An Analysis of the United States Vaccination Policy and Corresponding Campaigns – Deborah McSparren

Introduction

Vaccines are one of the greatest medical achievements of the 20^th century. The success of vaccine use, especially in children, has eliminated two diseases in the United States, polio and smallpox, plus reduced the incidence of several other diseases by at least 95%. By the end of the 20^th century, immunization rates in children under two reached a record high of 90%. There is a relatively successful movement that discourages parents from vaccinating their children. This population experiences increased hospitalizations and deaths due to these vaccine-preventable diseases (1). Additionally, there is a societal burden associated with the anti-vaccination movement which can be significant; this includes missed school days, missed work days and secondary illness in family members (2).

The Centers for Disease Control and Prevention (CDC) is the main advocate for vaccines within the United States and recommends vaccine scheduling guidelines. However, federal law allows each individual state to establish its own requirements. Historically, people have always challenged these laws and requirements. In 1809, Massachusetts was the first state to require the smallpox vaccine. This law’s constitutionality was challenged because a resident was concerned about an adverse reaction to the vaccine. The Supreme Court in 1905 affirmed the rights of the state to require vaccination because “the protection of the health of the public supersedes certain individual interests, within reasonable boundaries” (3). By 1963, 20 states required immunization of children before entering school. The effects of not requiring immunizations were obvious during the 1970s when occasional outbreaks of the measles occurred most commonly in states without immunization requirements. This prompted activists to push for compulsory laws and measles eradication. By 1980, all 50 states passed laws requiring vaccinations before school entrance. There are exceptions to the requirements; all states allow medical exemptions with a doctor’s permission and 48 states allow religious and/or philosophical exemptions (3).

The high vaccination rates and declining disease incidence creates an environment that evokes public debate about the safety of vaccines. The anti-vaccination movement appeals to people’s anxieties by alluding to a number of unsubstantiated claims such as: safety issues, cover-ups by medical professionals, bureaucrats regulating parenting and greedy pharmaceutical companies (4).

The current anti-vaccination campaign is successful at accessing larger populations because of the reach of internet and social networks. At the forefront of the anti-vaccine campaign is the supposed link between thiomersal in the measles, mumps, rubella (MMR) vaccine to autism in children. This belief was perpetuated by the Wakefield paper from 1998 that linked the MMR vaccine to autism. The Wakefield paper was later retracted after subsequent studies failed to reproduce his results but the public mistrust remained (5). After investigating this claim, the Institute of Medicine (IOM) and the Immunization Safety Review Committee (ISRC) concluded there was no scientific basis to establish a causal relationship between the MMR vaccine and autism (1). Despite these reassurances, rates of the MMR vaccine have declined in some areas. An effective aspect of this anti-vaccination campaign is the ability to exaggerate isolated, coincidental incidents and promote them as fact. These claims are accepted without scientific evidence of causality and exacerbate parental fears about their child’s health (6).

Health practitioners fear that once immunization rates fall below 90%, herd immunity will be lost. Herd immunity refers to high immunization rates among the population that protect the few who are not immunized from disease. This drop in vaccination rates may result in vaccine-preventable diseases circulating more freely with an increased incidence of disease (6). This phenomenon has already occurred with various outbreaks of measles, pertussis and whooping cough in the United States. One study found that un-immunized children aged 6 to 10 years were 15 to 59 times more likely to acquire pertussis and measles than immunized children (1). This resurgence of vaccine-preventable disease shows that vaccination campaigns need to become more effective to counteract the anti-vaccination movement.

Critique #1: Vaccination Requirements Invoke Psychological Reactance

All states require that children be vaccinated before attending school (1). These requirements, although meant to protect the population, cause some parents to react negatively toward the idea of vaccinating their children. This is an example of Psychological Reactance Theory. It describes a motivational state when someone perceives their freedom is being threatened, reduced or eliminated (7,8). Reactance occurs when rules, regulations and policies limit behavioral freedoms and people are forced to accept a particular view. People try to restore their freedom by embracing a contrary stance; thus these parents opt out of vaccinating their children. Psychological reactance is an emotional response that is not based on rational decision making, which helps explain the appeal of the anti-vaccination movement. This phenomenon parallels Brehm’s observations, people respond negatively to an influence even when the influence is in their own best interest (7).

Psychological reactance to vaccination requirements can be found throughout history. People and groups have been challenging requirements since the 1800s on the basis that the government is intruding on personal autonomy. However, governments and courts in the United States have always upheld vaccine mandates because of their success in virtually eliminating disease (3). Some parents object to vaccine requirements because they believe it affects their right to make decisions about their child’s health (1). In regards to vaccinations being required versus voluntary, governments have always had to weigh individual freedoms against the benefits of the society as a whole (3). Anti-vaccination movements have always been able to build support based on people’s reactance to the perceived threat on their freedom and irrational behavior. Even though overwhelming evidence points to the effectiveness of vaccines, some people still choose to embrace the autism link to support their anti-vaccination stance, despite the lack of scientific evidence supporting these conclusions.

