Challenging Dogma - Fall 2011

Monday, December 19, 2011

The NYC Condom Campaign: A Program With Glaring Deficiencies – Joel Dankwa

Interest in particular social interventions almost always begins with some kind of incidental introduction from a concerned friend. As such, a recent conversation with my close friend, Wyatt, has sparked the inquiry that gives this paper motion. This past November, I was visiting Wyatt, who is currently employed by the New York Teaching Fellows Program. While in transit to a sporting event, our conversation took an unanticipated turn from nostalgia to conversation about discrepancies in education. To be clear, Wyatt was most conflicted by New York City’s beleaguered teaching environment, and the Board of Education’s inability to address this issue. Furthermore, one of the many points at issue was the lack of intervention programs for inner city youth and homosexual teens in areas where teaching fellows are sent. Most solutions, he argued, are blanket solutions – never fixing a specific problem. Intrigued by this, I began to think of several themes within this conversation that are available in other contexts. Of course, as a graduate student in public health, my approach focused on areas of health where similar issues occur. Our dialogue has been the impetus for the conversation in this paper. This paper essays to challenge programmatic schema that inform health interventions for HIV prevention, and suggest an approach that addresses deficiencies in programs implemented by NYC’s department of health.
To continue, Dr. Thomas R. Frieden, current Director of the CDC and former New York City Health Commissioner, has written that most public health agencies have inadequately implemented programs that prevent current health problems1. Frieden clarifies, however, that New York City has had an extensive history of innovation to address chronic disease prevention and control, noting especially that all interventions were evidence based relying heavily upon epidemiology. For example, to combat smoking, the New York City Department of Health and Mental Hygiene (henceforth NYC DOHMH) enforced the Smoke-Free Air Act, prohibiting smoking indoors. Furthering this objective, the department not only enforced prohibitive legislation, but also provided programs targeting various demographics and geographic areas. There were clear targets of intervention, and pursuant of these objectives, were clear directives. Likewise, the DOHMH had also implemented home-visiting initiatives to aid high-risk first-time mothers. Visits occurred during regular weekly or bi-weekly intervals during pregnancy and into the child’s second year of birth. The purpose of such a program was to engage new parents in language development of their children and school preparation.
Of course, it is not inconceivable that, from the desk of a former New York City Health Commissioner, Freiden’s report is a compendium of innovative public health programs, replete with successes. One would be hard pressed to identify the issues regarding the expansiveness of New York City’s current health measures. Yet, given success in the previously mentioned programs, it seems rather uncharacteristic, and vastly negligent of the DOHMH to fail to suffuse similar investment in its HIV prevention programs – specifically through one of its most recent vehicles, the NYC Condom program.
Brief investigation of NYC’s condom distribution program is quick to expose its lack of depth. What’s more is that the NYC Condom campaign does not squarely address the issue of protection in individuals prone to high-risk behavior, and contraction of HIV consequent of such conduct. Rather, this health measure is a simple blanket approach, paying no mind to the specific needs of individuals that most require attention. Intervention requires that the NYC DOHMH acknowledge backgrounds of target populations most likely to suffer from HIV2. Consistent with the Sexual Health Model, a pluralistic approach to prevention is key to success. What will become clear is a dearth of specific programmatic interventions for populations more apt to acquire the disease, such as men who have sex with other men (henceforth MSM).
Part I: The Critique
The NYC Condom campaign
To begin, it would be remiss to engage in discourse on the NYC Condom program without first highlighting its salient features. The DOHMH’s website explains that the use of a condom during various anal, oral, or vaginal sex can protect both partners from HIV and sexually transmitted diseases3. NYC Condom sets out as a method of structural level intervention, distributing condoms with its own NYC Condom brand. Recently the Centers for Disease Control and Prevention (CDC) produced an article highlighting the benefits of condom distribution. Surely, distribution programs have been efficacious in increasing condom use among many populations4–6. Condom distribution is most notably cost effective and reproducible as a measure against HIV/AIDS4. Likewise, the task of building awareness does not require overwhelming effort, in that it only requires that distributors leave condoms in highly frequented areas. It is presumed that awareness and availability of the condoms translate into equal use of the product. This is advanced by recent data that shows high levels of awareness of the NYC condom brand and usage of these condoms by those who were aware of their availability5. Furthermore, NYC DOHMH has been consistent with technological changes by announcing the launch of a free condom smartphone application7.
