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

The Failure of Creating an Effective Campaign: A Critical Analysis of “Beating Eating Disorders” with Proposed Modifications –Shamaila Usmani

The Failure of Creating an Effective Campaign: A Critical Analysis of “Beating Eating Disorders” with Proposed Modifications –Shamaila Usmani

Introduction

The National Institute of Mental Health describes eating disorders as “an illness that causes serious disturbances to your everyday diet…the urge to eat less or more spiraled out of control”. (1) It is prevalent throughout the world, in some form or another, with societal and environmental factors often contributing to the illness.

It is only recently that abnormal eating patterns and related research have emerged into public spheres as celebrities and other influential people started speaking about their eating habits. (2) A custom once practiced in secret for centuries, the 80s brought along a wave of awareness about these issues and a higher prevalence of disordered eating. (3)

Many campaigns have attempted to use awareness as a technique for change. Others have used disturbing ad campaigns trying to play with emotions, but statistics continue to rise spreading to different age groups and demographics. (4)

This is due to the lack of understanding the target population’s needs. Often times campaigns are built upon what creators think they need not what they actually need. Campaigns need an element of understanding and appropriately addressing the root causes, in addition to providing the right resources, planning the correct interventions at the right times, as well as portraying appropriate role models in creative ways.

Beating Eating Disorders (Beat): Current Approach

Beating Eating Disorders (Beat) is the United Kingdom’s only nation-wide eating disorder organization, which campaigns for individuals, family and friends affected by eating disorders. Founded in 1989, Beat has come a long way since their beginning, including a change in name and vision. Many organizations and British celebrities such as Keira Knightly have supported Beat. Their activities are primarily based on raising awareness by providing information about eating disorders, lacking solid prevention component. Beat’s missions and aims are as follows:

Mission: “Eating disorders will be beaten”

Aims: “To change the way everyone thinks and talks about eating disorders”, To improve the way services and treatment are provided” and “To help anyone believe that their eating disorder can be beaten”

Although Beat has many different annual activities such as conferences and awareness weeks, their main source of support is through online services. Beat has two help-lines, online resources in addition to media including videos. (5)

However the foundational core that Beat is built off of is highly flawed. While their campaign aims to change the way people think and help inspire change amongst those that have the disorder, it really succeeds to isolate those that are suffering by making assumptions about their behavior. Beat’s approach to beating eating disorders is flawed for the following reasons: 1) inappropriate use of the Theory of Planned Behavior as a platform for behavioral change, 2) failure to create a behavior through the Social Learning Model and 3) it fails to take the root causes into account.

1) Using TPB: Human Rationality, Feelings, and the Lack of Perceived Control

Icek Ajzen first proposed the Theory of Planned Behavior (TPB) in 1985. Evolved as a revised version of the Theory of Reasoned Action, the central idea of the TPB is that behavior change occurs due to a combination of three factors: attitudes towards behavior, subjective norms, and perceived control. The individual internally weighs these three factors to procure an intention, which supposedly will lead to behavior change. (6)

Beat relies on the TPB as a platform to encourage individuals to either call Beat’s helpline or to make a positive behavior change related to his/her eating disorder. It is assumed that providing information and creating awareness will contribute to controlling the behavior or at least calling Beat’s helpline. Things such as workshops, awareness weeks, and mental health conferences are all aligned with their goal to raise awareness about eating disorders. The program continues to assume that by using examples of the emotional toll the behavior takes on the family and friends through videos, the targeted individual will succumb to the subjective norms leading to behavior change. Lastly, the program assumes that the targeted individual believes that s/he is capable and has the desire to take control of the behavior therefore will access the program’s resources: help-lines and online resources.

