who the consumer is, how to contact them and what message to be imparted (Kotler P et al, 2013). These questions are answered by the essential criteria of segmentation, targeting, positioning and advertising.

Dixit A, et al, 2015 in their study admits that aggressive promotion led to a high market share of the top 2 ECP brands (more than 84% sale), although there are 30 other brands of ECP in India. Similarly, Rogan M et al, 2010 in their study indicate that pharmacists and other health care providers agree that promotion by ‘word of mouth’ is the most appropriate strategy to promote emergency contraception, although information is available at public health facilities. Rogan et al (2010), further shows that emergency contraception is largely promoted in the private sector that it is in the public sector, reason being it is perceived that demand exists in the private sectors with consumers having the purchasing power, all that is needed is efforts towards promotion. Therefore, the private sector is targeted, as it is in this sector that the affluent women are and have the purchasing power.

In India at the time of introduction of ECP, aggressive advertisements by some manufacturers attracted negative attention and led to nationwide ban on advertising. It is asserted that the advertisements takes away responsibility from the act of sexual intercourse and leads to promiscuity (Dixit A. et al, 2015). This attitude seems to be the perception and believes of the policy makers. Contrary to this negative attitude, representatives of manufacturing firms indicated that if no permission is granted for advertising, than it would be an uphill battle to promote ECP in smaller towns and urban areas and as a consequence expressed concern that many firms may stop manufacturing it. However, in view of this predicament, the Government of India has relaxed its ruling to allow advertisements, provided a committee formed by the Ministry of Health and Family Welfare approves the content. Yet, despite this deregulation the long and slow procedure of government approval discourages manufacturers to seek for such approval.

4. Place

Place includes direct or indirect channels to market, geographical distribution, territorial coverage, retail outlet, market location, catalogues, inventory, logistics and order fulfillment (Kotler P, et al 2013). The placement of contraceptives is convenient to end users, available in accessible outlets such as pharmacies, drug stores, private clinics as well as public health centers (Harrison et al, 2016). The supply channels for contraception in Malaysia is through: commercial, public sectors and social marketing, as elsewhere in the world. Each of these channels has its own promotion and marketing strategies targeting at different segments of the population. For instance the commercial sector targets the affluent segments of the population through its network of private wholesalers and retailers, while the public sector focuses on the lowest socio-economic status, marketing through government hospitals, reflecting a social responsibility of government to its people. On the other hand, the social marketing segment targets the lowest socio-economic and hard to reach groups, with its network of clinic extension and community based distributors who are private suppliers and retailers affiliated to the social marketing organization, reaching out to the end user. The motive of the commercial sector is to make profits as compared to the public and social marketing sectors which are less motivated by profit and more towards social responsibility.

Dailand C (2005) in her article indicate that as a matter of management policy Wal – Mart, the third larger pharmacy with a wide network in the United States refuses to supply emergency contraceptive depriving women who solely rely on those pharmacies, especially in rural areas and in geographical isolation who may have no alternative sources for their needs. This would not be a sound business decision because allowing customers to go to a competing pharmacy could decrease profits, greatly affect the business and shareholders (Des Jardins, 2006).

Harrison et al 2010, is of the view that users are interested in product availability, along with convenience and privacy. The authors propose that a healthy contraceptive market makes birth control widely available in public and private facilities, including retail outlets and other regulated channels. Providers and pharmacists in these environments should be incentivized to recommend and provide products based on a woman’s health, medical needs, lifestyle and interest in spacing or limiting births.

Through culturally appropriate outreach, woman should know that her provider / pharmacist can suggest a method that best meets her personal needs and wants and can than help her select different methods as her lifestyle changes or when a product does not work for her.

5. Product

Product covers variety, quality, design, features, brand name, packaging and services (Kotler P, et al 2013). Harrison et al, 2016 defines product as the type of contraceptives (and packaging) that addresses the needs and wants of the end user, meeting a wide range of needs for a wide-range of customers. The lack of a product specifically packaged, labeled and marketed as an emergency contraceptive was a major obstacle to more widespread use of emergency contraception in the United States till 1998. Complete packaging occurred when Preven was approved and Plan B introduced in 2005 (Trussel J. et al, 2015).

Dawson et al, 2014 in their review of literature recommend that one of the promising strategies to upscale emergency contraception through branding of ECP packets and social marketing through media campaign and use mobile technology to deliver ECP information and advice. Harrison et al, 2016 asserts that a healthy market should offer a wide variety of contraceptives that are approved by appropriate regulatory agencies which meet end users’ needs and wants and that are perceived to be valuable. However, a healthy market in the eyes of the end user offers not only a wide range of methods but also a wide range of products and brands. The authors indicate that brands matter to the users as brands tell women what to expect and assure that they are making good choices. A wide range of methods, products and brands that truly meet women’s preferences needs to be available if we wish to sustain a healthy market over the long term.