There is no doubt regarding the dispersion of the campaign. Upon this approach, Ryan Burke exclaims that high levels of NYC condom awareness translates into use5. An earlier paper from Sally Guttmacher further explains the benefit of this program. That is, condom availability programs decrease barriers, both financial and psychological, as well as goads conversation of condom use and safer sex practice8. Key to the effectiveness of this program is the method and area of distribution. The CDC provides guidelines for structural level intervention programs, and cites NYC DOHMH as exemplar of distribution methods. Condoms must be free of charge and be promoted by a wide-scale marketing campaign – via phone applications, for example. Suggestions for marketing campaigns include TV and subway ads, web banners, as well as posters4. However, the CDC also suggests that condom distribution be targeted to individuals at high risk, at venues frequented by high-risk individuals, and communities at greatest risk for HIV infection. It is this type of specificity that does not seem apparent. Although it occurs in a very dispersive manner, mere distribution is hardly pursuant of modified behavior for those that have a greater proclivity for conduct that puts them in danger of HIV infection. The limitations of the NYC Condom campaign can be best consolidated within three specific areas of fault. These areas include: over-commitment to procedure, action-targeted versus behavior targeted programs, and lastly, failure to address sexual health among HIV’s most common demographic – men who have sex with other men (or MSM).
NYC Condom Campaign’s first limitation: Fixation with Procedure
In order to address HIV, the CDC’s Division of HIV/AIDS Prevention provides guidelines for organizations wanting to design and implement a condom distribution program. The CDC suggestions, however, are smugly ensconced by procedure that often precedes many public health efforts. As criticized earlier, intention to squarely address the users of the NYC Condom brand does not seem apparent. Bullet-points, steps, and definitions of programmatic objectives distract from the actual purpose of intervention4. A recent street intercept study conducted interviews in areas targeted by the campaign, at large public events in New York City where many attendees were people of color and gay persons. The intention was to “target groups with higher HIV prevalence5. However, targeting at-risk populations does not sufficiently attend to individuals within these populations who are at a high risk of attaining HIV. The study polled individuals on the premise that it observes condom use within populations of higher HIV prevalence. However, the study does not look at drug users, MSM that engage in high-risk behavior, and MSM who do not identify themselves as homosexuals or bisexuals. Although the survey supports a positive relationship between condom use and availability, it may include people who would already make good decisions about their sexual health. This critique is the same of the campaign itself, as this blanket approach may not successfully identify and address individuals for which this program would be most beneficial.
Guttmacher et al conducted a study in New York City public high schools to determine the relationship between condom use and sexual behavior. The study suggests that teens who are more prone to engage in sex were the ones to target, not particularly all teens. Perhaps this should be the perspective of the NYC Condom campaign – individuals more prone to HIV infection should be most heavily approached. Procedure and programmatic steps, on the other hand is insufficient in properly determining whether specific populations are receptive to a public health message. Rather, it only assures that public health officials have “done enough” or satisfied all “approved steps” of intervention. However, key to mediating this limitation is to address behavior.
Failure to attend to social and psychosocial factors
Aside from attention to specific groups, I find failure in the campaign to target behavior. Grimley et al explain that a major limitation of condom distribution programs rests in the fact that they are action oriented and not behavior oriented. “Action-oriented approaches to behavior change view condom use adoption as a dramatic and discrete movement from never using condoms to always using condoms.” However, Grimley argues that this approach is unrealistic, as it fails to recognize variability in behavior9. Variation in behavior is attributed to variation in populations and proclivities that govern behavior within populations. Attention to proclivities, as it follows, should be at the forefront of the campaigns.
Even Burke et al recognize the importance of adjusting to the persuasions of target populations. The framers of the street intercept study indicated that perceived needs should be considered when designing condom distribution programs5.
