Abstinence-Only vs. Comprehensive Sexual Education Efficacy in Reducing Teenage Pregnancy Rates in the United States—Lauren Dustin

Teenage Pregnancy Rates in the U.S.

Teenage pregnancy is a public health issue that affects every individual in a community. In 2006, 750,000 teenage girls, aged 15-19, became pregnant. Having a child during teenage years carries many emotional, physical, and financial costs to the parents and community. Teen childbearing costs $9 billion to taxpayers annually, and teen birth rates in the U.S. are up to 9 times higher than most other developed countries. (1) Teens get most information about sex and pregnancy prevention from their school curriculum. About 70% of school districts teach comprehensive sex education that includes information on the risks of sexually transmitted diseases, unintended pregnancies, contraception methods, and abstinence, while other schools teach abstinence-only curriculums. Between the years of 2006-2008, most teens had received information about most of these topics; however, about one-third of teens had not received any formal instruction about contraceptive methods and use. (2) In 2009, there were 39.1 births per 1,000 women aged 15-19, marking an historic low with a decline of 37% from the peak rate of 61.8 in 1991. (3) Although the rate of teenage pregnancy has been steadily declining, there is still a lot more work to be done in finding the most effective educational program.

How Teen Pregnancy is Currently Addressed

Sexual health education is handled in varying ways throughout our nation’s schools. About 35% of school districts in the U.S. believe in abstinence-only education that does not provide any additional information on other methods of prevention from STDs and pregnancy. Discussion of contraception is either prohibited completely, or only permitted in order to emphasize its ineffectiveness. The remaining school districts use comprehensive sex education programs sometimes referred to as abstinence-plus programs. These programs teach abstinence as the most effective method, but also include information and resources on other effective measures of prevention. There have been some shifts in which programs schools prefer, and the biggest change in sex education policies has been toward more schools using abstinence-plus policies. (4)
Abstinence-only education is based on the belief that young men and women are unable to develop committed, loving relationships, and that this leads to childbearing out-of-wedlock. These programs focus on how to develop loving and enduring relationships first before sexual activity. Supporters of abstinence-only programs argue that teaching teenagers about contraception implicitly encourages sexual activity. (5) So instead, abstinence-only education teaches that abstinence is the only way to avoid STDs and pregnancy, and every other method is ineffective. Most programs focus on instilling moral or religious values rather than providing accurate health information. Evaluation of abstinence-only programs found no delay in first sex and analysis of federally funded programs were even found to contain false, misleading, or inaccurate information about reproductive health. (6)

Supporters of comprehensive sex education or abstinence-plus programs say that it may not be reducing sexual activity in teens, but it is teaching them how to do it safely in order to prevent negative outcomes. About half of all teens ages 15-19 are sexually active, and a sexually active teen that does not use contraception has a 90% chance of becoming pregnant within one year. (2) This type of program recognizes the inevitability that most teens are going to be sexually active at some point during their adolescence, and their aim is to prepare them to make healthy and informed choices about contraception. A national survey revealed that 78% of parents of teenagers agree and believe that their children should learn about birth control and safer sex in school. Many medical organizations such as the Institute of Medicine, American Academy of Family Physicians, American College of Obstetricians and Gynecologists, and American Academy of Pediatrics also support the inclusion of contraceptive information with abstinence education to prevent teen pregnancy and STDs. (7)

There is no evidence to date that abstinence-only education delays teen sexual activity. However, research shows that abstinence-only strategies may deter contraceptive use and increase a teen’s risk of unintended pregnancies and STDs. (2) A study that compared abstinence-only and abstinence-plus education found that programs offering contraceptive education significantly influenced students’ knowledge and use of contraception methods. The study also found that abstinence-plus education led to increased contraception use by teens at follow-up compared to abstinence-only education. In addition, the use of abstinence-plus programs did not lead to an increase in sexual activity by teens, as mistakenly believed. (7) Evaluations of comprehensive sex education show that they do not increase rates of sexual initiation, they do not lower the age of first sex, and they do not increase the frequency of sexual activity or number of partners. In fact, teens who receive comprehensive sex education have a lower risk of pregnancy than those who receive abstinence-only or no sex education. (8)

New studies have shown that an increase in contraception use, not abstinence, is responsible for the decline in teenage pregnancy rates. According to the Guttmacher Institute, “86% of the decline can be attributed to the use of contraception, while only 14% can be attributed to abstinence.” (9) To reduce rates of teenage pregnancy, programs need to either improve contraceptive behaviors, reduce teen sexual activity, or both. Prohibiting contraceptive education in school-based programs keeps the very information that may have the greatest potential to decrease pregnancy rates from the people who need it the most. However, community attitudes towards teenage sexuality, rather than evidence-based interventions, greatly impact the acceptance of publicly funded school-based sex education programs. (7)

Government funding and policy-making by Congress, and individual state governments provide the basis for which type of education is used in certain school districts. In December 2009, Congress replaced the rigid Community-Based Abstinence Education Program with a new $114.5 million teen pregnancy prevention program to support evidence-based interventions and created the five-year Personal Responsibility Education Program (PREP). Its purpose is to educate adolescents on both abstinence and contraception, and to prepare them for adulthood by teaching subjects such as healthy relationships, financial literacy, and decision-making. Congress also renewed the Title V abstinence-only programs for another five years to provide funding to schools that choose to promote abstinence. (3)

Critique of Abstinence-Only Sexual Education Programs

Although abstinence-only education has not been proven to be effective or ineffective in preventing teen pregnancy in the United States, we can see how these programs have failed to apply social science theories correctly and are flawed in three fundamental ways.

