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.
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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

HPV Vaccination Promotion: Current Flaws and Possible Improvements – Allyson Shifley

Approximately 20 million Americans currently have genital human papillomavirus (HPV) infections. HPV is the most common sexually transmitted infection with at least 50% of sexually active people getting HPV at some point in their lives (1). In 2006, the first preventive HPV vaccine was approved for females aged 9-26 by the FDA. In 2009, the vaccine was also approved for males aged 9-26 (2). There are over 40 HPV types that can infect the mouth, throat, and genital areas of both males and females. This vaccine protects against types 6, 11, 16, and 18. Types 16 and 18 primarily cause cervical cancer (1).

HPV is passed on through genital contact (vaginal and anal sex), oral sex, and genital-to-genital contact. Most people do not realize when they are infected, and therefore do not realize they are passing on the infection to their partner. HPV infections can cause genital warts, respiratory papillomatosis (rarely), cervical cancer, and other less common cancers, including cancer of the vulva, vagina, penis, anus, and oropharynx (3). The HPV vaccine can protect both males and females against most types of HPV that can cause disease and cancer and most cervical cancers. If the vaccine is widely adopted, it is estimated it will prevent 70% of cervical cancers in the U.S. (1).

It is estimated that fewer than 11% of girls in the United States have received all 3 doses (4). And in 2010, 32% of the U.S. female adolescent population aged 13-17 had received all 3 doses of the HPV vaccine (5). This is a low adoption rate; kept low by the widespread reluctance to accept the vaccine. This paper will outline the current approach towards HPV vaccination adoption and present its major flaws. Then, following the flaws, possible improvements will be suggested for a new intervention approach to increase the acceptability and adoption rate of the HPV vaccination.

The Current Approach

The current approach toward HPV vaccination is flawed. There are two main faces of pro-HPV vaccination: the Centers for Disease Control and Prevention (CDC) and Merck, the producers of the vaccine Gardasil. The three main flaws in the current approach are the lack of a centralized messenger, the reliance on the Health Belief Model, and an education only promotion approach.

Flaw 1: The Messenger

Public knowledge about HPV is limited. About 40% of women aged 18-75 have heard of HPV and even less than that know its association with cervical cancer (6). Gardasil and the CDC have successfully increased knowledge about HPV. In fact, Gardasil commercials were a common source of information about HPV and have increased people’s knowledge of HPV (7). Still, there has not been enough knowledge disseminated throughout the population, and this is in part because there is not a single leader of the pro-HPV vaccination campaign. There is no point person to rally behind, no leader to give a single voice to the campaign. Currently there are so many opinions, both pro- and anti-HPV vaccination, that parents find it difficult to determine who to trust for safety information (8). And the information available is very contradictory.

Again, the two main faces of pro-HPV vaccination are Gardasil and the CDC. Gardasil is marketed by Merck, a pharmaceutical company. People are wary of Merck, aware that it has motives other than health. Most fault has been found in how Merck has marketed Gardasil. Merck is viewed as marketing Gardasil for self-promotion. Some people blame the wording in these advertisements on misleading the public about how protective these vaccines are and what exactly they prevent against (9). The bottom line is that a pharmaceutical company pushing its own vaccine is not seen as a trustworthy source, with only 2% of parents placing a lot of trust in websites from companies that make vaccines (8).

The CDC is a governmental component of the Department of Health and Human Services. Although its mission is to create information and tools for people to protect their health, a study conducted by Freed et. al. (2011), cites that only 23% of parents reported placing a lot of trust in government vaccine experts and officials (8).

There is a lack of public trust in these messengers. Following communication theory, the source of information is an important consideration to take into effect when trying to transit information to an audience (10). The pro HPV vaccination campaign is using Gardasil and the CDC as their messengers, two sources that the pubic do not have a lot of trust in. Neither messenger inspires trust and neither is a point for which people to rally behind.

Flaw 2: The Reliance on the Health Belief Model

The campaign’s reliance on the Health Belief Model is another fatal flaw. The Health Belief Model depends on affecting an individual’s perceived susceptibility and severity of having the negative health outcome to lead to behavior change. There are four variables to the Health Belief Model. First, an individual needs to be motivated to act in healthy ways if she believes she’s susceptible to a negative health outcome. Second, the stronger an individual’s perception of severity of the negative health outcome, the more motivated she is to avoid the negative outcome. Third, she must believe that the target behavior will provide strong positive benefits, or that the target behavior prevents the negative health outcome. Lastly, if the individual perceives barriers preventing her from adopting the target behavior, then she will be unlikely to adopt the target behavior (11).

In this campaign, the negative health outcome is developing cervical cancer. Although, HPV most commonly causes genital warts, the focus on genital warts as a negative health outcome has largely been dismissed in favor of the focus of cervical cancer. And, the target behavior adoption is receiving all 3 doses of the HPV vaccine. Therefore if the individual perceives an increase in her risk of having cervical cancer, then rationally she will change her behavior and get the HPV vaccine to decrease her likelihood of cervical cancer. However, in a meta-analysis conducted by Carpenter, susceptibility is unrelated to behavior change. And perceived severity of a negative health outcome is the weakest predictor out of the four variables to predict the likelihood of adopting the target behavior. According to this, susceptibility and severity do not affect the person’s motivation to make a positive behavior change. The Health Belief Model relies on rational behavior and logical decision-making process. Humans, however, are not rational supported by the susceptibility and severity not affecting behavior change.