Parental attitudes toward vaccinations have also been examined and the outcomes have confirmed Psychological Reactance Theory. Even though vaccines are required for school entry, they are voluntary in theory because of the “opt out” options for parents. One study found that health professionals are resistant to the idea of parents making their own informed choices. By not presenting parents with vaccination options, parents view health professionals as obstacles to information. The same is true with the immunization literature. Parents felt that the information in pamphlets was not designed to inform but to generate conformity. This tactic causes parents, especially educated ones, to be resentful and perceive the plan as a deterrent to making an informed decision. Further analysis finds a contradiction between health care’s emphasis on patient’s rights to informed consent and the actual practices around immunization (6). Parents may construe these practices as a perceived threat to their freedom and thus react against vaccinations. This choice endangers their children because without the immunization they are vulnerable to vaccine-preventable diseases.

Critique #2: Vaccination Campaigns Use of the Health Belief Model

Government sponsored campaigns promoting vaccines traditionally employ the Health Belief Model (HBM) to encourage parents to get their child vaccinated. The Health Belief Model is based on four main constructs: perceived seriousness of a disease, perceived susceptibility of acquiring the disease, perceived benefit of the behavior and perceived obstacles to adopting the behavior (2). Theoretically, this model relies upon people making informed, rational decisions and modifying their behavior based on this information (9). But, campaigns that inform the public about vaccines and the consequences of vaccine-preventable illnesses do not take into account parental attitudes and the emotions the anti-vaccination invoked. The anti-vaccination movement was able to establish vaccines as a perceived barrier to a child’s health by suggesting vaccines could cause autism. Studies have found that parents are already aware of these diseases and the threat to their children but this knowledge does not necessarily convince them to immunize their children (10). While educating parents through the HBM remains necessary, campaigns need to be adapted and modified to address the root causes of anti-vaccination behavior.

Most public health campaigns still only rely upon the HBM to increase vaccination rates. This one dimensional approach severely limits the effectiveness of the campaign’s message. The CDC’s website lists the goals and objectives for their vaccination campaigns. For example, the objectives for their preteen and teen campaign rely heavily on the HBM. The current six objectives on the CDC website are focused on raising awareness, educating stakeholders and promoting open lines of communication. One example of the HBM in action is a CDC brochure that pictures a father playing basketball with his son. The caption reads “Thinks meningitis is a band from the 80s” (11). This is purely the Health Belief Model in action because the objective of the campaign is limited to informing the public about the existence of the disease and no other pertinent information is provided. Most people are exposed to reports in the news media reporting outbreaks of bacterial and viral meningitis; it would be difficult to have never heard of this disease. The CDC appears to be wasting time and money focusing on informing the public about diseases instead of finding the actual reasons for not vaccinating children and teens.

The CDC’s use of the HBM to promote vaccinations in the meningitis campaign mentioned above assumes rational behavior, whereas the success of the anti-vaccination movement has taken advantage of people’s emotions causing irrational decision making. Anti-vaccination messages have dramatized single cases of autism lacking a causal link to the MMR vaccine while ignoring the prevention of disease in millions of people. Public health authorities are perplexed at the popularity of the anti-vaccination campaign since their main themes are based on irrationality and misunderstandings (6). Their confusion stems from believing that people act rationally and educating the population will result in higher vaccination rates. Public health organizations must take into account the emotional, sociocultural and psychological factors that affect vaccination rates.

Critique #3: Law of Small Numbers Applied to Perceived Disease Risk

The Law of Small Numbers is used to explain that even though people realize they are susceptible to vaccine-preventable diseases, this belief does not always translate into actually being vaccinated. The theory states that people have erroneous assumptions about the laws of chance, more specifically their individual chances of acquiring a disease. They tend to believe that small samples taken from the population are representative of the population as a whole (12). In other words, if a person has never known anyone that has contracted a vaccine-preventable disease, then they will believe that they cannot get the diseases themselves. This causes people to be overly optimistic and they expect other people to acquire a disease, not them (13). Studies have found that people underestimate the likelihood of a negative event and overestimate the likelihood of a positive event. So being overly optimistic coupled with a person’s direct experience of a vaccine-preventable illness results in a reduction in vaccination rates.

Vaccines have become a victim of their own success. They are so effective that people have paid more attention to potential side effects of vaccines rather than the diseases themselves that are much less prevalent (5). The public’s loss of confidence in immunizations will result in declining rates of vaccine use, whereas disease outbreaks can occur again and have already taken place in some areas. An effective intervention needs to convince the public that everyone is susceptible to vaccine-preventable disease.

Proposed Interventions

There are two factors that point to the necessity for policies and campaigns focused on public health interventions to be reexamined and likely modified. The factors are the anti-vaccination movement and declining rates of vaccinations. The issue with current practice is the expectation that people will act rationally by protecting themselves from vaccine-preventable diseases. However, the anti-vaccination movement is popular because it appeals to emotions while not having solid scientific evidence to support their claim. New interventions should look to present less factual statistics and education since it does not necessarily translate into modified behavior. I propose less traditional theories to increase vaccination rates: Framing Theory, Advertising Theory and Protection Motivation Theory.