The first major flaw in abstinence-only education programs is that it takes freedom and control away from teenagers when it comes to making decisions about sexual activity. Abstinence is stressed as the only effective method to prevent STDs and pregnancy, and teens are simply told to abstain. There is no information given about other methods of contraception so teens are not even given a choice to make, it is made for them. This type of program fails to consider the Theory of Psychological Reactance and how people react to their freedom being threatened or taken away. The theory says that when a person feels their freedom is being threatened, they experience reactance, a motivational state aimed at restoring the threatened freedom. (10, 11) In other words, they react by doing the negative behavior they are told not to do. When a teen is not given the freedom to make their own choices about sexual activity and contraception and they are simply told not to have sex, they will act out by doing the opposite of what they are told. Since abstinence-only programs do not provide information about contraception, these teens are at a greater risk for STDs and pregnancy because they are less likely to use any form of contraception when they do engage in sexual activity. (7)

Another flaw in abstinence-only education is the use of an improper communicator. These programs use adults, specifically teachers, to convey the message of abstinence as the only option. Teachers are the dominant player in the student-teacher relationship and their dominant and explicit messages can evoke increased psychological reactance. (11) Abstinence-only programs do not take into account the importance of similarity that is stressed in the Communication Theory, and that is also used as a way to reduce reactance and increase compliance. Teenagers who find it hard to relate to adults teaching them about abstinence will resist the very message. One of the most important aspects of the Communication Theory is the use of a messenger that is as similar as possible to the target audience. (12) The use of similarity has been found to reduce reactance and increase compliance. In a study done by Silvia, results showed that similarity increases liking and positive forces towards compliance while reducing negative forces toward resistance. Similarity also increases the communicator’s credibility and reduces the perceived threat to freedom. (10) Teachers and other adults may be the most practical communicator for school-based education, but in reality they are the least similar to the target audience and most likely to evoke reactance.

The last flaw of abstinence-only sex education is that providing inaccurate information or withholding information about contraception is morally and ethically wrong and unsafe. Abstinence is often presented as the moral choice for adolescents contemplating sexual activity. However, the current federal approach to supporting more funding for abstinence-only education raises serious human rights concerns. Access to complete and accurate sexual health information has been recognized as a basic human right and essential to make critical health decisions regarding sexual activity and the prevention of STDs and pregnancy. Abstinence-only programs are problematic because they withhold information and promote sometimes questionable and inaccurate opinions rather than facts. This threatens the fundamental human rights to health, information, and life. (13)

This flaw is a result of the incorrect usage of the Consumer Information Processing Model. This model explains that information is a necessary tool in health education; however, it is not sufficient for knowledge in general. Consumers, or students in this case, tend not to engage in extended searches for information. Therefore, if information about safe sex practices is not given to them in a structured way, they will most likely not seek it out themselves and this puts them in danger of contracting an STD or becoming pregnant if they do not know how to protect themselves. The Consumer Information Processing Model also states that before people will use health information it must be: available, seen as useful and new, and presented in a friendly format. This is where abstinence-only programs are flawed. They do not provide the new, useful, and necessary information in the first place, and the information they do provide, sometimes inaccurate, is not presented in a friendly way. (14)
Without complete and accurate information about sexual health and contraception, teens are unable to make a fully informed decision regarding sexual activity and STD and pregnancy prevention. In fact, teens who only receive abstinence messages face a greater risk of contracting an STD or becoming pregnant because they do not possess the necessary resources on other methods of contraception. (7)

Assessment

The actual causes of teenage pregnancy are not fully understood, but public health professionals would likely argue that a lack of information is a main reason. Teens that are not getting information about contraception and other prevention resources are at an increased risk for negative consequences because they are not informed or prepared to make these important decisions in a safe way. As discussed, abstinence-only sex education programs may be the least effective way to reduce teenage pregnancy rates because they are severely flawed. The explicit, forceful, and dominant messages portrayed by abstinence-only educators are the definition of what evokes psychological reactance in teens. When teenagers are told simply not to do something, they perceive their freedom to be threatened and they react to gain back that freedom by doing that behavior. This is the opposite of what abstinence-only programs want. Additionally, the use of a dissimilar communicator only heightens reactance and resistance to the abstinence-messages. People respond well and tend to comply with the beliefs and messages of a person who is most similar to them, often regardless of how threatening the message is. Lastly, the use of abstinence-only sex education in schools is morally and ethically wrong because they withhold crucial information that can be considered a basic human right in the context of making sexual health decisions. Teens need to be given the information that is new and useful to them because they are likely not going to seek out the information themselves. All of these flaws create inefficiencies that can severely hinder any possible progress made towards lowering the rate of teenage pregnancy.

New Theories

Using the social and behavioral theories previously discussed in the correct way along with several new theories will help to create a new and more effective sexual education intervention. These theories keep the target audience in mind and they recognize the need to reduce reactance in order to be successful. The new intervention will be comprehensive to include information not only about abstinence as the most effective method of STD and pregnancy prevention, but also additional information on other methods of contraception and how to use them.