Two variables of Health Behavioral Model do relate to behavior change, benefits and barriers. Barriers are the largest predictor of the four variables. The pro-HPV vaccine campaign, however, does not address these factors to encourage behavior change. And the model does not allow for combating the perceived barriers. The most commonly cited perceived barriers were parental concerns about promoting sexual activity, financing the vaccinations, and low perceived vaccine safety (1, 12, 13). For parents who responded that they would not likely vaccine their daughters before ages 13 or 16, in a survey by Constantine and Jerman, the main reasons concerned pragmatic sexual behavior concerns, HPV vaccine concerns, general vaccine concerns, moral sexual behavior concerns, and denial of any need (14). The current approach does not address these parental concerns. Instead, the campaign focuses on susceptibility and severity – the two factors that do not motivate positive behavior change.

Flaw 3: Education Only Blinds

In addition to the lack of an appropriate messenger and the reliance on an inappropriate model to promote HPV vaccinations, the current promotional approach is flawed. To motivate people to receive this vaccine, the CDC and Gardasil use an educational approach.

The CDC has a Preteen and Teen Vaccine Communication Campaign to improve vaccination rates for several vaccines, one of which is the HPV vaccine. They cater to parents and health care providers of adolescents 9-18, adolescents 9-18, and Public Health professionals promoting immunization. The current objectives include raising awareness and educating parents, educating health care providers, providing communication tools for public health officials, and educating adolescents, all on the importance of vaccinations and on the diseases they prevent (15). The focus is on education, promoting information and statistics through pamphlets, brochures, podcasts, a short video and sending e-cards to others.

Gardasil has promoted the vaccine through the One Less campaign. The campaign is more consumer-oriented with advertisements on television, radio, Internet, and in print (16). But again, it promotes education on HPV and the diseases the vaccine prevents.

The CDC and Gardasil campaigns have been successful raising awareness and knowledge to parents and adolescents (7, 17). These campaigns rely on the Health Belief Model, which is an inappropriate model as addressed in Flaw 2. Still, these approaches use the Health Belief Model in an attempt to increase an individual’s knowledge about the health problem to affect her perceived susceptibility and severity of having the problem. Education alone, however, does not lead to behavior change. One study found that individuals with a higher risk perception were more likely to be vaccinated (13). However, these high-risk perceptions were not formed from educational materials but from emotional appeals and life experiences. For example, parents with a history of genital were more likely to have their child vaccinated (17). A study by Dempsey et al. concluded that providing parents with HPV information improved their knowledge about HPV, however, this uptick in knowledge had little effect on the acceptability of the vaccine (17).

Also, increasing knowledge does not address or make the connection between an individual and her ability to change her behavior. This connection needs to be addressed through ownership of one’s health and through appealing to core values. In addition, it needs to make plans of action to break through perceived barriers.

However, the focus is solely on statistics and education. Insisting that the public should get this vaccine, and only giving the public statistics, actually incites a reactance on the part of the public. Reactance is shown as the backlash against mandates for girls to receive the HPV vaccine for school attendance. A survey found that 57% of US voters opposed Texas’s mandated HPV vaccines (4). And the current political debates show just how powerful this reactance is with Perry reversing his original support for HPV vaccination mandates (18).

The reactance is directly related to how the pro-HPV vaccination advocates are conducting the campaign. The focus on an education only approach blinds the campaign, making in unable to focus on the important factors that could increase HPV vaccine acceptability and awareness. This reliance on an education only approach is a mistake. The CDC focuses on facts and statistics to promote behavior change. This non-causal information does not address people’s concerns with the vaccine. Nor do statistics help people overcome the perceived barriers to receive the vaccine.

The Proposed Intervention

Public health officials, healthcare providers, the pharmaceutical companies, parents, and adolescents needs to work together to create a campaign using social science theories to increase awareness of and acceptability of the HPV vaccine. Currently public trust in immunization is decreasing, with an increasing amount of parents expressing more fear over the vaccine than of the diseases that the vaccine is supposed to prevent (19). Part of this fear is a result of a great number of parents today never experiencing the diseases that vaccines prevent. There are several important differences from the time that vaccines were first introduced and the climate around vaccines today. There has been a dramatic increase in available and recommended vaccines and in mandated immunizations. People increasingly want to understand health issues and want to assume responsibility for their health decisions. The Internet and other social media have rapidly grown and quickly disseminate information and misinformation to the population. People can now look up anything on the Internet and have a flurry of “hits”– but it is not as easy to determine which sites are real and which contain incorrect information. It is also important to realize the extent to which the media has propelled the vaccine controversy. Bad news sells, so any allegation of a harmful effect of a vaccine is more frequently reported (19).

Keeping all of this information about the changing climate around immunizations in mind, I suggest a two-part intervention designed to address the method in which information is disseminated to the public.

The first part concerns the communication skills of the healthcare providers. Healthcare providers are an incredibly important source for health information and immunization information. These providers may have all of this knowledge to give to their patients, but lack the ability to successfully communicate it. To address this, healthcare providers are to attend trainings on social communication, specifically about addressing vaccinations with their patients. Then, they are to establish a checklist for patient visits that includes conversations about sexual activity, and therefore the HPV vaccination. These checklists regulate their visits with patients to ensure these conversations are occurring.