Intervention #1: Use of Framing Theory to Modify Immunization Views

Framing Theory is a form to communicate meant to change the perception of a public health problem or intervention. Framing studies conclude that the way in which information is presented impacts health behaviors. People routinely respond to positive framing as opposed to negative framing (14). This first critique discusses psychological reactance as a result of the state requirements of vaccines. I also discuss how vaccines are voluntary in theory because of “opt out” options in all US states. I believe that the requirement aspect of vaccinations must be reframed for it to increase vaccination coverage.

A pro-vaccination campaign to reframe vaccinations as a choice and further expand parental options to include a flexible vaccination schedule would be optimal. Even though this campaign seems counterintuitive, but removing psychological reactance to vaccines may actually increase coverage. Many experts would disagree to this claim. Health practitioners are fearful of vaccination rates dropping below herd immunity and feel that voluntary vaccinations would facilitate lower rates (15). I believe that this aggressive change in framing vaccines will combat anti-vaccination proponents. Dr. Lawrence Rosen, who is a Vice Chair at the American Academy of Pediatrics, argues that a flexible schedule responds to the public’s mistrust of government agencies, such as the CDC which sets the vaccination schedule. He states that a flexible schedule would encourage parents who otherwise would not vaccinate their children to adopt a vaccination schedule of their choosing. The flexible schedule responds to parents who worry about autism to be able to vaccinate their children at an older age when emergence of autism is less likely. This option could also appeal to parents who have been ridiculed by health practitioners about their vaccination views (16).

This issue is considered reframing because vaccinations have always been a choice for parents and scheduling has always offered some flexibility. However, parents are constantly encountering, between doctors office visits, school districts and governments, vaccines as a “requirement” and schedules as rigid and uncompromising. Vaccines are understandably termed “required” because of concern about the health of children and society as a whole. Unfortunately, this method of presenting vaccines may be doing more harm as parents attempt to oppose authoritative messages. A revised, more focused campaign would frame vaccinations as a choice and offer flexible schedule options provides a positive environment for parents to increase vaccination coverage of their children.

Intervention #2: Use Advertising Theory to Appeal to Emotions

The decision to vaccinate is a complex social act. In order to make the decision to vaccinate, an individual may examine the issue on a number of levels. First, on the individual level a person is concerned about their own health in the possibility of contracting the disease; secondly an individual parent may be concerned about the safety of their children, and lastly an individual may be concerned with the probability of the disease spreading throughout the community. Trust in government and trust in health practitioners add to the complexity of the decision the individual must make (5). The traditional Health Belief Model is very one-dimensional and includes presenting facts and statistics to change behavior without accounting for the complexity of the problem. Because of this complexity, health practitioners find it difficult to create an effective campaign that addresses all individual and social behaviors. Advertising Theory is actually a very basic method to change health behaviors simply by making a promise to remain consistent within the core values of the target audience (17). The Advertising Theory uses branding to create associations that supersede other types of advertising mainly by invoking emotions. A public health brand can link a health behavior to an enviable lifestyle and therefore; change the health decisions of a person by ultimately adding value to the decision or lifestyle. A public health brand can also promote a beneficial exchange; most effectively by delivering a positive message (18). To paraphrase from Dr. Siegel’s class lecture, the most effective way to convey this promise is through stories, music and visual images (17).

I would design a campaign focused on appealing to the overwhelming public sentiment which at its core is an individual’s desire to exercise his or her right to freedom of choice. By presenting to the public a campaign that connects with the values of the individual decision-maker, Advertising Theory will be used effectively; I propose appealing to a person’s sense of freedom. I feel that most people, especially Americans, highly value their freedom and a positive campaign promoting freedom as a result of getting vaccinated may change beliefs and practices. The campaign would depict an American family on a road trip throughout the United States, showing famous landmarks in the background with a song playing in the background. I would show the same family traveling the world, again with European, Asian and other identifiable world landmarks in the picture frame. At the end of the clips I would ask “Do you want to freely travel around your town, state or country (or world)?” I would continue with “Do you want to travel without fear of illness?” I would conclude with “Then make sure that you and your children are vaccinated against preventable diseases.”

A successful pro-vaccination campaign would apply the guidelines of Advertising Theory. The ads will appeal to emotions and the core value of freedom by promising people the right to travel. Typically, people do not want their freedom taken away. Mandatory vaccinations cause the negative reaction leading to the choice not to vaccinate. A beneficial exchange is also offered in a positive manner; a person is offered freedom, more specifically freedom of travel, which they obtain by getting vaccinated. This approach is an improvement over HBM because instead of trying to change behaviors by informing and educating mainly by listing statistics; a marketing campaign will promise core values as a result of a health decision or behavior.