Limiting Psychological Reactance & the Illusion of Control

Instead of using forceful abstinence-only messages, sex education programs should give the freedom of choice. Don’t tell teens what to do (abstain from sex), tell them what they can do instead (use protection if they become sexually active). Psychological Reactance can be a risk factor for initiation of the negative health behavior so it is important to limit reactance in order for an intervention to be successful in achieving its goal. One way to limit reactance to an intervention is to measure it before starting by finding out if the campaign would elicit reactance in the target audience. Public health professionals can do this through pilot studies or through questionnaires given to teens to assess their attitudes towards abstinence-only versus comprehensive abstinence-plus programs. To avoid reactance we need to know what elements can lead to it. Explicitness, dominance, and reason are three items that can influence reactance. The more explicit or forceful a message is, the more it evokes psychological reactance. When a communicator is perceived to have dominance over the message recipient, this increases reactance as well. However, when reason or support is given for the claim, this is likely to reduce perceived threats and reduce reactance. (11)

The Illusion of Control Theory explains that people value control over their lives or events that happen to them most when they have ownership over that behavior. If public health professionals were to use an intervention that sells control rather than takes it away, this would be accepted much more readily by our target audience. To give teen’s ownership over their sexual health decisions they will value their sexual health and choices they make much more, and this will lead to more informed choices about sex and contraception. The Illusion of Control Theory can also be used to decide when to intervene on a behavior. Intervening during the hot state (when someone is thinking about sexual activity or is already sexually active) will have the greatest effect on helping teens develop realistic plans for sexual activity and the use of contraception. (15)

Communication Theory & the Use of Similarity

The school setting is the most common place where teens learn about sex, both from their teachers and their peers. It is a logical strategy that the adults or teachers of the school system are the ones who educate teens about sex, but perhaps using a more similar messenger would have an additional impact on lowering the teen pregnancy rates. In addition to adults teaching sex education in the classroom, peers can be used to convey messages and information to other teens about contraception and pregnancy prevention in other settings through various forms of media. Interventions can use peers from the same school who are around the same age or even a celebrity who is of similar age.

The Communication Theory and study done by Silvia explains that the most important part of effective communication is to use a messenger that is similar, well-liked, and attractive to the target audience in order to increase compliance and reduce psychological reactance. The messenger should also deliver non-threatening information, unlike the messages in abstinence-only programs. (10, 12) Teens should be given the freedom of choice and control over their sexual health. Using similarity will help to balance positive and negative forces of compliance and reactance and give teens the confidence and freedom to make their own decisions about their sexual health. Providing the resources will enable them to make safer choices and help to decrease the teen pregnancy rate.

Bringing About Change with the Agenda Setting Theory

To learn from the flaws of abstinence-only programs and to eventually eliminate these programs all together I would propose using the Agenda Setting Theory. This theory is based on the idea that there is a public agenda, and it consists of what people are talking about and what people are interested in at that specific moment in history. If you can get people to think and talk about your issue, it will be a part of the public agenda and it will be much easier to have an impact on the public health issue. Public health professionals can use this theory to get people to realize the flaws with abstinence-only programs and why comprehensive programs can be more effective and safer for teens. This would tie in very well with the use of a media campaign targeting teens because often times the media dictates the public agenda. (12)

New Intervention

The first strategy towards creating a more effective sexual education intervention program that reduces the rate of teenage pregnancy in the U.S. would be to make all education programs comprehensive. I believe having comprehensive sex education as the primary form would be the most effective in increasing contraception use, and reducing STDs and pregnancy rates in teens age 15-19 as previously supported. (7) Information about safe sex and contraception is critical to teenagers who are faced with decisions about sexual activity. To withhold this information puts them at greater risk for negative consequences. The new intervention will offer control and freedom to the teenagers so as to not threaten them and evoke psychological reactance. Instead of explicitly stating that abstinence is the only way to go, the new intervention will feature other choices for contraception and prevention, in addition to abstinence. This has shown to be more effective in increasing the use of contraception, which in turn leads to a decrease in pregnancy rates. (9) The most effective curriculum-based programs have focused on a specific behavior, such as using contraception, and provide the basic information, not too much detail . They are age appropriate and based on theoretical approaches; they address peer pressure, and teach skills in problem-solving and decision-making to prepare students for difficult life choices they will encounter. Teaching basic life skills along with sex education has shown to be effective in increasing knowledge and changing attitudes and behavior towards contraception. (16, 17)

To give teens the freedom to choose how they handle their sexual health may not be enough to achieve the overall goal of reducing teen pregnancy. For this reason, the new intervention will also add another communicator to the program who is more similar to the target audience to deliver messages to teens. On top of the comprehensive school curriculum, the program will feature media ad campaigns emphasizing safe sex and “the choice is yours” type statements. The campaign will be marketed like a mass movement, urging teens to join the “Safe Sex” movement by choosing to abstain or use contraception, and realizing they have the freedom to choose and they have control over their sexual health decisions and the consequences of those decisions. By joining a movement, this will make the teens feel like they truly are in control and they will not feel threatened to obey abstinence-only messages. These messages will be delivered by someone who is familiar and similar to the target audience. Studies by Silvia show that similarity increases compliance and decreases resistance. This will have the greatest effect on getting teens to use contraception in order to reduce the teen pregnancy rates. (10, 12) Teens can relate to someone who is most similar to themselves, and this is not going to be the teachers or adults in a school. A peer-to-peer media campaigns will be a more effective element to the comprehensive sex education already in place.