The second part is a campaign to the public to hopefully reach everyone, specifically those who do not regularly visit a healthcare provider. This campaign is to use the principles of social marketing. It will be nationwide, but research will be done to distinguish areas that contain high at-risk populations to aim increased efforts in those areas. At-risk populations and areas have been described in previous research, including African-American and Asian American parents who have reported lower acceptability of an HPV vaccination (14). And, data shows that Hispanic and African-American women are 1.5 times more likely to develop and die from cervical cancer, when compared to white women (6). More research needs to be conducted to identify at-risk populations so that future interventions can be tailored to each racial group or geographic community to address that group’s specific needs (1).

For this intervention to work, the flaws from the current approach to HPV vaccinations need to be addressed. There needs to be an appropriate messenger to give voice to the campaign and for people to rally behind. The approach should not rely on the Health Belief Model. Also it should address parental concerns and broaden the approach beyond just HPV and HPV vaccination education.

Support 1: Getting Healthcare Providers Talking

In one study, 77% of survey respondents reported that their healthcare provider is the most trusted source of health information (7). Healthcare providers are an integral part of making sure their patients are healthy. This involves regular check ups, screenings, tests, and immunizations. It also includes having conversations about health behaviors, immunizations, and any patient concerns. HPV and HPV vaccination discussions should occur during these visits. However, not everyone is having these discussions about HPV vaccines, or vaccines in general, with their doctors. 87% of doctors say they have talked to their patients about vaccines, but only 47% of patients report that their doctor has actually talked to them about them, other than the flu vaccine (20). This is a large disconnect between doctors and patients that needs to be addressed. Social communication strategies can improve this situation.

Social communication is the language used in social situations. It overlaps language abilities and social-cognitive abilities. There are both verbal and nonverbal actions. Healthcare providers need to take into account their patients’ social situations, lives outside of the clinic, and use language that is familiar to the patients. (21)

Healthcare providers need to learn how to present information in perspective– which includes presenting the benefits of the vaccine but also the risks and the gaps in knowledge concerning the vaccine. Taking the time to explain HPV and the benefits, risks, and uncertainties about the HPV vaccination can establish trust and a good relationship with the patient (19).

Support 2: Using Social Marketing Strategies

Although data and rational arguments are important, they are not enough to get people to be vaccinated (22). Social marketing is the use of marketing tools or techniques to induce social and behavioral changes (23). It focuses on using different theories and strategies, drawing from commercial marketing, behavior change theories, social psychology, and human reaction to message, to influence healthy behaviors and improve personal and societal welfares. To successfully induce positive behavior changes, social marketing-led campaigns rely on the 4 P’s of marketing (product, price, place, and promotion) and tailoring the campaign to different population subgroups (22).

The 4 P’s of marketing (product, price, place, and promotion) are instrumental in this process. The ultimate objective is for the target audience to take action, for people to get the HPV vaccination. To do this, the campaign leaders need to design an intervention that motivates people to get to a healthcare provider and receive this shot. The benefits need to outweigh the risks and any barriers need to be broken down.

The product is clearly the HPV vaccination. Presently, the price is expensive, costing $360 for all 3 doses. However, many private and public sectors cover the vaccine. Most girls are covered by private insurance, but for those who are not Vaccines for Children, Immunization Grant Program, Medicaid, and State Children’s Health Insurance Program are options to get the vaccine covered. Several states offer free or low-cost vaccines for girls who are not covered by any of the above-mentioned options (6). Cost is one of the most common perceived barriers (1, 12, 13, 14). To break down this perceived barrier, this campaign needs to directly address the price of these shorts and give information about insurance coverage. The easier it is for the patient the more likely she is to receive the vaccine.

The place for HPV vaccinations is technically throughout the world, but this campaign will focus on the United States. The campaign will be nationwide, but will specifically address at-risk populations and areas and provide tailored information for these communities. The campaign will include and emphasize information about where local health centers are located to get these shots. This emphasis on available locations aims to make it easier for individuals to access the vaccinations.

Promotion is how the health behavior is marketed to the public, including the product, price, and place information. HPV vaccinations are going to be promoted by healthcare providers and through our campaign. The campaign will be both media and print. IT will provide brief basic HPV knowledge, however, that is not what is currently needed for behavior change. Instead it will be based on having an effective messenger, telling people’s stories, and showing families who have received the vaccine. A main strategy when considering our product promotion is to appeal to core values. Core values are people’s deepest aspirations– freedom, control, justice, love, etc. These create mass appeal. Social marketing is about the consumer driven and not expert driven market. The campaign needs to find consumers who are willing to share their stories to others, to show them the benefits of the HPV vaccination (24).

Using this marketing mix of the 4 P’s, social marketing can help increase HPV vaccination rates.

Support 3: The New Messenger

An important hinge of social marketing, and integral to both parts of this intervention, is the messenger. Currently, the pro-HPV vaccination campaign lacks a central messenger and the public does not trust the two prominent faces for pro-HPV vaccination.

This new intervention needs to focus on the messenger, message delivery, and the public reaction. The goal is to increase vaccination rates and to do this parents need to know that receiving the vaccine is in the best interest for their daughter’s health. Although this can be done through statistics and study results, scientific evidence must be present in all health campaigns, we need a messenger that the public likes and trusts (22). Presumably parents and children/adolescents already see a healthcare provider that they like and trust. Parents and children/adolescents should also have common goals as their healthcare provider– hopefully the intent to work toward the best health for the child. So these traits– likeability, trustworthiness, and working toward the same goal– need to be embodied by a messenger. For this campaign, however, the messenger needs to appeal to a broad audience.