Intervention #3: Use of Protection Motivation Theory to Counteract the Anti-Vaccination Movement’s Use of Fear

The Protection Motivation Theory (PMT) was originally proposed by Rogers in 1975 to impart clarity in understanding fear and its influence on behavior. The theory states that behavior is based on the perceived severity of the threat, perceived vulnerability of occurrence, efficacy of the recommended behavior and perceived self-efficacy. This starts out exactly like the Health Belief Model; except the theory takes it one step further, it says that once a person evaluates the perceived risks and vulnerabilities, then that person processes a threat appraisal and later a coping appraisal based on the amount of fear the person experiences. The coping appraisal translates to decisions made about health behavior to reduce the threat (19,20). I think that the anti-vaccination movement employs this theory by producing fear in parents about giving their child autism after the MMR vaccination. Since the anti-vaccine campaign is successful with this tactic, I propose using the Protection Motivation Theory to instead promote vaccine use.

A campaign that uses PMT will increase a parent’s fears about vaccine-preventable diseases. As stated in the earlier critique, people usually do not have any memory of disease outbreaks and have never known anyone with any vaccine-preventable diseases; therefore, they concentrate their concerns on their fear of vaccine related autism. The campaign would show that the reality is that children still contract measles and other vaccine-preventable diseases; outbreaks are still possible. I would include some elements of Advertising Theory to invoke emotions by adding music and focus on the expressions of individual children. The catch-phrase of the advertisement would include the statistics related to children that have died as a result of these diseases. The overarching message would be, “These diseases can be prevented by vaccinating your child.”

This campaign is designed to appeal to the emotions of parents and show them that there remains concern about these diseases and that their children are vulnerable; thus creating a threat appraisal leading to a coping appraisal, which should result in parents having their children vaccinated. I think this campaign would be effective in promoting vaccines; especially when evaluating a parent’s reasoning when deciding for or against vaccines. Using focus groups, one study found that parents who were most likely to vaccinate their children did so because they found “vaccine preventable diseases as threatening and frightening” (4). The parents also added that they would feel tremendous guilt if their child contracted a vaccine-preventable disease (4). This evidence further supports my claim that the fear parents feel about the MMR vaccine and its link to autism can be combated by matching that emotion with a parent’s fear for their own children’s vulnerability to contract one of these diseases.

Conclusion

The advent of immunizations has been an extremely important health achievement by virtually eliminating multiple diseases in many countries. However, this practice has been threatened by anti-vaccination movements making sensational claims about the safety of vaccines. The strict requirements of vaccination policies coupled with the very basic educational campaigns and the public’s lack of exposure to vaccine-preventable diseases results in lower vaccination rates. Instead, governments should make vaccinations a choice for parents while creating campaigns that appeal to core values and emotions. This altering of perception will increase parent’s acceptance of vaccines and increase overall rates.

References

1. Abramson JS, Pickering LK. US Immunization Policy. JAMA. 2002 Jan 23;287(4):505–9.

2. Flood EM, Rousculp MD, Ryan KJ, Beusterien KM, Divino VM, Toback SL, et al. Parents’ decision-making regarding vaccinating their children against influenza: A web-based survey. Clin Ther. 2010 Aug;32(8):1448–67.

3. Salmon DA, Teret SP, MacIntyre CR, Salisbury D, Burgess MA, Halsey NA. Compulsory vaccination and conscientious or philosophical exemptions: past, present, and future. Lancet. 2006 Feb 4;367(9508):436–42.

4. Leask J, Chapman S, Hawe P, Burgess M. What maintains parental support for vaccination when challenged by anti-vaccination messages? A qualitative study. Vaccine. 2006 Nov 30;24(49-50):7238–45.

5. Larson HJ, Cooper LZ, Eskola J, Katz SL, Ratzan S. Addressing the vaccine confidence gap. Lancet. 2011 Aug 6;378(9790):526–35.

6. Blume S. Anti-vaccination movements and their interpretations. Soc Sci Med. 2006 Feb;62(3):628–42.

7. Brehm, Jack W. Psychological Reactance: Theory and Applications. Advances in Consumer Research. 1989;16:72–5.

8. Woller KMP, Buboltz WC Jr, Loveland JM. Psychological reactance: examination across age, ethnicity, and gender. Am J Psychol. 2007;120(1):15–24.

9. Edberg M. Individual Health Behavior Theories (Chapter 4). In: Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Jones and Bartlett Publishers; 2007. p. 35–49.

10. Strobino D, Keane V, Holt E, Hughart N, Guyer B. Parental attitudes do not explain underimmunization. Pediatrics. 1996 Dec;98(6 Pt 1):1076–83.

11. CDC Preteen and Teen Vaccine Communication Campaign [Internet]. Centers for Disease Control and Prevention; [cited 2011 Dec 3]. Available from: http://www.cdc.gov/vaccines/who/teens/campaigns.html

12. Tversky A, Kahneman D. Belief in the Law of Small Numbers. Psychological Bulletin. 1971;76(2):105–10.

13. Weinstein N. Unrealistic Optimism About Future Life Events. Journal of Personality and Social Psychology. 1980;39(5):806–20.

14. Bigman CA, Cappella JN, Hornik RC. Effective or ineffective: attribute framing and the human papillomavirus (HPV) vaccine. Patient Educ Couns. 2010 Dec;81 Suppl:S70–6.