The intervention will feature positive and freedom enforcing messages on posters throughout the schools, on computers, on school news broadcasts, on local television, and social networking websites. The campaign will say things like “Safe sex is sexy”, “The choice is yours, own it” and other positive, non-dominant messages. Teens say that they would prefer to get information about sex from their parents, but more than half of them report getting information about sex, birth control, and pregnancy from television shows, movies, and magazines. (18) Because teens most often learn about sex through these channels of communication, using magazines and local television would successfully reach the target audience. The messages will be created and delivered by peers and persons who are the most similar to the target audience such as students from the same school. The combination of control and the use of a similar communicator will greatly reduce reactance and increase compliance. (10)

Summary

Although many school-based and community interventions have been used to try to reduce the rate of teenage pregnancy in the U.S., most have been ineffective. The designs of abstinence-only programs are especially flawed because they evoke psychological reactance from the dominant and forceful messages they portray. They fail to provide the necessary information about contraception that teens need in order to make safe decisions about their sexual activity. Teens that do not receive information about contraception are at an increased risk for getting and STD or becoming pregnant. Educational programs that are comprehensive in nature and include information on both abstinence and other methods of prevention, as well as teach important life skills, are the most successful at increasing knowledge and changing attitudes and behavior. Teens respond best and tend to comply more with messages that use a communicator that is most similar to them. Interventions that take advantage of similarity effectively limit reactance while increasing compliance. This will have a positive effect on reducing the teen pregnancy rate in the U.S. The first step in creating a more effective sexual education program for all school districts to use is to get this issue on the public agenda through the use of the media. This intervention will depend on public support and community acceptance in order to be successful, and this will be the most difficult element to achieve.

References
1. Preventing teen pregnancy in the us. (2011, April 5). Retrieved from http://www.cdc.gov/vitalsigns/TeenPregnancy/index.html
2. Facts on american teens' sexual and reproductive health. (2011, August). Retrieved from http://www.guttmacher.org/pubs/FB-ATSRH.html
3. Facts on american teens' sources of information about sex. (2011, February). Retrieved from http://www.guttmacher.org/pubs/FB-Teen-Sex-Ed.html
4. Landry, D. J., Kaeser, L., & Richards, C. L. (1999). Abstinence promotion and the provision of information about contraception in public school district sexuality education policies. Family Planning Perspectives, 31(6), 280-286. Retrieved from http://www.jstor.org.ezproxy.bu.edu/stable/pdfplus/2991538.pdf?acceptTC=true
5. Rector, R. (2002, April 8). Effectiveness of abstinence education programs in reducing sexual activity among youth. Retrieved from http://www.heritage.org/research/reports/2002/04/the-effectiveness-of-abstinence-education-programs
6. The Content of Federally Funded Abstinence-Only Education Programs. (2004, December). Retrieved from http://www.apha.org/apha/PDFs/HIV/The_Waxman_Report.pdf
7. Bennett, S. E., & Assefi, N. P. (2005). School-based teenage pregnancy prevention programs: A systemcatic review of randomied controlled trials . Journal of Adolescent Health, 36(1), 72-81. Retrieved from http://www.sciencedirect.com.ezproxy.bu.edu/science/article/pii/S1054139X04001673
8. Kohler, P. K., Manhart, L. E., & Lafferty, W. E. (2008). Abstinence-only and comprehensive sex education and the initiation of sexual activity and teen pregnancy. Journal of Adolescent Health, 42(4), 344-351. Retrieved from http://www.sciencedirect.com.ezproxy.bu.edu/science/article/pii/S1054139X07004260
9. U.s. teenage pregnancies, births, and abortions: National and state trends and trends by race and ethnicity. (2010, January). Retrieved from http://www.guttmacher.org/pubs/USTPtrends.pdf
10. Silvia, P. J. (2005). Deflecting reactance: The role of similarity in increasing compliance and reducing resistance. Basic and Applied Social Psychology, 27(3), 277-284.
11. Dillard, J. P., & Shen, L. (2005). On the nature of reactance and its role in persuasive health communication. Communication Monographs, 72(2), 144-168. Retrieved from http://classweb.gmu.edu/gkreps/820/009.pdf
12. Shaw, E. F. (1979). Agenda-setting and mass communication theory. Retrieved from http://xa.yimg.com/kq/groups/22925642/1944236267/name/Shaw- Agenda-Setting and Mass Communication Theory.pdf
13. Santelli, J., Ott, M. A., Lyon, M., Rogers, J., Summers, D., & Schleifer, R. (2006). Abstinence and abstinence-only education: A review of u.s. policies and programs. Journal of Adolescent Health, 38(1), 72-81. Retrieved from http://www.sciencedirect.com.ezproxy.bu.edu/science/article/pii/S1054139X05004672
14. Campbell, C. (2001, August 21). Health education behavior models and theories: A review of the literature part i. Retrieved from http://msucares.com/health/health/appa1.htm
15. Langer, E. J. (1975). The illusion of control. Journal of Personality and Social Psychology, 32(2), 311-328.
16. Nitz, K. (1999). Adolescent pregnancy prevention: A review of interventions and programs. Clinical Psychology Review, 19(4), 457-471. Retrieved from http://www.sciencedirect.com.ezproxy.bu.edu/science/article/pii/S0272735898000877
17. Harris, M. B., & Allgood, J. G. (2009). Adolescent pregnancy prevention: Choosing an effective program that fits. Children and Youth Services Review, 31(12), 1314-1320. Retrieved from http://www.sciencedirect.com.ezproxy.bu.edu/science/article/pii/S0190740909001571
18. Brown, J. D., & Witherspoon, E. M. (2002). The mass media and american adolescents. Journal of Adolescent Health, 31(6), 153-170. Retrieved from http://www.sciencedirect.com.ezproxy.bu.edu/science/article/pii/S1054139X02005074