In this area, the pro-HPV vaccination campaign should look at and learn from the anti-vaccination movement. The anti-vaccination movement has found an effective messenger in Jenny McCarthy. She is a celebrity and she has a child with autism. Jenny McCarthy blames vaccinations for her child’s autism. She is has all of the traits of an effective messenger–likeability, trustworthiness, and working toward the same goal as parents (trying to keep her child healthy)– but most importantly, she has a personal and emotional connection and a story to tell. Not only should effective messengers embody these traits, they also appeal to the public because they have a personal connection and a moving story. In addition, because she is a celebrity, her voice is heard and her pictures appear in the media, giving further propulsion to her anti-vaccination message.

Although celebrities can be a powerful voice in the community, currently only about 26% of parents placed at least some trust in celebrities touting vaccine-safety information. However, 73% of parents placed at least some trust in other parents who say their child has experienced a negative effect from a vaccine (8). Jenny McCarthy is a celebrity, but what gives her message weight is that she is a parent. This intervention should take advantage of the latter statistic and have parents inform other parents about why they chose the HPV vaccine for their child. Between information from other parents and information from healthcare providers, this campaign should be ell equipped to deliver its pro-HPV message.

Conclusion

We have to create a movement based on people’s core values. It is not about selling a behavior; it is about creating a movement and setting a new standard for health. The pro-HPV vaccination campaign needs an overhaul. Currently it does not have an effective messenger, is based on an inappropriate model to create health behavior change, and does not address parental concerns or other important factors because it is an education only approach. But if these flaws are fixed– if we can find an effective messenger whether it be healthcare providers in local communities or an outspoken celebrity, if we make sure healthcare providers are having these immunization conversations with patients, and if we utilize social marketing– then we can successfully increase the acceptability and adoption rate of the HPV vaccination.

References

1) Reiter, P. Brewer, N., Gottlieb, S. McRee, A. & Smith, J. Parents’ health beliefs and HPV vaccination of their adolescent daughters. Social Science & Medicine 2007; doi:10.1016.

2) Centers for Disease Control and Prevention. 2010 Sexually Transmitted Disease Surveillance. Atlanta, GA: Centers for Disease Control and Prevention, 2010.

3) Centers for Disease Control and Prevention. Genital HPV Infection- Fact Sheet. Atlanta, GA: Centers for Disease Control and Prevention, 2011.

4) Giacobbe, A. A Drug Double Standard. Boston Globe Magazine, 11 Dec 2011.

5) Centers for Disease Control and Prevention. 2010 NIS- Teen Vaccination Coverage Table Data. Atlanta, GA: Centers for Disease Control and Prevention, 2011.

6) Kaiser Family Foundation. Fact Sheet: Women’s Health Policy Facts. CA: www.kff.org, Feb 2008.

7) Caskey, R., Lindau, S., & Alexander, G.C. Knowledge and Early Adoption of the HPV Vaccine among Girls and Young Women: Results of a National Survey. Journal of Adolescent Health 2009; 45, 453–462.

8) Freed, G., Clark, S., Butchart, A., Singer, D., & Davis, M. Sources and Perceived Credibility of Vaccine-safety Information for Parents. Pediatrics 2011; 127(1), S107-S112.

9) Siers-Poisson, J. Research, Develop, and Sell, Sell, Sell: Part Two in a Series on the Politics and PR of Cervical Cancer, 2007. http://prwatch.org/node/6208

10) Shannon, C. E., & Weaver, W. The Mathematical Theory of Communication. Urbana, Illinois: University of Illinois Press, 1949.

11) Rosenstock, Irwin. Historical origins of the Health Belief Model. Health Education Monographs, 2(4) Winter 1974. 328-335.

12) Brewer, N. T., & Fazekas, K. Predictors of HPV Vaccine Acceptability: A Theory-informed, Systematic Review. Preventive Medicine 2007; 45, 107-114.

13) Brewer, N. T., Chapman, G. B., Gibbons, F. X., Gerrard, M., McCaul, K. D., & Weinstein,

N. D. Meta-analysis of the Relationship Between Risk Perception and

Health Behavior: the Example of Vaccination. Health Psychology, 2007; 26(2), 136–145.

14) Constantine, N. A., & Jerman, P. Acceptance of Human Papillomavirus Vaccination among Californian Parents of Daughters: A Representative Statewide Analysis. Journal of Adolescent Health, 2007; 40(2), 108–115.

15) Centers for Disease Control and Prevention. Preteen and Teen Vaccines: CDC Preteen and Teen Vaccine Communication Campaign. Atlanta, GA: Centers for Disease Control and Prevention, May 2011

16) Gardasil. www.gardasil.com

17) Dempsey, A. F., Zimet, G. D., Davis, R. L., & Koutsky, L. Factors that are

Associated with Parental Acceptance of Human Papillomavirus Vaccines: A Randomized Intervention Study of Written Information about HPV. Pediatrics 2006;

117(5), 1486–149.

18) Kotz, D. Rick Perry’s HPV Vaccine Misstep: The Real Problem was His Conflict. 2011. www.boston.com.

19) Cooper, L.Z., Larson, H.J., Katz, S.L. Protecting Public Trust in Immunization. Pediatrics, 2008; 122:149-153.

