Challenging Dogma - Fall 2009

Thursday, December 17, 2009

A Critical Analysis of LOVE Condoms Campaign: Prescriptions for Change – Alexis Werner

The global HIV/AIDS epidemic is one of the greatest challenges of medicine in the modern world. As of December 2008, 33.4 million people in the world are living with HIV (19). The number of those newly infected each year remains relatively constant and in some like the United States are beginning to show slight decreases since the turn of the 21st century (3). One of the most reliable ways to avoid contracting HIV/AIDS is through the use of condoms. “Latex condoms, when used consistently and correctly, are highly effective in preventing the sexual transmission of HIV, the virus that causes AIDS” (2). Condoms are seen as a safe, relatively inexpensive method for sexually active people to prevent the spread of HIV/AIDS and other STDs.
Many nonprofit and non-government organizations have chosen to back condom use and distribution as a primary means of protecting vulnerable populations from HIV/AIDS because of their accessibility. In 2002, condoms were noted as the third leading contraception method, 18%, used among women in the United States who practice contraception behind only the pill, 30.6%, and tubal sterilization, 27% (5). The newly established LOVE Condoms Campaign, launched globally in the summer of 2009 promotes condoms as the best way to combat the HIV/AIDS epidemic and to achieve “’Global AIDS Control’” (9).
LOVE Condoms Campaign’s goal of 100% use of and access to free condoms to stall the spread of HIV/AIDS while good in its aim, unfortunately has not been successful (9). Developed solely out of the Health Belief Model, it is unsuccessful in many ways. The LOVE Condom Campaign falls short when being evaluated by the Law of Small Numbers and Optimistic Bias, the Theory of Gender and Power as well as Advertising Theory. Each of these theoretical models can be applied to the LOVE Condoms Campaign to evaluate its inability to make condoms accessible to everyone who may need them and therefore curtailing the HIV/AIDS epidemic.
The LOVE Condoms Campaign ignores sound social and behavioral theories that would aid it in becoming a much larger success in increasing condom use to decrease the incidence of HIV/AIDS. By employing alternative social and behavioral science theories such as Psychological Reactance Theory, as well employing the Theory of Gender and Power and Advertising Theory in the correct ways, the LOVE Condoms Campaign could be changed and altered to reach and effect change in far more people than it currently has the strength to do.
LOVE Condoms Campaign’s Structure is Ineffective in Influencing Behavior
The development of the LOVE Condoms Campaign is based entirely on the Health Belief Model of weighing perceived benefits, accounting for both perceived susceptibility and perceived severity against perceived barriers which will lead to intention of behavior and finally behavior itself (6, 13, 15). In applying this theory, the LOVE Condoms Campaign’s belief is that if people are given easy and affordable access to HIV/AIDS testing as well as condoms that the choice will be simple. People will choose to get tested and regularly use condoms to protect themselves from the virus (9). The perceived benefits of protecting oneself against disease would far outweigh the perceived barriers because the LOVE Condoms Campaign has, in its implementation, eliminated the barriers of locating a testing site as well as the cost of condoms. Unfortunately, the limitations of the Health Belief Model do not address the irrationality of human behavior or social factors that would influence someone’s behavior. Finally, the campaign does not cater to the core values of human desire and instinct which makes its advertising campaign entirely ineffective.
A. The Innate, Irrational Belief in the Law of Small Numbers and Optimistic Bias
One of the main goals of the LOVE Condoms Campaign for “global AIDS control involves identifying those who are undiagnosed and linking them to treatment, which will render them less infectious” (9). The LOVE Condoms Campaign assumes, reasonably under the Health Belief Model, that if one has access to HIV/AIDS testing that he or she will take advantage of it and find out his or her disease status. This is, in fact, untrue. Less than half of those surveyed in a study on HIV attitudes and voluntary testing conducted in Cape Town, South Africa chose to get tested even though everyone surveyed had access to various testing facilities (7). Many people who have regular and easy access to HIV/AIDS testing facilities irrationally choose not to get tested because of a belief that they are safe from infection, even if their sexual practices may leave them at risk. This attitude is based on the Law of Small Numbers and Optimistic Bias.
The Law of Small Numbers is based on people’s strong judgment and intuitions about the probability of events. People often have a skewed interpretation of what the outcomes of random sampling should be and as a result one may find themselves at “the heart of the gambler’s fallacy…a misconception of the fairness of the laws of chance” (14). As a result of these preconceived expectations one may be overconfident in early results, consistency of patterns and overestimate significance (14). One may not view the benefit of having the HIV/AIDS test done as a personal benefit because of the results of previous negative outcome tests or the negative results of others with similar lifestyles. This leads to an overestimation of invulnerability.