15. Perisic A, Bauch CT. Social contact networks and disease eradicability under voluntary vaccination. PLoS Comput. Biol. 2009 Feb;5(2):e1000280.

16. US News Staff. Vaccine Schedule: This Doctor Supports a Flexible Schedule. US News and World Report [Internet]. 2009 Jan 30 [cited 2011 Dec 3];Available from: http://health.usnews.com/health-news/family-health/articles/2009/01/30/vaccine-schedule-this-doctor-supports-a-flexible-schedule

17. Siegel M. SB721 Class Lecture. 2011 Oct 20;

18. Evans W, Hastings G. Public health branding: Recognition, promise and delivery of health lifestyles (Chapter 1). In: Public Health Branding: Applying Marketing for Social Change. Oxford University Press; 2008. p. 3–24.

19. Protection Motivation Theory: Influencing and Predicting Behavior [Internet]. [cited 2011 Dec 3];Available from: http://www.utwente.nl/cw/theorieenoverzicht/Theory%20clusters/Health%20Communication/Protection_Motivation_Theory.doc/

20. Cameron KA. A practitioner’s guide to persuasion: an overview of 15 selected persuasion theories, models and frameworks. Patient Educ Couns. 2009 Mar;74(3):309–17.

Inadequacies of Male Condom Promotion as a Means of HIV/AIDS Prevention Among Commercial Sex Workers in Madagascar – Alison Mickiewicz

Introduction

Madagascar, an island nation located off the south east coast of Africa, is a country faced with numerous health issues, one of the direst being rising rates of sexually transmitted infections (STIs) and HIV/AIDS. With a population of approximately 21.3 million, the number of persons 15-49 years of age living with HIV/AIDS is estimated at 0.1%, a number that has risen steadily over the past 20 years (1).

Figure 1. Source: Epidemiological Fact Sheet on HIV and AIDS, UNAIDS, 2008.

Although this is a relatively low figure compared to many countries in sub-Saharan Africa, the rates of STIs including syphilis, gonorrhea, and trichomoniasis remain high (2). According to the U.S. Agency for International Development (USAID), rates of STIs in Madagascar are among the highest in the world (1). The presence of an STI has been linked to heightened susceptibility to HIV infection (3). In addition to the prevalence of STIs in Madagascar, low literacy, limited access to healthcare services, pervasive poverty, and the acceptance of multiple sexual partners, has created the potential for epidemic-level HIV infections among the general population (4).

Three groups have been identified by USAID as most at risk of HIV infection: commercial sex workers (CSWs), men who have sex with men (MSM) and injecting drug users (1). This paper will focus on the effectiveness of condom promotion interventions as a method of HIV/AIDS prevention among CSWs. In Madagascar, CSWs have their own set of challenges for HIV prevention in addition to those of the general population. Fifty percent of the Malagasy population lives at or below the poverty line (5), when combined with low literacy rates and poor infrastructure, sex work is a quick and easy option for women to support their families (6). The work of a CSW is not without risk, in 2001, a study found the prevalence of chlamydia, gonorrhea, syphilis, and trichomoniasis among CSWs to be: 16.35%, 23.2%, 29.5%, and 53.05% respectively (7). In 2005, , the rate of HIV/AIDS among CSWs ranged from 0.6% for ‘major urban areas to 1.3% for ‘outside major urban areas’ (8), rates higher than the general population.

Focusing specialized interventions on CSWs is imperative, as this population has been described as the ‘nucleus of HIV transmission” (9). Condom promotion as a means of prevention against HIV transmission and other STIs is important to the general population, and critical to high risk groups such as CSWs. Current condom promotion interventions are centered around social marketing techniques which are based on the Theory of Reasoned Action (TRA). By employing mass media campaigns, the majority of the population is exposed to radio ads, billboards, and store signs promoting the use of condoms, an effective way to reach large numbers of people. However, my argument lies in the lack of support and education aimed directly at CSWs, given that they are such a high risk group with potential to act as a catalyst to the transmission of HIV and other STIs.

Developed in 1975 by Martin Fishbein and Icek Ajzen, The Theory of Reasoned Action lies on the premise that an individual’s actions are determined by said individual’s intentions (10). According to Fishbein, “at the simplest level, a reasoned action approach to the explanation and prediction of social behavior assumes that people’s behavior follows reasonably from their beliefs about performing that behavior” (11). Employing behavioral intentions as a basis for a health intervention appears reasonable, however, emotions and innate human irrationality is not taken into account. It is fair to say that what an individual intends to do is quite often not what that individual actually does; this is even more evident with behaviors related to health.

Figure 2. Theory of reasoned action. Adapted from Glanz, Rimer, & Lewis, 2002.

Sheppard, et al. point out that the original intention of TRA is to manage behaviors, not consequences that result from behaviors; more specifically, the behaviors outlined in the model are completely under the control of the individual (12). These limitations make TRA an unsuitable model for interventions that aim to modify behaviors with any strong outside influence, such as that from family, friends, media, and in the case of a CSW, a client.