20) Reinberg, S. CDC Report Finds Adult Vaccination Rates Still Lagging. HealthDay News 17. Now. 2010.

21) University of Washington. Models of Social Communication. Department of Speech and Hearing Science, 2001.

22) Opel, D.J., Diekema, D.S., Lee, N.R., Marcuse, E.K. Social Marketing as a Strategy to Increase Immunization Rates. Archives of Pediatrics and Adolescent Medicine, 2009; 163(5):432-437.

23) Healey, B. & Zimmerman, R. The New World of Health Promotion: New Program Development, Implementation, and Evaluation. Sudbury, MA: Jones and Bartlett, 2010.

24) National Cancer Institute. Theory At a Glance. US Department of Health and Human Services, 2005.

NYC Department of Health’s “It’s Never Just HIV” Campaign: An Impractical Public Health Approach - Leilani Hernandez

Introduction

The population most severely impacted by HIV in the United States is men who have sex with men (MSM). The Centers for Disease Control estimates that men who have sex with men are 44 to 86 times more likely to be diagnosed with HIV compared to other men (3). The high prevalence of HIV infections coupled with unawareness of having an infectious disease increases the risk of men transmitting HIV to other men. A study conducted by the CDC revealed that in 2008, 19% of men who have sex with men in 21 U.S. cities were infected with HIV and 44% of these men were unaware that they were infected (3). New York City recognized that MSM in their city are particularly vulnerable to HIV since men with male partners account for 55% of annual new diagnoses in their city (5). They decided to address this problem by convincing men who have sex with men to adapt to the behavior of using condoms and their means of persuasion to doing this was creating a poorly designed educational campaign that appealed to men’s fear for their health.

New York City’s Response to the HIV Problem

In December 2010, New York City’s Department of Health and Mental Hygiene debuted their new educational campaign for combating HIV in the MSM community which revolved around the saying “It’s Never Just HIV (5).” The outright, threatening message of their campaign’s catch phrase meant that becoming infected with HIV will ultimately ruin your life. The sad video associated with this campaign has a deep-voiced, disembodied narrator bluntly stating that having HIV puts you at higher risk for ‘dozens of diseases even if you take medications,’ and in addition to having many sad-faced male models, the commercial showcases three types of medical conditions (bone loss, dementia, and anal cancer) which it deems are follow-up diseases to getting HIV and then finally ends by telling the viewer to stay HIV free by always using a condom (18). This video ran on television for two weeks in December 2010, two weeks in January 2011, and can still be viewed on YouTube today (5). This campaign also included a subway advertisement component which started in February 2011 (6). The poster component used in the city’s subways displayed identical images and written scripts that were from the video.

Why this campaign was ineffective

NYC’s public health department had had previous success in using a fear appeal message for an anti-smoking campaign so they decided to apply this same fear tactic into convincing MSM into wearing condoms. However this just demonstrated that there are not one-size fits all solutions for public health problems since this campaign was met with much criticism from the media. The practice of not using a condom during anal sex with someone is a high risk behavior for HIV infection; however, this is not the only behavior that needs to be addressed in order to reducing HIV transmission among men who have sex with men. Other behaviors that impede our goal of reducing transmission in the MSM population is being unaware that you have HIV (which is more prevalent amongst young black men), having multiple sexual partners, and using drugs during sex (3). Also homophobia and the stigma are social factors associated with HIV which create significant barriers to reducing the prevalence of HIV within the MSM population. Homophobia can affect these men’s ability to make health choices for themselves while stigma can affect these men’s disposition for seeking methods of prevention or care for HIV (3).

The New York City campaign, which only had the goal of convincing men who have sex with men to wear a condom, mainly took the appeal to fear route but also included other social behavior models such as the Health Belief model and Theory of Reasoned Action. These theories and New York City’s inappropriate application of them will now be dissected in order to prove why the “It’s Never Just HIV” Campaign was an impractical approach to reducing HIV transmission among MSM living in NYC.

Fear Appeal: Extended Parallel Process Model

The most obvious theory that officials at the department of health tried to apply when designing this campaign was appealing to people’s fear of contracting a serious medical disease on top of HIV. Fear appeal models posit that “an emotional response and a desire to eliminate the danger are triggered upon exposure to a fear appeal.” (2). The most modern fear appeal model is called the Extended Parallel Process Model (EPPM). This model simply states that a “perceived threat contributes to the extent of a response to a fear appeal whereas perceived efficacy contributes to the response of the nature and if no information on the efficacy is provided then individuals will rely on past experiences and beliefs to determine perceived efficacy (17).” And while fear appeals have been highly criticized in class and in the literature for use in public health interventions they have proved to be effective for certain issues used with certain populations. A campaign in Uganda was extremely effective in changing Ugandans attitudes towards sexual behavior thus significantly reducing HIV prevalence in this country. The campaign’s simple ‘ABC message’ was that you can choose either choices A, B, C or you can choose D with D standing for Death and used imagery of skulls, coffins, and grim reapers to get this message across to Ugandans (9). Ugandans surveyed were asked why their sexual behavior was changed and their two most common responses were first ‘Fear of AIDS’ and second ‘so many people are dying from AIDS (9).’