A Critique of the National Breastfeeding Awareness Campaign: Three Ways in Which the Campaign was Flawed- Rachel Bernier

Introduction

Breastfeeding is increasingly regarded to benefit the baby, mother and society. Breastfeeding benefits are so apparent that Healthy People 2o1o prioritized increasing breastfeeding rates as one of their goals (1). Additionally, the American Academy of Pediatrics highlighted the benefits of breastfeeding in its policy statement, “Breastfeeding and the use of human milk”(2). Studies show that infants who are breastfed have fewer occurrences of infectious disease, obesity, asthma, and several other health related outcomes (2). Breastfeeding also benefits the mother. Mothers who breastfeed are more likely to have a longer duration of time between the births of their children. They tend to have decreased bleeding after giving birth and a decreased risk of breast and ovarian cancers (2). Breastfeeding mothers benefit society because they are not producing waste from formula containers and infants who are breastfed are sick less often, resulting in lower health care costs (2). Furthermore, when an infant is sick less often, parents miss fewer days of work since they do not have to stay home to take care of a sick baby (2). Ultimately, Wolf (2007) states, “Human milk is the ‘gold standard’ when it comes to feeding babies” (3).

The Office of Women’s Health, a branch of the U.S. Department of Health and Human Services, launched the National Breastfeeding Awareness Campaign (NBAC) in June 2004 (4) . The campaign’s goal was to target first time mothers and African American mothers and convince them to breastfeed their infant (4-5). The campaign, and more specifically the media outreach campaign, consisted of several public service announcements in the form of television advertisements, radio advertisements, and print advertisements. The advertisements can be seen on the U.S. Office of Women’s Health website http://www.womenshealth.gov/breastfeeding/government-in-action/national-breastfeeding-campaign/#materials. The print advertisements displayed images of dandelions, ice cream or otoscopes and stated that babies should be breastfed exclusively for six months to reduce their risk of respiratory illness, obesity, and ear infections (4). The television ads showed either a pregnant woman log rolling or a pregnant woman riding a mechanical bull. The text on both television ads said “you wouldn’t take risks before your baby’s born, why start after” (4). The radio advertisements had two styles: a soul music song and a country music song (4). In each song, a man sang about the benefits of breastfeeding (4).

The NBAC intended to increase breastfeeding based on evidence suggesting healthier outcomes in breastfed babies, but the campaign had several flaws. First, the NBAC failed to address the barriers to breastfeeding that keep some mothers from breastfeeding their newborn baby. Second, the campaign did not address the fact that breastfeeding is not a social norm in this society, and is rarely portrayed in the media. Lastly, the National Breastfeeding Awareness Campaign did not deflect psychological reactance in their audience. The people used to deliver this message were not similar to the target audience.

Campaign did not address barriers to breastfeeding

The National Breastfeeding Awareness Campaign provided information regarding the many benefits of breastfeeding throughout their advertisements, but they failed to address the barriers to breastfeeding. Women may encounter several barriers, making breastfeeding difficult or inconvenient and this may cause these women not to breastfeed. A workplace that is not accommodating to breastfeeding mothers is an example of an environmental barrier that might discourage a woman from breastfeeding (5). A mother’s social group (family and friends) can be another barrier to breastfeeding if they are unsupportive of her decision to breastfeed (5). Since some women have difficulty breastfeeding, being surrounded by unsupportive people may discourage her from breastfeeding. Wolf (2007) states that the NBAC was not intended to be “supporting, or otherwise being sensitive to the concerns of women but rather an attempt to manufacture and exploit fear among pregnant women and new mothers” (3). The campaign provoked fear in women instead of addressing the barriers women may be facing.

Based on Bandura’s Social Learning Theory, public health campaigns must take into account the environment of the targeted individuals. The Social Learning Theory acknowledges that the environment plays a role in an individual’s decision to change a behavior or not (6). Moreover, the Social Learning Theory suggests that self-efficacy is a necessary component for a successful behavior change (6). An individual will not attempt a new behavior if they do not believe that they are capable of performing it (6). According to Grusec, people can gain self-efficacy “from observation of what others are able to accomplish” (6). However, women exposed to the NBAC were unable to achieve self-efficacy concerning breastfeeding in the workplace since the NBAC did not portray this in the ads. The NBAC failed to address the environment in the campaign and therefore mothers were unable to achieve self-efficacy.

Bronfenbrenner’s Ecological Perspective Theory also supports that it is critical to address the environment when trying to change a behavior (7 -8). This theory suggests that living conditions, neighborhoods and communities, institutions and social policies all play a role in one’s decision to change a behavior (7-8). The NBAC did not specifically influence multiple factors affecting a mother’s ability to breastfeed, specifically the workplace or social environment. A campaign that fails to address factors like the one’s included in the Ecological Perspective Theory will be unsuccessful in changing a behavior. The Ecological Perspective Theory shows that the NBAC campaign only focused on changing an individual’s “intrapersonal level factors” (8). The theory describes some of the intrapersonal factors as knowledge, attitude and beliefs (8). However, a crucial aspect of the theory is that a behavior is influenced by multiple levels of influence including not only intrapersonal level, but also interpersonal level and community level factors (8). The NBAC only addressed intrapersonal level factors (ie. Education) and therefore was unsuccessful.