People also have a tendency to be naively confident about what their lives will hold in the future. This “uncharacteristic optimism” is considered Optimistic Bias (8, 16). When reviewing HIV/AIDS incidence rates, people tend to view their personal vulnerability as minimal while viewing others’ as much more likely, which proves Neil Weinstein’s point in ‘Unrealistic Optimism About Future Life Events’ that “people tend to think they are invulnerable” (16). This is especially true because people feel that they have more control over their sexual health than they actually do. According to Weinstein, “the greater the perceived controllability of a negative event, the greater the tendency for people to believe that their own chances are less than average” (16). As a result of people’s irrational belief that contracting the HIV/AIDS virus is unlikely, due to the Law of Small Numbers and Optimistic Bias, one is unlikely to voluntarily choose to get tested.
B. Gender Power and Cathexis as a Social Factor Obstructing Women from Accessing Condoms
As the primary means of achieving “’Global AIDS Control’” the LOVE Condoms Campaign calls for “an aggressive re-integration of condoms” as critical to the success of the ABC “Abstinence – Be Faithful – Condoms” model (9). In essence the LOVE Condoms Campaign relies on fidelity and condom use to keep sexually active people safe from the HIV/AIDS virus. The LOVE Condoms Campaign’s reliance on the Health Belief Model is again false. The model bases this assumption on the reliance of personal responsibility (6, 13) and “negates the gendered contexts in which individuals attempt to enact behavior change,” (4) which ignores the social influence of gender and power.
The Theory of Gender and Power characterizes this sexual division of power as the second of three structures, the others being the sexual division of labor and cathexis (18). “Inequalities in power between the sexes form the basis for the sexual division of power at the societal level” (18). It is sustained at the institutional level by
Social mechanisms such as the abuse of authority and control in relationships [and] the inequalities resulting…are manifested as physical exposures and behavioral risk factors. As the power inequity between men and women increases and favors men, women’s sexual choices and behavior may be constrained, thereby increasing their risk for HIV (18).
The Joint United Nations Programme on HIV/AIDS illustrates the affect of the sexual division of power by noting the rise in women infected with HIV/AIDS in its 2004 epidemic report. Women now account for “nearly 50% of infected people worldwide, up from 35% in 1985…Of those new infections, 50% were occurring between spouses and that women were most often at risk from their male partner” (4). Illustrating the sexual division of power further as it relates to HIV/AIDS, the Centers for Disease Control and Prevention now states that 26% of those newly diagnosed with the virus in the United States are women and that high-risk heterosexual contact is the cause of 80% of those infections (1). Women in high risk relationships may feel that they cannot demand their partner use a condom for fear of abuse or abandonment (1).
Cathexis, or social exposures that structure the social norms and affective attachments of relationships, also may influence a woman’s ability to demand condom use, even if they are readily available, free through LOVE Condoms Campaign (18). Young women in relationships with older men often feel less control over the relationship as well as protection methods used during sex. In fact,
In a Centers for Disease Control study of urban high schools, more than one third of black and Hispanic women had their first sexual encounter with a male who was older (3 or more years). These young women, compared with peers whose partners had been approximately their own age, had been…less likely to have used a condom during first and most recently reported intercourse, or less likely to have used condoms consistently (1).
The implications of the Theory of Gender and Power on the sexual division of power and cathexis, as well as the sexual division of labor on women in relationships may strongly prevent them from protecting themselves against HIV/AIDS via condom use, even if condoms are free and readily accessible.
C. Improper Advertising and Marketing Prevents Value of LOVE Condoms Campaign from Resonating with Audience
LOVE Condoms Campaign commits one of the ultimate Public Health faux pas when employing Advertising and Marketing Theories in its promotional campaign. The website engages in a condom debate. It addresses the point “condoms are not ‘hip’ and the challenge to make condoms ‘hip’ is a big one.” LOVE Condoms Campaign counters this point by stating “anything can be made ‘hip’ if marketed cleverly and it has been done. It is ‘hip’ to be healthy, good-looking and also responsible” (9). LOVE Condoms Campaign has not done extensive market research with its target audience to find out what people really want; the absolute necessity within Marketing Theory (10). Marketing Theory is based on conducting formative research to discover what the target audience or consumer desires. While health and responsibility may be intrinsic values within the Public Health community, they are not within the general population.
The advertisement produced by LOVE Condoms Campaign, already failing to adhere to Marketing Theory, does not follow Advertising Theory. As a part of Marketing Theory, Advertising Theory applies effective market research to construct a promotional campaign with a salient promise that “positions the product as a way to fulfill important needs and desires” which represent the core value(s) of the target audience (10). The promise is properly supported by showing the audience that “the product does and will fulfill their specific needs and desires” within the promotion (10). In the LOVE Condoms Campaign the promise made is using condoms makes one a more responsible lover. This highlights the core value of health, all of which is supported by the LOVE Guy, a goofy superhero who spouts off alternative terminology for condoms (20). The poor construction of the advertisement, based on little or no market research, along with a hero that is not influential in any way (who even comes off as a joke) prevents the LOVE Condoms Campaign’s commercial from reaching its audience.