However Americans have a more ‘sex-positive’ culture than Ugandans do which could be the reason why the NYC campaign’s use of the instilling fear was not very effective for changing sexual behavior over here (9). A meta-analysis conducted on fear appeal research highlighted certain implications for using this model. These implications are that fear appeals are effective only if they show a significant and relevant threat and when they increase perceptions of self-efficacy by outlining a response that is easy to accomplish(17). The imagery and messages sent out by the NYC campaign failed to take into account both of these implications. First off, while HIV is associated with anal cancer, osteoporosis, and dementia the way that the video depicted these medical conditions was not done in a manner that would incite fear in the viewer especially in a an age where most people are extremely de-sensitized to the most shocking images. Showing x-rays of bones, brains, and other body parts is not very frightening to most people nowadays. Also these diseases that HIV can lead up to are too far into the future for a person to consider as significant threat or even possibly relevant to them. As a public health student interested in HIV, I was not even aware that these diseases are associated with HIV so I’m not sure how the common lay person would know this thus believing that they could actually affect him if he gets HIV. This video and its images are not enough to elicit a strong response to perform the video’s recommendation which is to start using condoms. The very best possible scenario that these scare tactics would accomplish is have the individual use condoms for a short time period. Secondly, while wearing a condom seems like a simple thing to do it is not easy to do if a person does not have a condom on them at the time of sex or if alcohol and/or drugs are clouding a person’s judgment. A report by the CDC states that men who have sex with men continue to engage in sexual and drug-use which increases the risk for HIV infection (8).

Health Belief Model

The New York City campaign also applied the Health Belief model (HBM) since they sought to educate men who have sex with men about the dangers of not wearing a condom. HBM is an individual level model which identifies factors associated with influencing a person’s behavior. Decisions that a person makes are based on the susceptibility or the subjective risks of contracting a condition, perceived seriousness or perceived difficulties that person believes a given health condition will create, and the perceived benefits and barriers of performing the recommended action which will be determined by that subject’s beliefs and availability and effectiveness of taking this action (13). The primary focus of the Health Belief Model is on health education which the video does do. New York City thought that simply educating people on the risks associated with HIV and telling them that a condom would offer them enough protection from these risks was convincing enough evidence for MSM. Dialogue from the “It’s Never Just HIV” Video states, “HIV puts you at higher risk for dozens of diseases even if you take medications, like osteoporosis a disease that can dissolve your bones, dementia a condition which causes permanent memory loss, and you’re over 28x more likely to get anal cancer.”

In this video, new information regarding the severity of AIDS was clearly communicated in this video. However, men who have sex with men are most likely already aware that they are highly susceptible to getting HIV and the message of the severity of HIV/AIDS is also probably already well known to them as well. So the HBM was an inappropriate use of this theory in attempting to get people to change their behavior since most MSM are already aware of this information and yet still continue to engage in risky behavior. The message and the images shown were not persuasive enough to change a person’s perception of how HIV can change his life. But most importantly, this theory assumes that people are rational thinkers so educating them about the dangers of HIV will convince them into using condoms. But in reality most people, not just men who have sex with men, are not rational thinkers in the moments leading up to or during sex.

Theory of Reasoned Action

Lastly, the campaign also included elements from the theory of reasoned action since the models in the video acted their best to make the viewer feel guilty for not having worn condoms in the past. This theory assumes that people are rational beings and so they consider their actions before they decide to perform or not perform a behavior; thus intention is a function of two basic determinants: the person’s attitudes towards the behavior on whether it is good or bad and the person’s perceptions of social pressures to do the behavior or not (14,15). The recommended behavior of the “It’s Never Just HIV” Campaign for men who have sex with men is to use condoms. For their HIV campaign, New York City employed attractive men in their video and subway posters. The men used in the video would be considered a social group that a man who viewed the video might be concerned about their perception of him for not using a condom. In the video, these men are seen looking glumly into the camera. A few of them even give accusing glares into the camera as the video talks about the consequences of HIV. You as the viewer feel as if you’re the one that had unprotected sex with them and accidently transmitted the disease and now it’s your fault that they are being diagnosed with anal cancer. The intention of doing this is to make men who do not wear condoms feel guilty and shame for this behavior. Unfortunately, another side effect of this video places a higher burden of shame and guilt on those men who already have the HIV infection. This video is blaming them for other men getting osteoporosis, dementia, or anal cancer since they are the ones who can spread the HIV to others. And like the HMB, the theory of reasoned action also assumes that people are rational thinkers and again it’s ridiculous to use this theory for promoting condom use since most people don’t think rationally during sex.

Proposed, alternative intervention

When used consistently and correctly, condoms are an effective way to reduce HIV transmission so I agree with this campaign’s message to promote condom use. However condoms are not the only preventative measure against HIV transmission. The “It’s Never Just HIV” campaign did not address the underlying causes of HIV transmission amongst men who have sex with men and further did not mention other preventative measures. We also need to discourage multiple sexual partners and use of drugs during sex since they increase the risk of becoming infected. HIV stigmatization compounded with homophobia is an underlying root cause of why this is such a problem in this population. Also none of NYC’s advertisements mentioned the importance HIV testing especially since symptoms of having the disease do not begin to appear until later stages of the disease. Knowing one’s HIV status is important because obviously you would make more conscious choices in regards to sex and you will also be referred to the health care and treatments you need to properly manage the disease. Furthermore, I also feel as if the way that HIV is spread is also important information that not many people know. If people understand the methods by which HIV is transmitted then they would be able to recognize situations in which they could possibly be at risk for infection.