Campaign did not address that breastfeeding is not a social norm

The National Breastfeeding Awareness Campaign was a media campaign, but it did not portray breastfeeding as a social norm or acknowledge that breastfeeding is not seen in the media in this society. The NBAC did not use any advertisements showing women breastfeeding, typical for today’s media. Television rarely depicts breastfeeding; babies are most often with a bottle. Many women feel uncomfortable breastfeeding in public because breastfeeding is not a social norm. Breastfeeding an infant can become quite challenging if a woman is uncomfortable to breastfeed in public. Since the NBAC did not acknowledge that breastfeeding is not a social norm in this society, the campaign was not as successful as it could have been.

According to the Social Learning Theory, people do what they see other people doing, often referred to as modeling (6). However, the NBAC advertisements did not actually depict women breastfeeding. Instead, the ads displayed women participating in log rolling, women riding a mechanical bull, and images of dandelions, ice cream and medical equipment (otoscopes). This campaign did not demonstrate the act that NBAC was established to encourage. This campaign suffered from this particular failure because people are likely to act in ways that they see other people acting. Since women are exposed to more images of babies being fed bottles than they are of babies breastfeeding, its sensible that breastfeeding is not more common. According to modeling, women who viewed the NBAC ads were more likely to ride mechanical bulls and participate in log rolling than they were to breastfeed (6).

Schultz et al (2007) suggest that social norms are an incredibly strong indicator of behavior (9). Many successful public health campaigns have recognized this and adopted a campaign method called social-norms marketing (9). Social-norms marketing campaigns work to impact the true social norms of a behavior instead of merely educating people on the benefits of the behavior (9). According to Schultz et al, people overestimate how common undesired behaviors are and they compare their own behaviors to those of their peers (9). Therefore, campaigns led by the social-norms marketing approach show people that a behavior is more common than they may have thought. This information causes people to be more likely to adopt the suggested behavior (9). However, the NBAC did not affirm breastfeeding as a social norm or convince people that it is more prevalent then they may think. Ultimately, the targeted women were unlikely to embrace the behavior of breastfeeding since they were not reassured that it was socially acceptable.

The Theory of Planned Behavior recognizes that people consider how they will be perceived by others before behaving in a particular manner (8). Not everyone supports breatfeeding, which is evident since it is not portrayed in the media and not always welcomed in public settings. Many women are influenced by the opinions that individuals in their lives hold concerning breastfeeding. According to the Theory of Planned Behavior, if these women do not feel that breastfeeding will be perceived positively by others, they will not breastfeed (8). The National Breastfeeding Awareness Campaign had insufficient results because their ads did not address this.

Campaign did not deflect reactance by having the message delivered by someone similar to the target audience

The National Breastfeeding Awareness Campaign’s goal was to increase the breastfeeding rates in first time mothers and in African American mothers (5). However, the advertisements did not suggest that these particular groups of women were the target of the intervention. When the recipient of a behavior change message believes that the message is threatening their freedom they display reactance and do the opposite of the message or merely ignore it (11). One way to avoid Psychological Reactance is by having the message delivered by someone with similarities to the recipient of the message (10-11). The NBAC’s advertisements were not delivered by a messenger similar to the target audience. The print ads were not even depictions of people, they were objects. The radio ads were delivered by singing men and the television ads were delivered by pregnant women partaking in strange activities. The NBAC did not display any breastfeeding mothers. Based on the Psychological Reactance Theory this may have caused reactance in the women viewing the ads and caused them to not breastfeed.

The Social Learn Theory also suggests that the role of the messenger is crucial (6). The theory acknowledges that the source of a message must be in some way attractive to the audience of the message (6). If the deliverer of the message is not attractive to the audience then they must possess a form of power that compels the recipient of the message to be interested (6). The audience will lack attention if a message is delivered without a powerful or attractive messenger. It can be argued that individuals are attracted in some way to people that have similar characteristic as themselves (12). Since the NBAC failed to use a source of the message that had similarities to the recipient of the message, the recipients were not receptive.

Additionally, individuals are more likely to try a behavior that they can picture themselves doing (13). This is referred to as self-referencing (13). Since the NBAC’s advertisements did not display breastfeeding women with similarities to the target audience, the target women were unable to self-reference. Because these women were unable to imagine themselves breastfeeding when viewing the ads, they were unlikely to breastfeed as a result of the ads (13). The campaign failed to include characters in the ads that the viewers could relate to, this was extremely apparent in the radio ads, which were sung by men.

The article “Is Breast Really Best? Risk and Total Motherhood in the National Breastfeeding Awareness Campaign,” suggests that the NBAC’s attempt to target African American women was unsuccessful (3). The campaign tried to target these women by using an African American woman in one of the television ads and by the genre of music in the radio ads (3). While the NBAC’s intention may have been the opposite, Wolf’s suggestions raise questions about stereotyping. Ultimately, the campaign would have been more successful if it had put in a much greater effort to learn about the culture of their target populations (11). If the NBAC researched the cultures of their target audience it would have been able to use people to deliver the message that were similar to the target audience, this would have deflected reactance (11).