In a study of longitudinal determinants of condom use, Kapadia et al examine the influence of individual behavior and partner type. It was concluded that positive attitudes toward condom use and partner norms were associated with regular condom use10. In addressing individual- and partner-level factors, another study relays conclusions consistent with the theory of planned behavior. Targeting intention and behavior may prove more successful11. This approach requires direct attention to the variation in behavior respective to different populations. One cannot address the issue of condom usage, decision-making, and HIV to inner city teenagers the same way one would gay adults, as there are different sets of factors affecting the decision of each group.
Failure to address a population with the greatest prevalence of HIV
Following attention to behavior, I believe discourse on safer sex intervention in men who have sex with other men requires its own section for reasons that will become clear shortly. NYC Condom is not clear in its campaign to address HIV with the population in which the disease is most communicated (MSM). Firstly, the CDC reported that MSM accounted for 70% of estimated HIV infections12. Given the disproportionate rates of HIV and AIDS within this demographic, it would seem almost intuitive for the NYC condom campaign to target safer sex behavior among this group of individuals. Contrary to this suggestion, however, the campaign does not seem to do this, except for distributing NYC Condom brand within highly frequented areas – a very detached approach. Conversation within the campaign also fails to accommodate a conversation that would even consider safer sex and HIV concerns within this demographic. Even the website establishes heteronormative discourse, that makes little, if any, effort to engage a dialogue among the gay community3. This dialogue, however, is crucial as it has been proven that the mere neighborhood gay presence and conversation goads consistent condom use in MSM13.
To continue, culturally sensitive programs have significant effects, for it has been shown to foster HIV/AIDS prevention in African American males14. So, within this same vein, equal sensitivity is imperative for the success of the NYC condom program. For what reasons such a pointed approach necessary in addressing MSM? Recently, Dr. Marc Lamont Hill produced a paper highlighting the affect of culture, pedagogy, and social norms on the dissemination of masculinity and sexual identity. His paper clearly explicates an atmosphere that is hostile to the outing of males ascribing to a queer identity. Consequent of this environment, individuals are “forced to remain in the closet out of fear that his ‘sexual business’ – sexual orientation, partners, proclivities, etc. – will be publicly exposed”15. Such a phenomenon is not undisclosed to the larger population. So then, why dwell on this conversation if it is well known?
A study conducted by Pathela et al, gives premise to an imperative for specific attention of the NYC Condom program to MSM. Much like Dr. Hill, Pathela also attributes nondisclosure of sexual identity to social and cultural contexts. It is reported that there is a vast discrepancy in reported behavior and actual behavior among MSM. Thus, addressing those more prone to HIV exposure is, in actuality, much more complex. Pathela asserts that persons reporting sexual identity discordant with their sexual behavior may also participate in riskier sexual behaviors than those with concordant identity and behavior. Among men who have sex with men, data demonstrates increases in high-risk sexual behaviors, STDs, and HIV diagnoses16. Promoting safer sex within a discordant cohort is crucial to the abatement of the spread of sexually transmitted disease, such as HIV. Individuals may be reluctant to acknowledge homosexuality or tend to use a more narrow definition of what homosexuality constitutes. This reluctance may diminish the efforts of a campaign that aims to address HIV/AIDS. For this reason, the campaign must adjust to the complexities specific to this demographic.
Furthermore, a recent study indicates that ways of meeting partners is indicative of riskier sex practices, namely unprotected sex. Intervention should, perhaps, target these methods. Bars, clubs, bathhouses, and the Internet were the most endorsed venues for meeting partners. The survey indicates that rates of sexual risk behaviors, such as unprotected sex, had risen. What’s more is that “the social environment in which MSM meet sex partners has been implicated not only for impacting the decision to use a condom…but it also has been an effective outlet for reaching at-risk men.” Thus, if campaigns were to be mindful of ways in which MSM meet one another, issues regarding safe sex can be addressed. A finely tuned outlook on the behaviors of MSM is clearly imperative to he success of the DOHMH’s NYC Condom campaign within this group of men.

Part II: Intervention
Despite the NYC Condom campaign’s limitation, there are clear avenues of improvement that may catapult the program’s success. As mentioned in the introduction of this paper, a pluralistic approach to intervention would address variability in populations. Complexities concomitant with differing communities and sexual identities will perhaps bolster retention of NYC Condom’s grand message – the prevention of HIV transmission.