Condom promotion in Madagascar is based heavily in brand recognition using mass media outlets. In 1998, Population Services International assumed management responsibility for the marketing of Protector brand condoms (13). In addition to administrative infrastructure changes and a product line expansion, PSI began an aggressive social marketing campaign to encourage use of Protector condoms as a means of HIV and STI prevention. PSI has succeeded in increasing sales, and presumably the use of, Protector brand condoms for the general population (see Figure 3). However, many studies conducted in recent years have demonstrated that condom use among CSWs is extremely low (14-16). Data suggests that such high risk groups present a need for dedicated condom promotion efforts that exceed current social marketing strategies through the TRA model. Current strategies do not address a number of limitations that CSWs are faced with in regard to condom use.

Figure 3. Source: Madagascar: Revitalizing a Social Marketing Program. PSI/Madagascar, 2003.

CSWs Have Limited Control Over a Male Partner’s Use of Condoms

Although male condoms do not eliminate the risk of infection, they are one of the most effective and economical options for prevention of HIV and other STIs (17,18). The drawback of male condom use is female reliance on her male partner to agree with use, therefore reducing female control over HIV and other STI prevention. In a study investigating perceived control over condom use among CSWs, it was found that almost 44% of the women interviewed answered “sometimes” when asked how frequently they used condoms with a client, approximately 41% answered “almost always,” and less that 7% answered “always” (16). Additionally, 40% of participants responded that they had “none/little” perceived control over male condom use with their client (16). CSWs face resistance to male condom use from their clients for a variety of reasons, some attributed to lack of knowledge, while other reasons stem from perceived loss of pleasure. Thomsen et. al. identified 50 reasons for not using a condom, gathered from interviews with male clients of CSWs in Mombasa, Kenya, an area that is similar to Madagascar in terms of CSW activity, as well as similar condom promotion techniques (19).

Clearly, current strategies are effective in condom promotion to the general population, but CSWs are faced with a set of challenges unique to their situation. When engaging in intercourse in exchange for money, CSWs are in a position in which they are often unable to negotiate the use of a male condom. Refusing to have sex with a client who will not use a male condom would mean loss of income for a CSW. More often than not, the decision is made to engage in unprotected sex; declining money is not an option for these women, many of whom support a family (6).Whether the CSW understands the dangers of unprotected sex and has knowledge of her risk for HIV/AIDS is inconsequential when her livelihood is dependent on satisfying her clients to obtain payment.

Variations in Definition of Relationship

Many CSWs polled in a study by Stoebenau, et. al. had a nonpaying “main partner” whom they identified as a boyfriend, husband, regular partner, or intimate partner (20). The majority of condom promotion mass media campaigns in Madagascar depict either a man and a woman together or a woman alone (21). The downside to this approach is that it does not clearly define what a partner is. Brochures and efforts targeting CSWs focus on condom use with a client, thus oversimplifying the range of relationships that a CSW may have. Often, the distinction between a nonpaying partner and a client can become unclear, as is the case when a tourist may began a relationship with a CSW as a paying client, but over the course of a two week vacation may enter into a relationship with the CSW. In this case, the tourist may pay for meals, clothes, and other gifts rather than exchange money for sexual intercourse exclusively; the definition of a “paying client” becomes uncertain.

Pettifor et al. found that of the CSWs participating in the study, approximately 42% had a nonpaying main partner; of those with a main partner, “the vast majority (70.8%) of women reported that their main partner probably or definitely had sex with other women in the past month” (16). Over 40% of CSWs surveyed reported never using a condom with their main partner; only 0.5% of CSWs in this same group reported that they never use a male condom with a client. Given that condom use with main partners is low, and sexual relationships with multiple partners is a common practice, relationships between CSWs and nonpaying or main partners are at a tremendous risk for HIV/AIDS and other STIs.

Social Marketing Campaigns Do Not Utilize CSW Support Systems

Although CSWs are stigmatized in Malagasy society, associations do exist to act as a support system. With the help of associations such as Fikambanana Miaro ny Zon’ny Rehetra (FIMIZORE), CSWs are able to seek out support in a safe environment. According to the International HIV/AIDS Alliance in Madagascar (the Alliance), a group that has provided financial and technical support to FIMIZORE, the group “promotes respect for [C]SWs through advocacy, information dissemination and training for relevant stakeholders, and contributes to the fight against infection” (9). Due to the shame many CSWs feel in response to societal marginalization, many are hesitant to join an association such as FIMIZORE. The association points out that CSWs are more inclined to prioritize their health when they are not forced to do so and when they have a strong support system (9).

Current condom promotion campaigns in Madagascar largely ignore the tremendous potential of groups like FIZIMORE as a resource. Creating a supporting environment for CSWs has been touted as an HIV/AIDS prevention best practice from the United Nations Programme on HIV/AIDS (22). A support system comprised of other CSWs promotes a sense of solidarity; by incorporating such groups into condom promotion interventions, the efficacy of such interventions will increase. Providing recognition to groups like FIZIMORE empowers CSWs and encourages positive health behavior change.