However, the program fails to take into account that raising awareness about eating disorders is ineffective as it relies on human rationality, forgetting that humans generally make irrational decisions. Dan Ariely explains this concept in his book Predictably Irrational as he states that humans are irrational or not capable of making the perfect and most ideal decisions. (7) For example in a rational world, one could assume that awareness campaigns including statistical information about eating disorders would somehow contribute to either prevention of the behavior or a positive behavior change. Unfortunately there are many cases that show exactly the opposite. The prime example is the Drug Abuse Resistance Education (D.A.R.E), which is a school based prevention mechanism that informed preteens about the dangers of drugs and alcohol. Over the years, numerous research studies were conducted to analyze the effectiveness of the program. It was found that tobacco and marijuana use was not reduced. Another study found that the knowledge of the types of drugs may have gone up, but alcohol and marijuana use was not affected. (8) In essence individuals are less likely to care about the core value of health, as they do not value the connection between their health and the information provided, nor do they understand the link.

In addition, Beat also assumes that the individual will be more likely to be motivated to change if s/he sees the effects of their behavior on friends and family. The video’s caption that portrays this is as follows: “The clip is about the effect eating disorders has on the family and the emotional process that the family goes through…how we have all moved forward by turning something so negative into something positive”. (9) Watching this video can ignite emotions of guilt as the individual may feel that s/he is putting their family through emotional turmoil. This idea of guilt is not the appropriate method especially since the disorders are often instigated by feelings of guilt and blame. (10) Beat’s expectation that individuals will be motivated by subjective norms is gravely flawed.

Lastly, the assumption that individuals will want to and are capable of controlling their behavior is faulty. A study conducted by Erica Berman at the University of Toronto shows that low eating self-efficacy is linked to negative thoughts about body image and weight preoccupation, both of which are considered to be traditional eating disorder symptoms. In addition, low eating self-efficacy is also linked to eating problems such as binge eating in both male and females. (11) Assuming that these individuals are capable (and have the desire) of taking control of their eating actions cannot be assumed until other underlying factors are addressed. Perhaps then, these individuals will make an effort to access these resources, as they will believe that they can control their actions.

2) Social Learning Theory: Failure to Create a Behavior, which Individuals will follow

The Social Learning Theory (SLT) suggests that individuals act/learn by watching and modeling others. “Most human behavior is learned observationally during modeling and from observing others, one forms an idea of how new behaviors are performed”. (12) This theory seems essential to understanding how affected individuals will model behavior if they are urged to seek help.

Beat has recorded many videos of which five are found on their website. One of these five portrays the stories of five individuals who have dealt with eating disorders. Beat tries to use the SLT with the expectation that individuals will be inclined to change their behavior once they see there are others who have gone through what they are currently experiencing and the positives of overcoming the behavior. The video caption claims that it is aimed towards “people who are suffering or are worried about someone who may have an eating disorder”. (5) One main issue is that most of the chosen individuals are pretty and relatively thin. The target individuals will be less likely to listen to those speaking about their experiences as their irrationality (stemmed from low self-esteem and body dissatisfaction) will not allow them to look past how these girls look. In fact it can even lead to more disordered behavior, which can lead to the SLT never taking off.

It is apparent that Beat never considered the negative effects that this could have on their intended population. This negative effect is otherwise known as Psychological Reactance Theory (PRT). According to this theory, people respond to perceived behavioral threats to their freedom by reinforcing control of their actions. (13) In other words, being told to do something (especially by those one does not hold in high esteem) will result in continued (or increased) engagement of behavior.

Another issue is that diversity is not acknowledged in this video, nor in most of their other productions. There is only one age group, one gender, and one race represented in this video even though eating disorders affect a wide range of age groups, races, and genders. (14) Beat claims to be working towards a national goal emphasized by words such as “everyone” and “anyone”, but their campaign, especially their website, hardly reflects this. In fact there is not a single colored person on their website (including the videos) and a limited number of males represented in their campaign. It is unfortunate that they have not taken other demographic factors into account, as this would contribute to Beat’s overarching mission of “to change the way everyone thinks and talks about eating disorders”. In addition Lizabeth Barclay suggests that because the social learning theory is an interactive approach, it is necessary to address issues of discrimination so that a more complete modeling behavior can occur. (15) In other words, people are more likely to act similar to those that are like them.