To continue, social sciences models provide a framework upon which such an improvement becomes feasible. Briefly introduced at the start of this critique was the Sexual Health Model. So, before intervention is articulated, the thought behind my proposal must be made clear.
Sexual Health Model
To begin, the Sexual Health Model (henceforth, SHM) acknowledges the importance of a target populations social background. Robinson et al explain that background characteristics can be sociocultural, interpersonal, or individual, thus requiring a pluralistic approach to attend to different characteristics. The aim of the model is provide a theoretical framework for “improving overall sexual well-being.” Under this model, it is understood that sexually healthy people are “more likely to make sexually healthy choices, including decisions concerning HIV and sexual risk behaviors. This includes condom use and non-penetrative safer-sex practices.”2
Furthermore, it is suggested there are clear benefits to particular forms of interventions. Individual-level interventions and group-level interventions are successful in directly addressing knowledge and attitudes, whereas community-level interventions are directly and indirectly address a community’s perspective on social norms and behaviors regarding sex17. Thus, rather than a blanket remedy, successful interventions are multifaceted and multipronged. Such is the construct recommended by the Sexual Health Model.
Thus, the Sexual Health Model proposes interventions that are composed of ten different spokes, all of which will not be addressed in this paper. What is clear is that each spoke speaks to different concerns of sexual health. The NYC condom campaign is effective in addressing two spokes, 1) sexual health care and safer sex and 2) discussion about sex on a social whole. There are two areas, however, that I believe the NYC Condom campaign should approach with greater fervor. I believe, that the NYC condom campaign must specifically address both challenges to practicing safer sex, as well as culture and sexual identity, in 3 different contexts - individual-, group-, and community-level.
Individual-level Intervention
Firstly, the practice of safe sex and condom use will always be reduced to individual decision-making. Certainly the influence of one’s partner will greatly weigh upon one’s decision10. However, NYC Condom must be sure to speak to individual decision-making; it is the greatest challenge in targeting high-risk populations. Individual-level intervention is may greatly affect challenges to practicing safer sex, thereby addressing a crucial spoke of the SHM. Currently, the NYC Condom campaign is very much a condom distribution campaign. However, along with distribution, the campaign should also market self-empowerment. For example, aside from pamphlets, it would be useful to not only have the NYC Condom brand available in city high schools, but also have representatives from the campaign regularly spend time in schools and in health classes to engage students about HIV and its effects. Furthermore, representatives must make clear that prior to any sexual activity, condom use should be considered strongly, even if it is against the wishes of one’s partner. Should the campaign galvanize relationships with students, it is not unlikely that the message conferred via pedagogical relationships will hold strong.
At the start of this paper, it was mentioned that the DOHMH has created a program that intervenes in the pregnancies of young mothers. Such a personal investment is required if the program wishes to access teens who are more prone to risky behavior, but are still engaging in risky sexual behavior.
Group-level Intervention
Ideally, intervention curriculums should include all factors of the SHM. However, as I have indicated, some parts of the model are better than others in addressing specific concerns. Group-level intervention may be a successful method of mediating further challenges to safe sex, such as group mentality.
When it comes to MSM, a recent study finds neighborhood gay presence to have a significant and positive impact on consistent condom use during anal intercourse. Should the NYC Condom campaign thusly target this group, then, aside from the campaign affecting a change of behavior, the group it targets would actually be the vehicle in accomplishing this goal. My second suggestion is further expansion of the program specifically dedicated to targeting MSM. The group, knowing the concerns of the gay community, will be able to enhance distribution by providing something a pamphlet or a bucket of condoms cannot provide – a personalized message. It would behoove the DOHMH to not only create an additional wing to their program, but also have offices of the NYC Condom program present in neighborhoods with a strong gay presence, and furthermore be a strong voice within this neighborhood. By this I mean that NYC Condom must be keen on sponsoring community events. Inherent in presence is a message – the use of condoms. In the same way the program attempts to increase usage by increasing dissemination of the NYC Condom brand, this approach will increase conceptualization of safe sex by disseminating and infusing perspectives into a mindset of this high-risk group.