Proposed Intervention

Current efforts to increase awareness of and reduce rates of HIV/AIDS in Madagascar are commendable, given that such efforts have increased tremendously from virtually nothing in 15 years. Utilizing condom promotion as a primary means of HIV/AIDS prevention has proven an effective and financially prudent method. I would like to suggest that a proposed intervention would not replace current social marketing techniques, but rather build upon and expand the scope of the intervention.

Creating a plan that involves a multi-faceted approach to HIV/AIDS prevention aimed at CSWs will draw upon existing resources such as CSW associations and health clinics. The current situation in Madagascar is akin to a ticking time bomb, if preventative action is not taken immediately, rates of HIV/AIDS cases will skyrocket to rates currently occurring in other sub-Saharan countries.

Changing perception of CSWs is difficult and will require time, but it is possible to change efforts now to provide CSWs with HIV/AIDS education that goes beyond male condom social marketing promotion. It is imperative that Malagasy CSWs are equipped with the correct tools to protect themselves against HIV transmission, as they are in a position to potentially transmit HIV and other STIs to a large percentage of the population in a short amount of time.

Health clinics are located throughout the country and provide a framework upon which increased interventions can be built. As part of the Malagasy national health care system, Centre de Santé de Base (CSB) are local health clinics located throughout the country, providing healthcare access (albeit often rudimentary) to the Malagasy people. The CSB provides a location for expanded HIV/AIDS prevention efforts to reach a larger audience of CSWs while remaining accessible. As the CSB is a primary source of healthcare for the vast majority of Malagasy citizens, it services a wide range of healthcare issues and will not stigmatize CSWs as a healthcare center branded for CSWs only would. To address the three flaws identified with current HIV/AIDS prevention methods, I recommend three solutions that can be achieved with the proposed multi-faceted intervention.

Increase Awareness and Accessibility of Female Condoms

The most difficult barrier to overcome in regard to condom use cited among CSWs is convincing a client to use a male condom. Often, a higher rate can be negotiated to engage in sexual intercourse without a condom or a client may become violent at the suggestion of condom use (16). In the instance that a CSWs client refuses to use a male condom, a female condom can be used often without the client’s knowledge. Hoke et. al. states “a woman’s capacity to propose use of an alternative prevention method has reportedly heightened her bargaining power to insist on male condom use, furthering contributing to increases in protection” (15).

With respect to the proposed intervention, ensuring that female condoms are as readily available in shops as male condoms are will provide CSWs with a method to prevent the transmission of HIV that has proven as effective as the male condom (23). Many CSWs are aware of the benefits of condoms, but often are in a position in which they have limited influence over the decision to use or not use a condom when negotiating with a client. Promotion of the female condom puts the control in the hands of the CSW. Current social marketing campaigns promoting male condoms can easily be adapted in the context of female condoms, thereby building upon existing techniques, while also utilizing new interventions by involving the CSB.

Defining Sexual Relationships

In Malagasy culture, having multiple sexual partners is a practice which is quietly accepted. Based on the evidence, it is quite clear that many CSWs that have reported having a boyfriend or intimate partner are less likely to use a condom with that main partner than they are with a client. It is feasible that the main partner maintains a sexual relationship with one or more women in addition to the CSW; the interconnected nature of this situation allows for potential transmission of HIV or other STIs to an enormous number of people.

It is also important to recognize the various “levels” of sex work, low, middle, and high. Low sex work takes place during the day, often taking place in shacks or locations rented out in half hour increments for the purpose of sex. Middle work typically takes place at night on the street and is often prefaced by a verbal agreement between the CSW and client regarding financial compensation. Taking place in bars and nightclub, the high level of sex work is often the most undefined. Financial compensation is rarely discussed before the sexual exchange takes place, as many CSWs hope to find a potential husband. Regardless of the level of sex work, CSWs are at risk at every level, whether the sexual encounter took place in 30 minutes or over the course of a one year relationship.

The proposed intervention would rework current condom promotion strategies to explain the health implications of multiple partners and clearly emphasize the importance of condom use with all sexual partners. Providing a visual aid to show the connections that can potentially exist between multiple sexual partners will educate everyone to their possible risk of HIV/AIDS. It is important to highlight that a nonpaying partner is still at risk by not using a condom.

Collaborating With Existing CSW Support Systems

Faced with a great many hardships, CSWs often have limited or no access to healthcare. Social and environmental factors are highly influential to the behaviors of CSWs (33). Specifically, Peer-influence and social network norms have been found to increase condom use among CSWs (24). A strong social support system has been shown to help in reducing rates of HIV/AIDS among CSWs by promoting the use of condoms in a trustworthy environment. A recent study of CSWs in China found that a well-structured CSW social network prompted condom use in several ways: promoting wholesale purchasing of condoms, mediating condom use with clients, and providing options for clients who refuse to use a male condom (24).

Existing CSW groups in Madagascar, such as FIZIMORE, could benefit from collaboration with the local CBS to increase influence over decisions such as condom distribution and the availability of HIV testing opportunities. By establishing a presence in the community and making condom use and HIV/AIDS prevention a topic of conversation, CSB doctors and nurses can provide backing to the work of the CSW groups. Additionally, demographic information and health statistics can be gathered at the CSB, allowing for quantitative analyses to aid in the overarching campaign goals.