Regrettably, the misuse of both Advertising and Marketing Theories results in LOVE Condoms Campaign missing the mark for a condom use promotion. It does not effectively reach the sexually active audience it aims to touch.
Updating LOVE Condoms Campaign to Become an Effective Tool in Preventing the Spread of HIV/AIDS
In order to make the LOVE Condoms Campaign successful, it must be restructured using multiple social and behavioral science models. Its underlying structure based on the Health Belief Model must be abandoned. Each of the issues previously highlighted can be altered to create a newly updated and more valuable LOVE Condoms Campaign.
Initially the LOVE Condoms Campaign must be changed to be personally relatable to its target audience: those who are at risk of HIV/AIDS exposure through sexual contact. In order to convince people that they should visit treatment centers and get tested for HIV/AIDS they need to be able to personally relate to the threat. Psychological Reactance Theory is essentially based on reverse psychology, if one is told to do something he or she will most likely do the opposite (11, 12). The way to convince people to do what the larger program desires is to create ‘allies’ of the program who are just like the target audience in every way. This will cause the target audience to identify with the program and therefore more likely to perform the task desired by the program.
Paul J. Silvia evaluated Psychological Reactance Theory in his study ‘Deflecting Reactance: The Role of Similarity in Increasing Compliance and Reducing Resistance.’ The study demonstrated that
Interpersonal similarity can reduce reactance by increasing compliance and by reducing resistance [while] threats caused boomerang effects only when the communicator’s similarity was low or unknown (12).
This study can be directly applied to promoting HIV/AIDS testing. Encouraging getting tested through brand ambassadors who are similar to the target audience will result in an increase in the number of people actually going to clinics to get tested. This will aid LOVE Condoms Campaign in their goal of linking people who are undiagnosed with treatment.
In order to combat the limitations gender places on women’s access to condoms and condom usage, the Theory on Gender and Power can be used to create programs whose aim is to actually empower women.
HIV prevention programs addressing the structure of power may include…developing HIV prevention social marketing programs…strengthening women’s control over their own sexuality… [and] examination of the role that male partners can play in influencing women’s risk of HIV infection (18).
The best way to aid women in overcoming power struggles within relationships is to empower them and help them develop a strong sense of self worth. Women also need to be educated on safer sex negotiation skills and taught that monogamy with their partner does not necessarily guarantee the safety of their partner’s choices (4). Every empowerment program must be culturally sensitive in order to highlight different cultural ties and issues. More recent gender-specific interventions “have moved beyond an emphasis on women and femininity to theorize how gender relations and masculinities contribute to risk, targeting heterosexually active men” (4).
Domestically, the Centers for Disease Control have acknowledged the significance of assimilating culture- and gender-relevant materials into current interventions. The SISTA (Sisters Informing Sisters about Topics on AIDS) programs have been growing in reputation across the United States. The Centers for Disease Control provides funding to state and local health departments in Illinois, California and Florida for different culturally specific SISTA programs. Other funded HIV/AIDS education programs include Massachusetts’ Women RISE (Risk Identification, Strategies, and Empowerment) and New York’s RAPP (Real AIDS Prevention Project) program (1, 18). By modeling local cultural community education groups on the Theory of Gender and Power, instead of simply giving people greater access to condoms, women will be able to learn more effective skills in persuading their partner to use condoms during sexual intercourse.
The message of the LOVE Condoms Campaign could be vastly improved upon through a more convincing advertising campaign. The basic message needs to reiterate the core values that really matter to the target, sexually active audience. If the campaign were to highlight the core values of independence, freedom and control instead of health (10) it would resonate better with its audience. People are much more influenced by short term satisfaction (having sex now) (17) than long term health and protecting oneself from HIV/AIDS. With this in mind, the LOVE Condoms Campaign could create an advertising campaign promising the freedom (core value) of being able to have fun, gilt free sex with the use of a condom. This new focus as a promotional campaign could be supported with sexual imagery or cultural icons that are respected by the individual cultures where the campaign is initiated.
Many organizations have been developed addressing the prevention of HIV/AIDS, but unfortunately not all are effective. Beyond the issues addressed here, the LOVE Condoms Campaign has many other problems that are created by its development around the Health Belief Model that should be tackled. Current public health campaigns need to be redesigned, updating their use of the Health Belief Model to using multiple alternative social and behavioral models, such as Psychological Reactance Theory, the Theory of Gender and Power, Marketing Theory and Advertising Theory. Campaigns need to recognize the imbalances that exist in societies and across different cultures, as well as the irrationality that people unconsciously live by.