Proposed Intervention

The National Breastfeeding Awareness Campaign had several flaws that reduced its success, but the motivation for the campaign was very important. The U.S. Office of Women’s Health was aware that increasing breastfeeding rates would benefit babies, mothers and society. According to Merewood and Heinig (2004), one goal of Healthy People 2010 was for 75% of mothers to initiate breastfeeding and for 50% of mothers to breastfeed their baby for six months (5). However, the NBAC was not able to increase the breastfeeding rates to the desired values. A more thorough intervention will need to be designed in order for breastfeeding rates to increase in the targeted population, striving for the Healthy People goal.

In order to reach women who were uninfluenced by the NBAC, a new intervention will be designed to promote breastfeeding in first time mothers and African American mothers. The new intervention will be multi faceted with the goal to provide mothers with the necessary support, education and convenience that is needed to breastfeed. One aspect of this intervention will be implemented during prenatal care and early pediatric doctor’s appointments. This will offer women a way to obtain knowledge concerning the importance of breastfeeding and the technical support to breastfeed successfully. The mother’s primary support group (family and friends) will also be educated at these doctors’ visits so that they can offer the breastfeeding women as much support and encouragement as possible. Additionally, mothers will be provided with a peer-support group of other breastfeeding women. The new campaign will also include workplace policy changes to make breastfeeding more convenient for working mothers. Furthermore, the new campaign will use advertisements depicting breastfeeding women. Each aspect of the new campaign will help the campaign be more successful than the NBAC.

Addressing Environmental Barriers to Breastfeeding

The National Breastfeeding Awareness Campaign was flawed in that it failed to address the barriers to breastfeeding, but this will be fixed in the new intervention. The new intervention will provide benefits to workplaces that accommodate breastfeeding mothers. Based on the Social Learning Theory, if there are environmental barriers to a behavior, individuals will not do this behavior (6). This suggests that barriers to breastfeeding in the workplace must be eliminated in order for working mothers to breastfeed. By offering benefits to employers that make the workplace conducive to breastfeeding, working mothers will realize that they are able to breastfeed and work. This realization or feeling of self-efficacy is highlighted by the Social Learning Theory as a necessary component for an intervention (6).

Similarly, family and friends can act as barriers to breastfeeding for some women. The NBAC did not educate the family and friends of a breastfeeding mother about the importance of being supportive. As described by the Ecological Perspective Theory, behavior is influenced by family, friends and peers (8). If a mother’s primary support group is not in favor of breastfeeding, why would the mother breastfeed? The new intervention will provide the mother’s support group with an educational experience to help them support the breastfeeding mother. This will occur during the doctor’s visits. Once these people learn about their role in the breastfeeding process, they will be able to support the mother and breastfeeding will be more successful. Ultimately, the new intervention will aim to eliminate barriers to breastfeeding in both the workplace and in a mother’s social environment.

Campaign will aim to make breastfeeding a social norm

The new intervention will strive to make breastfeeding a social norm in this society since the NBAC did not do so. According to the Social Learning Theory, people model the behavior that they see others doing (6). The NBAC did not model breastfeeding in any of the advertisements, which made women unlikely to breastfeed. The new campaign will accomplish modeling by including television advertisements that display mothers breastfeeding in various locations, for example in a restaurant, at home, on a bus, etc. By displaying mothers’ breastfeeding in the ads, mothers will see that it is socially acceptable to breastfeed, even in public. Also, the media will be urged to show breastfeeding as opposed to bottle feeding in movies, television shows and in commercials. The campaign will offer increased air time to media companies that incorporate breastfeeding. This will increase the frequency of breastfeeding modeling that women are exposed to.

Additionally, the NBAC did not acknowledge that free formula is distributed by maternity clothing stores, hospitals and formula companies. This undermines the social norm of breastfeeding, making formula seem more popular. Schultz et al (2007) state that people overestimate how many individuals partake in an undesired behavior (9). Schultz et al would argue that women believe that breastfeeding is less common than it really is and by dispensing free formula this idea is reinforced (9). The new campaign will discourage hospitals from providing free formula to mothers unless a mother and physician decide together that breastfeeding is not best in her particular situation. Mothers will believe that breastfeeding is common if free formula distribution is reduced.

Furthermore, the Theory of Planned Behavior suggests that people consider how they will be perceived by others before deciding to act themselves (8). Since the NBAC did not strive to make breastfeeding a social norm, women were unaware of how individuals would perceive their decision to breastfeed. The new campaign will make breastfeeding a social norm and therefore women will be more reassured that if they breastfeed, others will support their decision.

Campaign will deflect reactance by having the message delivered by someone similar to the target audience

The National Breastfeeding Awareness Campaign failed to use a source of the message that had similarities to the recipient of the message. The implications for this were that the lack of similarity induced reactance to the message (11). Silvia (2005) conducted a study in which he found that when the communicator of the message is dissimilar to the recipient of the message, there is a “boomerang effect” (11). This suggests that people did the opposite of a message since the message was not delivered by someone similar to themselves (11). Additionally, if the audience can not relate to the messenger, the individuals targeted by the campaign are unable to self-reference (13). However, the new campaign will include a peer-support group, which will allow women to learn about the importance of breastfeeding from their peers. Women who take part in a peer support group will be able to interact with other women who have actually breastfed. The peers could be neighbors, co-workers or friends. Women interacting with their peers while learning about breastfeeding will be more likely to comply with the message (11).