Community-level Intervention
Certainly, there are always profound implications of society on behavior. As mentioned earlier, cultural perspective greatly prohibits openness about sexual identity15. This poses a great challenge to the NYC Condom campaign’s ability to reach MSM whose sexual identity is discordant with their sexual practices. Frye et al find that community-level influences have a greater effect on behavior than individual-level behavior13. Moreover, another study suggests that community intervention targets norms among high risk groups18. Thus, community wide prevention efforts could also target peer norms for unprotected sex, by challenging beliefs about the prevalence of the practice in the gay community.
My final suggestion, thus, appeals to the NYC Condom campaign to exist as more than a public health initiative with a catch name and catch condom brand. Rather, my recommendation challenges the NYC Condom program to pursue full collaboration with school boards of education, hospitals, and health organizations. The objective of the organization will no longer be singular, but rather community based. In this vein, despite the community perspectives on homosexuality or bisexuality, what will be sure is a collective endorsement of usage of the NYC Condom brand or any other brand.
To conclude, it is clear that the NYC Condom campaign is committed to disseminating condoms among high-risk communities. However, its investment in seeing changes in behavior is not so apparent. Procedural guidelines forget the necessity of individualized intervention. There is no specific attention to behavior of the most at-risk individuals. Likewise, there does not seem to be any conversation about behaviors of MSM, closeted or open. The NYC Condom campaign is by no means a valueless program. However, given its limitations, it may maximize its intended effect – HIV prevention – by adhering to recommendations in this paper, as well as suggestions from others.

1. Frieden TR, Bassett MT, Thorpe LE, Farley TA. Public health in New York City, 2002-2007: confronting epidemics of the modern era. International Journal of Epidemiology. 2008;37(5):966-977.
2. Robinson B `Bean’ E, Bockting WO, Simon Rosser BR, Miner M, Coleman E. The Sexual Health Model: application of a sexological approach to HIV prevention. Health Education Research. 2002;17(1):43 -57.
3. New York City Department of Health and Mental Hygiene. NYC Condom, Get Some! NYC Condoms: Get Some! Available at: Accessed December 10, 2011.
4. Center for Disease Control D of HP. Condom Distribution as a Structural Level Intervention. Available at: Accessed December 10, 2011.
5. Burke RC, Wilson J, Bernstein KT, et al. The NYC Condom: Use and Acceptability of New York City’s Branded Condom. American Journal of Public Health. 2009;99(12):2178-2180.
6. Burke RC, Wilson J, Kowalski A, et al. NYC Condom Use and Satisfaction and Demand for Alternative Condom Products in New York City Sexually Transmitted Disease Clinics. Journal of Urban Health. 2011;88(4):749-758.
7. Anon. NYC Health Department Launches Free Condom App. Huffington Post. 2011. Available at: Accessed December 16, 2011.
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13. Frye V, Koblin B, Chin J, et al. Neighborhood-Level Correlates of Consistent Condom Use among Men Who have Sex with Men: A Multi-Level Analysis. AIDS and Behavior. 2008;14(4):974-985.
14. Asare M, Sharma M. HIV/AIDS prevention interventions in African American heterosexuals. 2010.
15. Hill ML. Scared Straight: Hip-Hop, Outing, and the Pedagogy of Queerness. Review of Education, Pedagogy, and Cultural Studies. 2009;31(1):29-54.
16. Pathela P, Hajat A, Schillinger J, et al. Discordance between Sexual Behavior and Self-Reported Sexual Identity: A Population-Based Survey of New York City Men. Annals of Internal Medicine. 2006;145(6):416 -425.
17. Charania MR, Crepaz N, Guenther-Gray C, et al. Efficacy of structural-level condom distribution interventions: a meta-analysis of U.S. and international studies, 1998-2007. AIDS Behav. 2011;15(7):1283-1297.
18. Parsons JT, Bimbi DS. Intentional Unprotected Anal Intercourse among Sex Who have Sex with Men: Barebacking—from Behavior to Identity. AIDS and Behavior. 2006;11(2):277-287.

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