My proposed alternative to is a multi-fold intervention that includes not only encouraging condoms during sex but also promoting HIV testing, reducing HIV stigmatization in the MSM community, reducing homophobia, promoting safe sexual practices, and educating men who have sex with men on how HIV is spread. Gary Marks from the Division of HIV/AIDS Prevention at the CDC wrote an editorial review about the need for collective responsibility in order to reduce HIV transmission. He wrote that “Collective responsibility emphasizes that all of us, infected or now, low right or high, bear a responsibility to change our attitudes and behaviors that promote HIV infection (11).” He suggests strategies to reducing HIV transmission at the population level would be promoting use of condom usage and HIV testing, promoting norms of responsibility and protection during sex, and fostering the perception that HIV is still a life-threatening disease (11). Due to this idea of collective responsibility not all components of my campaign will be targeted to the MSM community especially the components aimed at reducing HIV stigma and homophobia.

My campaign will have a positive, hopeful video that depicts gay men in a positive light and will also include a message that encourages sex safe practices and getting tested for HIV. Secondly, it will also have an educational component toward it geared towards educating these men about the different methods of HIV transmission, recognizing high risk situations, and again encouraging safe sex practices. Lastly, my intervention will include a program aimed at creating awareness of sexual diversity and HIV in the community by encouraging MSM to be more active thus increasing their visibility within the community.

Framing the message in a Positive Light

One of the reasons why the NYC campaign was such a failure amongst the MSM community was because of the video’s negative tone and the dreadful information they decided to include for supporting their message. For framing, it is important to incorporate emotional processes to influence a person’s decision-making between choices (12). While this campaign obviously had an emotional component to it, the tone and images used to bring about emotions were not persuasive enough to spur someone into using condoms.

For my intervention, I plan to frame my recommended action of using condoms and getting tested in a positive way. Like NYC, I will also create a short video that uses men to deliver message. Having gay men deliver the message to other gay men is a way to reduce resistance to the message. Similarity between the message deliverer and its recipient has been shown to increase persuasion by increasing the liking of the message heard and making the message less threatening (16). My video will involve men talking directly into the camera rather than having a creepy disembodied voice narrate it. I will recruit two gay men who are in a serious long term relationship to talk about their experience of one discovering the other has HIV, how they cope, and how one supports the other one. Most importantly they will say that having this discussion demonstrated mutual respect and trust in their relationship. The reason why their relationship has such a strong foundation is because they were courageous enough to talk to one another about it. This will shed light on the importance of using condoms, practicing other safe sexual practices and disclosure of the other’s HIV status. The video will show how in love they are with each other as a result of them sharing this information with each other. Framing the message positively is a more effective way of promoting condom use and testing rather than scaring people into doing it.

Promoting Self-Efficacy

Know your status and get tested! Have either you or your partner wear a condom so that you can protect yourselves from HIV! The NYC campaign did nothing to promote self-efficacy in their campaign. They just hoped that the information they provided would be enough to convince people to do what they want them to do. My intervention will support self-efficacy for doing the following actions: getting tested and using condoms. Whereas the NYC campaign utilized concepts from the Theory of Reasoned Action (TRA) into the design of their video, mine will use the most recent theory for this, Theory of Planned Behavior (TPB). This theory extends upon TRA by adding in an additional component called behavior intention which is the “degree to which a person believes they have control over whether they can do that action and the strength of the belief they can do it.” (7).

To promote self-efficacy, the men in my video will stress to MSM viewers that they have the control and the power to safeguard their health and their partners and make a difference in the fight against AIDS/HIV. They can do this if they speak up to their partners about condom use and knowing one’s HIV status. I am hoping that the video made for use in my intervention will be an empowering one, which is difficult to achieve. It will highlight how one man’s decision to talk with his partner about the sensitive issue of sex and HIV brought about a sense of admiration and respect from his partner. Hopefully this video will increase the viewer’s perception of how easy and most importantly rewarding it is to have this serious discussion before engaging in sex.

Increasing the general Community’s awareness of MSM and HIV

The third component of my intervention is not at all directed at men who have sex with men but includes everyone in the community since two of my intervention’s aims of this component are reducing HIV stigmatization and homophobia. This component involves a program that would increase the general community’s awareness of HIV and stigmatization. The program encourage men who have sex with men to increase their visibility in the community by engaging in activities in an effort to counter people’s perceptions of the homosexual lifestyle and those living with HIV (1).

In his article on preventing HIV in a context of HIV stigma, discrimination, and homophobia, Ronald Brooks suggests activities for gay men to do in the community would be ‘participating in HIV prevention programs at local health fairs, participating in gay and lesbian group festivals, and/or establishing a gay/straight alliance.” He also recommends venues for HIV prevention activities to take place in to be “churches, barber shops, beauty salons, jails and prisons, social service agencies, health clubs, schools, neighborhood center, needle exchange programs, and non-gay setting and non-HIV community events.” One community level HIV intervention program targeted towards young gay men recognized the importance of creating new setting and events to attract their target population. Setting for events to promote safer sex included dance parties, picnics, hikes, and bicycle rides (13). In my intervention, I would suggest that participants go to any of the places listed above as a starting point for spreading the word on HIV prevention and getting involved in the community.