Additionally, having a group of peers who are also breastfeeding mothers will allow the target audience to engage in self-referencing and imagine themselves breastfeeding (13). Burnkrant and Unnava (1995) state that self-referencing can be accomplished in a campaign that “addresses the audience directly and introduces experiences to which it can relate” (13). Not only will these women be able to self-reference as a result of the peer group, they will also become aware of the commonality of breastfeeding. While the NBAC did not deliver the message of their campaign by someone similar to the target audience, the new intervention will do this through the use of peers. Since the peers will share similarities with the targeted mothers, they will be able to contribute experiences that the targeted mothers can relate to. This will ultimately work in a persuasive way to promote breastfeeding and increase compliance (13).

Conclusion

The suggested intervention will be more successful than the National Breastfeeding Awareness Campaign in increasing breastfeeding rates because it takes into account flaws of the NBAC. First, many women face barriers to breastfeeding including lack of support from friends and family and also unaccommodating work environments. The new intervention addresses the environmental barriers in order to increase one’s feeling of self-efficacy (6-8). Second, breastfeeding is not a social norm in the United States society. The new intervention works to make breastfeeding become a social norm so people do not worry about how they will be perceived by others when breastfeeding (6-7). Also, people model the behavior they see; by seeing breastfeeding more often women will be more likely to model this behavior (6-7). Lastly, people are more likely to adopt a behavior change that is suggested to them if the message is delivered by someone similar to the recipient of the message (10-11). The new intervention recognizes this and delivers the message through peers. Using peers also allows mothers to self-reference and imagine that breastfeeding is something they are capable of doing (13).

The new intervention will incorporate improvements making it more successful than the National Breastfeeding Awareness Campaign’s attempt at increasing breastfeeding rates. The NBAC had several flaws that are corrected for in the new intervention and some of these concepts are recognized by the American Academy of Pediatrics (AAP) in its policy statement, “Breastfeeding and the use of human milk” (2). The AAP recognizes that a campaign’s promotion of breastfeeding must encourage breastfeeding to be a “cultural norm” (2). They also state that breastfeeding must be supported by families and society (2). The AAP believe that employers must provide “appropriate facilities and adequate time in the workplace” for breastfeeding mothers (2). Based on these recommendations by the AAP, it is clear that the National Breastfeeding Awareness Campaign was not sufficient in promoting breastfeeding. However, the proposed campaign recognizes the necessary aspects of breastfeeding campaigns as described by the AAP, and therefore will be more successful than the NBAC.

References

1. Healthy People 2010. 16 Maternal, Infant, and Child Health. Available at: http://www.healthypeople.gov/2010/Document/HTML/Volume2/16MICH.htm#_Toc494699668. Accessed December 10, 2011.
2. Section on Breastfeeding. Breastfeeding and the Use of Human Milk. Pediatrics. 2005;115(2):496 -506.
3. Wolf JB. Is Breast Really Best? Risk and Total Motherhood in the National Breastfeeding Awareness Campaign. Journal of Health Politics, Policy and Law. 2007;32(4):595 -636.
4. U.S Department of Health and Human Services. National Breastfeeding Campaign | womenshealth.gov. Available at: http://www.womenshealth.gov/breastfeeding/government-in-action/national-breastfeeding-campaign/. Accessed December 2, 2011.
5. Merewood A, Heinig J. Efforts to Promote Breastfeeding in the United States: Development of a National Breastfeeding Awareness Campaign. Journal of Human Lactation. 2004;20(2):140 -145.
6. Grusec JE. Social learning theory and developmental psychology: The legacies of Robert Sears and Albert Bandura. Developmental Psychology. 1992;28(5):776-786.
7. Bronfenbrenner U. The ecology of human development: experiments by nature and design. Harvard University Press; 1979.
8. Glanz K, Rimer BK. Theory at a glance: A guide for health promotion practice. Second Edition. U.S. Department of Health and Human Services, National Cancer Institute
9. Schultz PW, Nolan JM, Cialdini RB, Goldstein NJ, Griskevicius V. The Constructive, Destructive, and Reconstructive Power of Social Norms. Psychological Science. 2007;18(5):429 -434.
10. Dillard JP, Pfau M. The persuasion handbook ... - James Price Dillard, Michael Pfau - Google Books. Available at: http://books.google.com.ezproxy.bu.edu/books?hl=en&lr=&id=lsF8zLomQOoC&oi=fnd&pg=PA213&dq=psychological+reactance+theory&ots=3-xUb5C0DO&sig=Y87th9UAemibPALaciQYP8bLPTU#v=onepage&q=psychological%20reactance%20theory&f=false. Accessed December 2, 2011.
11. Silvia PJ. Deflecting Reactance: The Role of Similarity in Increasing Compliance and Reducing Resistance. Basic and Applied Social Psychology. 2005;27:277-284.
12. Griffitt W, Veitch R. Preacquaintance Attitude Similarity and Attraction Revisited: Ten Days in a Fall-Out Shelter. Sociometry. 1974;37(2):163-173.
13. Burnkrant RE, Unnava HR. Effects of Self-Referencing on Persuasion. Journal of Consumer Research. 1995;22(1):17-26.

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