Everyone would like to see the eradication of HIV/AIDS. The problem will continue to persist, however, as long as people do not take prevention into their own hands and into their own bedrooms. HIV/AIDS and condom sponsorship organizations need to tackle the decreasing use of condoms. Between 1995 and 2002, the percentage of women who use condoms as a form of contraception declined from 20% to 18% (5). Unfortunately the other leading methods women use as contraception, the pill and tubal sterilization, do nothing to protect from the spread of HIV/AIDS. Condoms usage needs to be expanded as much as possible as they are known to be one of the best and most reliable ways to protect oneself against exposure, when used correctly. Once the public health field adopts a multi-theory approach to designing campaigns, the people it affects will far outreach those the field currently does, thereby effecting far greater change in society. As more effective condom campaigns are created, the spread of HIV/AIDS will be diminished and hopefully one day will be prevented entirely.
1. Centers for Disease Control and Prevention. CDC HIV/AIDS Fact Sheet: HIV/AIDS Among Women. August 2008.
2. Centers for Disease Control and Prevention. Condoms and STDs: Fact Sheet for Public Health Personnel. Atlanta, GA: Centers for Disease Control and Prevention, 2009.
3. Centers for Disease Control and Prevention. HIV/AIDS in the United States: CDC HIV/AIDS Facts. August 2009.
4. Dworkin, Shari L. and Ehrhardt, Anke A. Going Beyond “ABC” to Include “GEM”: Critical Reflections on Progress in the HIV/AIDS Epidemic. American Journal of Public Health 2007. 97(1):1-6.
5. Guttmacher Institute. Facts on Contraception Use. January 2008.
6. Individual Health Behavior Theories (pp. 129-133). In: Edberg, Mark, PhD. Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Washington, DC: Jones and Bartlett Publishers, 2007.
7. Kalichman, S C and Simbayi, L C. HIV Testing Attitudes, AIDS Stigma, and Voluntary HIV Counselling and Testing in a Black Township in Cape Town, South Africa. Sexually Transmitted Infections 2003. 79:442-447.
8. Lapinski, Maria Knight, Rimal, Rajiv N., Klein, Katherine A. and Shulman, Hillary C. Risk Perceptions of People Living with HIV/AIDS: How Similarity Affects Optimistic Bias. Journal of Health Psychology 2009. 14(2):251-257.
9. LOVE Condoms Campaign.
10. Marketing Social Change—An Opportunity for the Public Health Practitioner (pp. 45-71). In: Siegel, Michael and Lotenberg, Lynne Doner. Marketing Public Health: Strategies to Promote Social Change. Sudbury, MA: Jones and Bartlett Publishers, 2007.
11. Mason, Tina Lynn. A Test of Psychological Reactance Theory and Risk-Related Sexual Behaviors Among HIV-Positive Men Who Have Sex With Men. Dissertation Abstracts International Section A: Humanities and Social Sciences 2004. 65(1-A):289.
12. Silvia, Paul J. Deflecting Reactance: The Role of Similarity in Increasing Compliance and Reducing Resistance. Basic and Applied Social Psychology 2005. 27(3):277-284.
13. Theories and Applications (pp. 9-21). In: Theory at a Glance: A Guide for Health Promotion Practice: National Cancer Institute, 2005.
14. Tversky, Amos and Kahneman, Daniel. Belief in the Law of Small Numbers. Psychological Bulletin 1971. 76(2):105-110.
15. Volk, Jonathan E. and Koopman, Cheryl. Factors Associated with Condom Use in Kenya: A Test of the Health Belief Model. AIDS Education and Prevention 2001; 13(6):495-508.
16. Weinstein, Neil D. Unrealistic Optimism About Future Life Events. Journal of Personality and Social Psychology 1980. 39(5):806-820.
17. Whipple, Thomas W. The Existence and Effectiveness of Sexual Content in Advertising (pp. 134-140). In: Danna, Sammy R. Advertising in Pop Culture: Studies in Variety and Versatility. Madison, WI: Popular Press, 1992.
18. Wingwood, Gina M. and DiClemente, Ralph J. The Theory of Gender and Power: A Social Structural Theory for Guiding Public Health Interventions. In: DiClemente, Ralph J., Crosby, Richard A. and Kegler, Michelle C. eds. Emerging Theories in Health Promotion Practice and Research: Strategies for Improving Public Health. San Francisco, CA: Jossey-Bass, 2002.
19. World Health Organization. Global Summary of the HIV/AIDS Epidemic, December 2008.
20. YouTube: Broadcast Yourself. LOVE Guy Promotes Free LOVE Condoms. July 2009.

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