6. Price

According to Harrison et al, 2016 price of the contraceptive is affordable to the end user and there are varying prices for varying perceived benefits. In India, consumers face barriers due to high cost (ranging from Rs 2 or USD 0.05 for the government brand to Rs100 or USD 2.5 for the most popular commercial urban brand of the product. High cost of many popular brands of ECP makes it less affordable to the poorer section of the population. In New Delhi, 24 out of 28 pharmacists’ qualitative interviews said they received 50 to 70 percent commission from medical representatives to sell their brand, thus hiking up the price (Dixit A, et al, 2015).

Good commission paid to the retailers’ was one of the contributing factors for high volume of sales of the top 2 brands (Dixit A, et al, 2015). This finding is consistent with that of Rogan M et al, 2010 where in order to encourage pharmacists to stock their product and promote it, manufacturers are forced to pay unusually high commission to the pharmacists thereby persuading them to keep the price high. Rogan M et al, 2010 asserts that the pharmaceutical industry is motivated by profit-driven prioritization referred to as ‘medical capitalism’. This behaviour sidelines the unmet needs of the vulnerable groups for emergency contraception, particularly those who cannot afford to pay, resulting in the hidden demand for emergency contraception.

According to Philisen NJ 2012, the financial incentives given to pharmacists for providing pharmaceutical services are very few, however the pharmacist’s income is largely dependent on the number of prescription drugs sold. Thus, it is imperative that all the more pharmacists are given financial incentives to motivate them to supply controversial drugs such as emergency contraceptive pills, as the pharmacists are expected to take extra care to counsel the client on the correct usage and the mechanism of action.

The procurement price for ECP varies by manufacturers and by brand, volume, specification / special ordering requirements, mode of shipment, competitors and quality. Several manufacturers are offering preferential price for the public and non-profit sectors, as an effort to increase access to ECP.

A study conducted by DKT International (an international social marketing organization) indicate the negative attitude of pharmacists resulting in refusing to sell emergency contraception fearing side-effects and irresponsible behavior. Similarly, a study in Nigeria (Bello M, et al, 2014) among newly graduate doctors shows their negative attitude towards Emergency Contraception will not allow them to prescribe the drugs. The findings of these studies are consistent with earlier studies (Richman et al, 2012, Ehrle 2011, Rogan et al, 2010, Lemme 2009, Cynthia 2005) that point to the negative attitude of the suppliers towards emergency contraception due to lack of knowledge and misconception of emergency contraception.

Attitude of pharmacists may be influenced by business ethics, as Hemphill TA et al 2006 asserts that the question of business ethics in the supply of emergency contraception emerges when pharmacies refuse to dispense such drugs. Besides the business aspect, the pharmacist has social responsibility to consider and to decide the importance of healthcare against the business component of the pharmacy.

7. Conceptual Framework

This study determines and investigates the effects of 4Ps on the purchase intention of ECP which is moderated by “attitude” and “subjective norms”. In its extended form which is an adaption of the Theory of Reasoned Action, the conceptual framework (Figure 2) shows the 4Ps of marketing mix on the far left, as the independent variables linking the “purchase intention” as the dependent variables. Attitude and subjective norm is used as the moderating variables between the 4Ps and purchase intention based on the Theory of Reasoned Action as the underlying theory. Previous studies did not show this linkage, particularly the 4Ps and the use of “attitude” and “subjective norm” as the moderating variables. The Theory of Reasoned Action serves as a useful model because it can help examine whether “Gen Y” intention to purchase ECP is influenced by the 4Ps, moderated by subjective norms (what others, referent think) and attitude towards the behavior (Selvarajah and Sulaiman, 2014).

8. Methodology

The study utilized quantitative methodology, to ensure a wider coverage, scientific in nature and at the same time subjected to rigorous statistical analysis. Data collection was through a simple random sample survey using a sampling frame used for the Malaysian Population and Family Survey 2014. The population coverage entails female “Gen Y” in the age group 22 to 39.

The sampling technique used for the study is probability or representative sampling, based on the concept of random selection. Also, the technique of probability sampling facilitates making inferences about the population based on the sample. The required number or sample size was determined based on 95% confidence interval and the number of “Gen Y” women in the study population with adjustments for non-response. Using the sample frame, the required number is selected randomly by using random number tables so that the selection of the sample is done without bias, making the sample representative of the population.

A questionnaire reflecting the independent and dependent variables were developed. This questionnaire was pilot-tested for reliability and validity and reviewed accordingly. The questionnaire was then printed in dual language (Bahasa Melayu and English) with a cover letter. It was then mailed to the selected sample, with a self-addressed return envelope. The completed survey questionnaires are edited for completeness and consistency and coded for data entry. The data is then computerized and analyzed using SPSS. The collated data is then presented in the form of frequency tables, cross-tabulations and pie charts. This study, in addition adopts the statistical analysis techniques undertaken by previous research (Sable et al, 2006) which used the Theory of Reasoned Action as the underlying theory. The statistical techniques include correlation, partial correlation, least squares and Generalized Linear Models.