3) Failure to Emphasize the Root Causes

Beat’s main goals consist of finding ways to help individuals beat eating disorders. It seems more appropriate to have a greater emphasis on targeting prevention and the root causes rather than treatment. Beat does have a small prevention component but it is not as comprehensive or developed as the treatment portion.

The prevention component should look at key contributing factors. The Beat campaign unfortunately overlooks many of these key factors involved in acquiring eating disorders as well as trying to overcome them. In fact the question “why?” is barely if at all addressed. This is visible throughout their videos as well as their online resources. For example media influence (societal pressure), peer and family pressure and stress are three huge aspects of why individuals partake in these behaviors (10) yet Beat barely addresses them.

In addition, Beat wrongly assumes that each individual has friends and family that will support them through their struggle. This generalization is quite troubling as each person’s situation is different. In fact the lack of this social support (either family/friends encouraging thinness OR no friends/family leading to depression) could be a reason why they have the disorder to begin with. (10) For all Beat knows, the videos may be instigating a self-perpetuated cycle of depression and the individual’s behavior. It is very important to explore the root causes before building a campaign.

Proposed Changes: FREEDOM.

Beating Eating Disorders has the potential to rise as a successful campaign once a few changes are made. A two pronged approach will be the most beneficial as it will firstly, address their two relevant aims of “To change the way everyone thinks and talks about eating disorders” and “to help anyone believe that their eating disorder can be beaten” and secondly, incorporate a new aim “to prevent the occurrence of eating disorders through a holistic approach”. This new addition to their program will introduce a strong prevention component known as FREEDOM. to reduce the incidence of eating disorders.

1) What (Wo)men Want

Theory of Planned Behavior fails to take into account the numerous factors that individuals with eating disorders experience therefore Beat needs to remove the TPB as the platform for behavioral change. The proposed change strategy will incorporate the Social Marketing Theory (SMT). This group level model is more ideal than the individual-based TPB and is far more likely to initiate behavioral change.

Beat will work within the framework of the SMT to research the target audience’s needs and wants in relation to different environments (high school/college, friends, family, and other effective environments). (16) Researching the target audience will also lessen the chances of instigating behaviors related to eating disorders, as well contribute to understanding who influences these individuals the most.

The SMT will then be used to develop new content for the same activities Beat has been conducting (workshops, hotlines, “awareness weeks”-will be changed to “empowerment weeks”-, conferences, etc.). The content will now be built directly off of what the target population wants, not what Beat believes they want. The product will be delivered through messages and content containing a core set of values including freedom, control, trust, acceptance, power, self-worth and hope. (17) The integration of these values is essential, especially as this population is more likely to lack confidence and self-worth. (10)

The use of the SMT is essential as the group level model motivates far more than an individual level model. The mere process of researching the target audience can make a world of a difference in reaching out to these individuals. Through the SMT, three critiques of the TBP (irrationality, accidently instigating disordered behaviors, and the desire to want to control the behavior) are addressed.

Too Hot in Here

The last critique of the TPB regarding underlying factors and self-efficacy will be addressed by a combination of the prevention component, which will be addressed later, as well as Ariely’s idea of “cold” and “hot” states. (7) Ariely demonstrates, through experiments that rational decisions vary depending on which emotional state a person is in. In a “cold” state, decisions are rational but in a “hot” state, decisions vary greatly. In a hot state, one is more likely to have a realistic expectation of what they are capable of Ariely states that is essential to understand the decisions that will be made in a hot state. His sexual arousal experiment can be related to eating disorders as well, since certain factors instigate the behavior. He suggests that teens need to be taught to turn away from temptation before they’re too close and are enveloped by it. His experiment results say that it is easier to avoid temptation than to overcome it. (7)

This can be applied in the cases of specific disorders such as bulimia and compulsive eating. Ariely’s theory of “cold” state/ “hot” state should be factored in to Beat’s trainings for mental health professionals, so that professionals can integrate it into their therapy. This behavioral change approach of training individuals to turn away from temptation before they are close to either purging or binging can result in self-efficacy as well.