Conclusion

Poverty, stigma, violence, and lack of education are just a few adversities facing CSWs in Madagascar. The threat of HIV/AIDS may not appear as a threat to many CSWs, as symptoms are not immediately visible. Given the reach CSWs have among sexual relationships with clients and nonpaying partners, adoption of an effective HIV prevention method such as condom use is critical to preventing new cases. Existing condom promotion campaigns have laid the foundation for expanded techniques, and have brought to light the importance of HIV/AIDS prevention among CSWs as factor in HIV/AIDS prevention for the entire population.

REFERENCES

1. USAID. HIV/AIDS Health Profile. Antananarivo, Madagascar: USAID/Madagascar, 2010.
2. World Bank. Results-Oriented Monitoring: A Successful Transition in Madagascar. World Bank Global HIV/AIDS Program, 2008.
3. World Health Organization Media Center. Treatment for Sexually Transmitted Infections Has a Role in HIV Prevention. Geneva, Switzerland: World Health Organization, 2006.
4. UNAIDS Regional Support Team for Eastern and Southern Africa. Madagascar Country Profile. Antananarivo: UNAIDS Country Office.
5. The World Factbook. Madagascar Country Profile. Washington, DC: U.S. Centeal Intelligence Agency, 2011.
6. Academic Presentation, Rachel Pryzby. Helping Women Help Themselves: Sex Work, Health, and Development in Mahajanga, Madagascar. Madagascar: Culture and Society, Fall 2007.
7. UNAIDS. Epidemiological Fact Sheets on HIV/AIDS and Sexually Transmitted Infections. Antananarivo: USAIDS Country Office, 2004.
8. UNAIDS. Epidemiological Fact Sheet on HIV and AIDS: Core Data on Epidemiology and Response. Geneva, Switzerland: UNAIDS/WHO Working Group on Global HIV/AIDS and STI Surveillance, 2008.
9. International HIV/AIDS Alliance in Madagascar. Giving a Voice to Sex Workers in Madagascar: The Alliance’s Work with FIZIMORE. Madagascar.
10. Fishbein, M and Ajzen, I. Belief, Attitude, Intention and Behavior: An Introduction to Theory and Research. Reading, MA: Addison-Wesley, 1975.
11. Fishbein, M. A Reasoned Action Approach to Health Promotion. Medical Decision Making 2008; 28:834-844.
12. Sheppard, B.; Hartwick, J.; Warshaw, P. The Theory of Reasoned Action: A Meta-Analysis of Past Research with Recommendations for Modifications and Future Research. The Journal of Consumer Research 1988; 15:325-343.
13. Profile: Social Marketing and Communications for Health. Madagascar: Revitalizing a Social Marketing Program. Antananarivo, Madagascar: PSI/Madagascar, 2003.
14. Feldblum, PJ; Hatzell, T; Van Damme, K; Nasution, M; Rasamindrakotroka, A; Grey, TW. Results of a randomised trial of male condom promotion among Madagascar sex workers. Sexually Transmitted Infections 2005; 81:166-172.
15. Hoke, et. al. Randomised controlled trial of alternative male and female condom promotion strategies targeting sex workers in Madagascar. Sexually Transmitted Infections 2007; 83(6):448-453.
16. Pettifor, A. Perceived control over condom use among sex workers in Madagascar: a cohort study. BMC Women’s Health 2010; 10:4.
17. Weller, S; Davis-Beaty, K. Condom effectiveness in reducing heterosexual HIV transmission. Cochrane Database of Systematic Reviews 2002, 1:4.
18. Warner, L et.al. Condom use and risk of gonorrhea and Chlamydia: a systematic review of design and measurement factors assessed in epidemiological studies. Sexually Transmitted Diseases 2006; 33(1):36-51.
19. Thomsen, S; Stalker, M; Toroitich-Ruto, C. Fifty ways to leave your rubber: how men in Mombasa rationalise unsafe sex. Sexually Transmitted Infections 2004; 80:430-434.
20. Stoebenau, K. “…But Then He Became My Sipa”: The Implications of Relationship Fluidity for Condom Use Among Women Sex Workers in Antananarivo, Madagascar. American Journal of Public Health 2009; 99(5):811-819.
21. Population Services International: HIV Department. Madagascar Condom Use BCC Catalogue. PSI/Madagascar. http://misaccess.psi.org/bcc_catalog/web/Content117.html
22. UNAIDS Best Practices Collection. Sex work and HIV/AIDS: Technical Update. Geneva, Switzerland: UNAIDS, 2002.
23. French, P.P. MD,MPH, et al. Use-Effectiveness of the Female Versus Male Condom in Preventing Sexually Transmitted Diseases in Women. Sexually Transmitted Diseases 2003; 30(5):433-439.
24. Tucker, J. et. al. Female Sex Worker Social Networks and STI/HIV Prevention in South China. PLoS One 2011; 6(9). http://www.ncbi.nlm.nih.gov.ezproxy.bu.edu/pmc/articles/PMC3172283/?tool=pubmed