Also gay role models from the community will be recruited and trained. These role models will educate everyone on the methods of HIV prevention and on how HIV is transmitted so that people can recognize situations in which they could possibly be at high risk for HIV infection. They will also dispel rumors on how HIV spread (which is not by casual contact, kissing, or sharing air or water with someone with HIV) in order to try to reduce HIV stigmatization. These role models will also be trained to act counselors for any MSM who experience homophobia and need the social support so that they won’t engage in self-destructive behavior in reaction to it.

Conclusion

Even though HIV transmission is preventable, sadly, the CDC estimates that 1.2 million people in the United States are living with HIV infection and 20% of those people are unaware of their infection (4). It is important that people, especially vulnerable populations such as MSM, know their status and understand ways to protect themselves and others from HIV because even though treatment is available, HIV is still a life-threatening disease. Prevention campaigns such as the “It’s Never Just HIV” campaign do not effectively showcase all of the prevention methods available or address underlying social factors of why MSM are the ones most severely impacted by HIV. Interventions to combat HIV need to be multi-fold in its approach since the root causes of this problem for the MSM population are multi-fold. Not only should they be aimed at promoting safer sexual practices but they also need to tackle the daunting task of reducing the social factors which are barriers for MSM to receiving the care they need. If these multi-fold interventions are implemented then we will be able to see a significant reduction in HIV prevalence for this group.

References

1. Brooks, Ronald and Mark Etzel, Ernesto Hinojos, Charles Henry, ad Mario Perez. “Preventing HIV among Latino and African American Gay and Bisexual Men in a Context of HIV-related Stigma, Discrimination and Homophobia: Perspectives of Providers.” AIDS Patient Card STDS. 2005 November; 19 (11): 737-744.

2. Camerson, Kenzie. “A Practitioners Guide to Persuasion: An Overview of 15 Selected Persuasion Theories, Models, and Frameworks.’ Patient Education and Counseling 74, 2009. Pp 309-317.

3. CDC. “HIV among Gay, Bisexual and Other Men Who Have Sex with Men (MSM).” http://www.cdc.gov/hiv/topics/msm/index.htm. December 7, 2011.
4. CDC. “HIV in the United States.”

http://www.cdc.gov/hiv/resources/factsheets/us.htm. December 7, 2011.

5. Craig, Susan and Celina de Leon. “New Health Department Media Campaign Shows How HIV can Compromise Health and Well Being, even when Treatment Controls the Infection.”

http://www.nyc.gov/html/doh/html/pr2010/pr059-10.shtml. December 7, 2011.

6. Craig, Susan and Zoe Tobin. “Health Department Takes Its Latest HIV Awareness Campaign to the Subway- Agency’s new subway posters show how HIV can lead to other serious diseases.”

http://home2.nyc.gov/html/doh/html/pr2011/pr002-11.shtml. December 7, 2011.

7. Edberg, Mark. ‘Chapter 4: Individual Health Behavior Theories.” Essentials of Health Behavior: Social and Behavioral Theory in Public Health, Sudbury, MA: Jones and Bartlett Publishers, 2007. Pp 35-49.

8. Finlayson, Teresa and Binh Le, Amanda Smith, Kristina Bowles, Melissa Cribbin, Isa Miles, Alexandra M Oster, Tricia Martin, Alicia Edwards, Elizabeth DiNenno. “HIV Risk, Prevention, and Testing Behaviors Among Men Who Have Sex With Men --- National HIV Behavioral Surveillance System, 21 U.S. Cities, United States, 2008.” MMWR Surveillance Summaries October 28, 2011 / 60(SS14);1-34.

9. Green, Edward and Kim Witte (2006). “Can Fear Arousal in Public Health Campaigns Contribute to the Decline of HIV Prevalence?” Journal of Health Communication, 11:3, 245-259.

10. Kegeles, Susan M and Robert Hays, Thomas Coats. “The Mpowerment project: A Community-Level HIV Prevention Intervention for Gay Men.” American Journal of Public Health. 1996 :86 :1129-1136.

11. Marks, Gary and Scott Burris, Thomas Peterman. “Reducing Sexual Transmission of HIV from those who know they are infected: the need for personal and collective responsibility.” AIDS 1999, 13: 297-306.

12. Martino, Benedetto and Dharshan Kumaran, Ben Seymour, Raymond Dolan. “Frames, Biases, and Rational Decision-making in the Human Brain.” Science, 313 August 4, 2006. Pp. 684-687.

13. Rosenstock, Irwin. “Historical Origins of the Health Belief Model.” Health Education Monographs, 2(4) Winter 1974. Pp. 328-335.
14. Salazar, Mary Kathryn. “Comparison of Four Behavioral Theories.” AAOHN journal, 39 (3) March 1991. Pp. 128-135.
15. Sheppard, B.H.; Hartwick, J. & Warshaw, P.R (1988). The theory of reasoned action: A meta-analysis of past research with recommendations for modifications and future research. Journal of Consumer Research, 15, 325–343.

16. Silvia, Paul. “Deflecting Reactance: The Role of Similarity in Increasing Compliance and Reducing Resistanc.” Basic and Applied Social Psychology. 27 (3) 2005. Pp 227-284.

17. Witte, Kim and Mike Allen. “A Meta-Analysis of Fear Appeals: Implications for Effective Public Health Campaigns.” Health Education Behavior 2000 27:591.
18. YouTube video by NYC Health- “It’s Never Just HIV.” Available at:

http://www.youtube.com/watch?v=d0ANiu3YdJg. December 7, 2011.