In addition to Ariely’s suggestion of turning away from temptation, part of the prevention/treatment campaign will include posters in bathrooms (near sinks and in stalls) with creative messages integrated with core values and pictures of a brighter future and hope. Intervening in the “hot” state will also return “control” to these individuals, further encouragement for perceived control.

2) Model On

The SLT an ideal component of Beat as individuals will always learn and act by modeling others. However, it is important to drastically re-frame Beat’s video productions into 30-second public service announcements. The Framing Theory (FT) defines how an issue is packaged in order to encourage or change a certain interpretation. (18) If used correctly, FT has great potential to influence people’s perceptions and beliefs. If recovered individuals are to continue to deliver their stories and experiences, Beat must reframe their approach to conveying the messages.

First and foremost, the cast of the videos will need to be replaced with diverse individuals. In addition, these individuals will need to be of healthy sizes. Recasting will contribute to reaching a broader audience consisting of a wider age range and a diverse racial and gender demographic. These individuals will become the new faces of the campaign. The cast will be more likely to be modeled once they build a personal relationship with their audience.

Instead of talking about their past experiences, the cast’s experiences can be symbolized by a notion of turmoil and emotional distress that is felt while suffering from an eating disorder. The focus can shift (through a tunnel with a light at the end) to the positives of life such as playing sports, graduating from high school/college, and being surrounded by positive things linked to acceptance and self-worth. The end scene can have the word “FREEDOM” transitioning into “TO CHANGE”.

Similarly the cast should also star in additional videos linked to the all core values mentioned above. This will further reinforce the core value system.

3) FREEDOM. To Prevent

Beat needs a prevention component that will address the various root causes of the question “why disordered eating?”. FREEDOM. will be an all encompassing, holistic approach of empowerment and wellness. The target population will be primarily high school and university aged individuals, including males and all races, as this age group is by far the most affected. (1) Over the years, most components will be phased out of the university atmosphere, as by then FREEDOM.’s program will have already empowered university aged young adults, in high school.

Because a huge portion of young individuals often compare themselves to others (peers, role models, celebrities) (19), it important to build a prevention program around the self as well. FREEDOM. will have already started their media campaign featuring the five familiar faces of the campaign. Even so, cultural and social norm change often takes time to change therefore FREEDOM. will also work on integrating empowerment workshops in educational settings. These workshops will run by individuals closer to their ages and will foster feelings of “control”, “power”, “acceptance” and “self-worth” by discovering their talents and worth. Additional workshops will work with individuals to break away from comparing oneself to others and empowering them to view themselves as beautiful/handsome.

In the competitive academic world mixed with other societal pressures, whether it be in high school or in university, stress is often a factor that everyone experiences at some point but often never taught techniques to handle it. (20) At a time where teenagers and young adults are often trying to discover who they are and their meaning in the world, individuals get lost never knowing where and who to turn to. FREEDOM. will advocate policy change to require that each educational institution require a Wellness Center offering services such as stress coping mechanisms, workshops on stress, how to develop positive lifestyle habits and learning the principles of fitness. These workshops will be far more than information based, rather filled with interaction and inspiring practical application, built around the needs of individuals that will be easy to apply once individuals are faced with stress. FREEDOM. will also recommend that high schools and universities integrate certain workshops into their required curriculum at strategic points of the year (at the beginning, a few weeks before midterms and finals).

The wellness centers will be strategically located and highly advertised on campuses. FREEDOM. In addition, a wide variety of fitness classes will be available, at no cost, at these centers including yoga and zumba fitness. Beat’s fabulous faces of the campaign will advocate for incorporating a fitness plan into one’s daily schedule, highlighting the “freedom”, “control”, “power” one achieves when they workout.