9. Findings

Consistent with the theory of reasoned action, the intention to purchase emergency contraceptive pill is associated with positive attitudes with the perception that specific referent groups, such as partner, family members, and friends support purchasing it. But the perception of the support group did not predict intention, as the women have such strong opinion about the positive or negative aspects of purchasing emergency contraception that they ignore the reference groups’ perspectives. Attitude, subjective norms, behavioral beliefs about the outcomes of purchase intention and normative beliefs about referents correlated significantly with intention to purchase. The regression analyses shows that attitude and indirect measure of subjective norms predicted “Gen Y” women’s intention to purchase ECP. The more positive “Gen Y” women’s attitudes about ECP, the greater their intention to purchase and the greater the perception that specific referents approved of purchasing ECP, the higher the intention. On the other hand, the direct measure of subjective norms, did not predict intention to purchase.

The 4Ps in it’s entirely has an effect on Female Gen Y’s intention to purchase ECP, however the strength of the association of each of the “P” to purchase intention varies. The strength of the association to purchase intention in descending order is ‘place’ followed by ‘promotion’, ‘price’ and ‘product’. Attitude has a greater effect on product and place in purchase intention as compared to effect of attitude on price and promotion.

Based on emergency contraception knowledge score ranging from 0 to 5, the average score was 0.75. None correctly answered all 5 questions, 5% gave four correct answers, 10% gave 3 correct answers, 20% gave 2 correct answers, 30% gave 1 correct answer and 45% gave no correct answer to any of the questions. Most of them had the misconception that it is an abortifacient.

Among the ‘Gen Y’ women, who indicated their intention to purchase, only 10% were classified as having high intention to purchase, 40% as medium and the remaining 50% as low. High intenders were more likely than low intenders to believe that purchasing ECP reduces the number of unintended pregnancies, enhances a woman’s reproductive options and reduces the number of abortions. Also, high intenders as a matter of convenience would prefer an unprotected advance purchase of ECP in the event of sex or contraceptive failure. Conversely, high intenders were less likely than low intenders to believe that purchasing it discourages consistent contraceptive use, encourages unprotected sex, encourages frequent use of postnatal birth control, poses health risks, causes an abortion if woman has conceived, takes too much clinical time and is inconvenient.

The medium intenders compared to the high intenders were less likely to believe that purchasing ECP enhances a woman’s reproductive options, and were more likely to believe that it encourages unprotected sex, causes frequent use of ECP, takes too much time and is inconvenient. High intenders compared to the low intenders were more likely to believe that accessibility and convenience (place), has an effect on purchase intention. On the other hand, the low and medium intenders were more likely to believe that affordability (price), promotion and product have an effect on purchase intention. Knowledge of ECP is a prerequisite for purchasing and interventions that increase knowledge alone have been successful in increasing ECP purchasing (Dixit A, et al, 2015). The findings of this study suggest that for high intenders’ knowledge of ECP is not associated with the intention or willing to purchase it. However, for medium and low intenders where poor knowledge on ECP has a corresponding low purchase intention indicated a direct association. As low intenders consider ECP as an abortifacient, and if they morally object to abortion, they object to ECP on the same principle.

The study in answering the research questions, show that it supports the theory in terms of attitude but not for ‘subjective norms’. Furthermore, the 4Ps are associated to intention to purchase in varying degrees of strengths. Also, knowledge in general has no effect on purchase intention.

10. Conclusions

The effect of the 4Ps on purchase intention could be used by the suppliers, particularly the pharmacies and drug stores in developing appropriate marketing strategies to induce women to purchase and use ECP. In this regard, appropriate training curriculum can be developed. Specific strategies on place, product, price and promotion could be undertaken to give the assurance that product is safe, affordable, convenient and widely available. Furthermore, suppliers can counsel women on the need for advance purchase of ECP for all sexually active women. Emergency contraceptive hotlines can be set-up as well as use of mobile technology can be explored to disseminate information on the availability and proper usage of ECP. Furthermore, product training including mechanism of action can be provided to healthcare personnel to equip themselves to answer potential users’ questions.

The study also enables policy makers to review existing distribution channels toward setting-up innovative and creative distribution channels to enhance purchase behavior. Notwithstanding the above strategies new and state of the art product knowledge and information could be disseminated to the consumers to enable them to decide and use ECP confidently. The survey was anonymous, therefore no attempt was made to track non respondents. Another limitation was that the study measured only intention to purchase, and not actual purchasing behaviour. A prospective study design would be able to test the assumption of “Gen Y” women’s intention to reliably predict purchasing behavior.

The knowledge questions in the survey may not be a complete assessment of the women’s knowledge about emergency contraception to be comprehensive enough to track respondents’ knowledge. Last but not least, the study did not rely on a validated measure in categorizing intention as high, medium or low. It was assumed that women who scored an average of five on each item assessing intention were prone towards intending to purchase. Intention was categorized in this manner based on the belief that the greatest changes in purchasing may occur with interventions on the medium intenders. Low intenders are probably less amenable to intervention because of the strong moral bias against emergency contraception that ECP is an abortifacient.