FREEDOM. will also advocate for a nation wide implementation of highly recommended exercise in all levels of schooling while taking care to present it to individuals in a way that their choice to make the decision is still under their control. Highly recommended exercise will come whichever form the individual chooses to participate in (sport, yoga, etc). Exercise has proved to be an effective mental health intervention as it helps with stress, depression, and low feelings about oneself. (21)

Conclusion

More often than not, interventions and campaigns for eating disorders are based on awareness often forgetting the needs of the target population. Beat, Beating Eating Disorders, is reflective of just this. Beat has a promising future of emerging as an organization of igniting social change, if a few additions and modifications are made. The Marketing Theory needs to be used to assess the target population’s needs and reformat the content of the messages conveyed. In addition Ariely’s theory of “cold” state/ “hot” state can be added into training professionals for intervening at the correct time. The last modification will use the Framing Theory to use the Social Learning Theory more effectively. In addition to the changes, Beat should also integrate a strong prevention competent: FREEDOM. This holistic approach to well-being will be an integral part of reducing the incidence of eating disorders.

REFERENCES

1. National Institute of Mental Health. Eating Disorders. http://www.nimh.nih.gov/health/publications/eating-disorders/index.shtml. Accessed on December 15, 2011.
2. Derenne J & Beresin J. Body image, media and eating disorders. Academic Psychiatry 2007; 30(3):257-61.
3. Flegal K, Carroll M, Ogden C, Curtin, L. Prevalence and Trends in Obesity Among US Adults, 1999-2008. Journal of American Medical Association 2010; 303(3):235-241.
4. Nicholls D, Lynn R, and Viner R. Childhood eating disorders: British National Surveillance Study. British Journal of Psychology 2011; 198:295-301.
5. Beating Eating Disorders. Norwich, UK. http://www.b-eat.co.uk/.
6. Ajzen I. The Theory of Planned Behavior. Organizational Behavior and Human Decision Processes 1991; 50:179-211.
7. Ariely D. Predictably Irrational: The Hidden Forces That Shape Our Decisions. New York City, NY: HarperCollins, 2008.
8. Mark M and Stewart I. Social Psychology and Evaluation. New York, NY: Guilford Press, 2011.
9. Beating Eating Disorders: Videos. Norwich, UK. http://www.b-eat.co.uk/get-help/online-community/videos/. Accessed December 14, 2011.
10. Polivy J and Herman P. Causes of Eating Disorders. Annual Review of Psychology 2002; 53:187–213.
11. Berman E. The relationship between eating self-efficacy and eating disorder symptoms in a non-clinical sample. Eating Behaviors 2006; 7:79-90.
12. Bandura A. The social learning theory. The Journal of Communication 1977; 28(3):12-29.
13. Brehm, J. "A Theory of Psychological Reactance." Social Psychology: A Series of Monographs, Treatises, and Texts. New York and London: Academic Press, 1966.
14. Marques L, Alegria M, Becker A, Chen C, Fang A, et al. Comparative prevalence, correlates of impairment, and service utlization for eating disorders across US ethnic groups: Implications for reducing ethnic disparities in health care access for eating disorders. International Journal of Eating Disorders 2011; 44(5):412-20.
15. Barclay L. Social learning theory: A framework for discrimination research. The Academy of Management Review 1992; 7(4):587-594.
16. Svenkerud P and Singhal A. Enhancing the Effectiveness of HIV/AIDS Prevention Programs Targeted to Unique Population Groups in Thailand : Lessons Learned from Applying Concepts of Diffusion of Innovation and Social Marketing. Journal of Health Communication 1998; 3(3):193-216.
17. Kotler P, Roberto N and Lee N. Social Marketing: Improving the Quality of Life. Sage Publications, 2002.
18. Rothman A and Salovey P. Shaping Perceptions to motivate healthy behavior: the role of messaging framing. Psychology Bulletin 1997; 121(1):3-19.
19. Thompson J and Heinburg L. The Media’s Influence of Body Image Disturbance and Eating Disorders: We’ve Reviled Them, Now can We Rehabiliate them? The Society for the Psychological Study of Social Issues 1999; 55(2):339-353.
20. Felsten, G., and Wilcox, K. Influences of stress and situation-specific mastery beliefs and satisfaction with social support on well-being and academic performance. Psychological Reports 1992; 70(1): 291–303.
21. Stathopoulou G. Exercise Interventions for Mental Health: A Quantitative and Qualitative Review. Clinical Psychology: Science and Practice 2006; 13(2):179-193.