Roll Back Malaria: Rolling out the Resources without Rolling out the Behavior – Ashley Dunkle

Introduction
Many international public health initiatives use innovative technologies developed in the West that need to be implemented in a developing context, often requiring behavior change of communities and individuals. One major international health problem that has been the target technological initiatives by many public health campaigns is that of malaria. Malaria is a leading global killer, particularly of children under 5 years of age (1). Over half of the world’s population is at risk of malaria while 350-500 million illnesses occur each year (1). A multitude of studies have shown the substantial economic, social, and health burden of areas of high endemic malaria (2,3).
Roll Back Malaria (RBM) is a partnership campaign that was formed in 1998 in order to align global health and development advocates in the fight against malaria (1). Recently RBM has developed a Global Malaria Action Plan (GMAP), which outlines techniques for partners to use in programming in prevention and treatment of malaria (4). One of the most important factors in preventing morbidity and mortality of malaria is vector control, reflected in the main intervention for prevention promoted by RBM: the scaling up of use of insecticide-treated bed nets (ITNs). ITNs are a technology developed to cover the beds of individuals in malaria endemic regions in order to prevent mosquito bites at night, when most malaria transmission occurs (5). This innovative technology is relatively cheap and has proven to be an effective prevention measure for the spread of malaria (6). Around 120 studies have shown the effectiveness of ITNs in reducing malaria transmission, and as a result, morbidity and mortality (6). In order to promote ITN use, RBM states they are working to a) organize public education campaigns in malaria-endemic areas, b) lobby for the reduction or waiver of taxes and tariffs on mosquito nets, netting, materials, and insecticides, c) stimulate local ITN industries and social marketing schemes so ITNs are available at a price affordable by everyone, and d) to capitalize on the potential of newly developed long-lasting treated mosquito nets (5). However, despite large donations and wide disbursement of ITNs and the implementation of RBM’s GMAP, malaria continues to be a major problem worldwide with little overall change in morbidity and mortality (7). This analysis will look at why RBM has largely failed in preventing malaria through its ITN initiative and offer ways in which the GMAP strategy could be improved to increase the use of ITNs worldwide.
CRITIQUE 1 – Assuming Induced-Demand Reflects Intended Use - Application to the Theory of Planned Behavior
RBM’s major indicator for use of ITNs among its beneficiaries is ownership of a net (1). Because ITNs are so effective at preventing transmission of malaria, many initiatives have targeted getting ITNs to the people in endemic, high-risk areas. In order to increase ownership, RBM’s methods involve inducing demand through social marketing (4). This first means inducing an increase in supply of ITNs by manufacturing organizations. After doing so, RBM focuses on getting ITNs to the people by giving ITNs away for free, subsidizing the cost, or delivering vouchers to exchange for ITNs, all of which is intended to induce demand (1). Recent reports by RBM has shown impressive scaling up in ITN ownership among individuals in endemic areas (1). However, despite widespread availability and possession of ITNs by people in malaria endemic areas, malaria is continuing to be a problem (7).
The major fallacy in RBM’s GMAP regarding ITNs is that they are only focusing on the possession of ITNs, not the actual behavior of use. In many of their reports, they provide accolade of the amount of nets disbursed throughout the world without measurement of the actual use of the nets (4). It is as though RBM is assuming that the “demand” they are seeing, which they induced, will lead to an intention to use the ITNs. We can apply this assumption to the Theory of Planned Behavior (TPB), an individual-based behavioral theory that focuses on rational, cognitive decision-making which presumes that people think about what they do before they do it (8). This theory states there are four factors leading to the intention to perform a behavior and that intention will lead to actual behavior. These factors are: 1) attitudes - the person’s belief about the outcome of the behavior and whether it is good or bad, 2) subjective norms - the person’s belief that other people in their social group approve of the behavior and there is motivation to conform, 3) perceived behavioral control – the person’s belief about the existence of factors that promote or prevent the behavior, and 4) perceived power – the person’s belief in the amount of power they have over the behavior. TBM assumes all of these factors influence behavioral intention and that behavioral intention then results in behavior (9).
What RBM seems to be assuming is that the demand they induced reflects attitudes that owners of ITNs believe there is a positive outcome from use (attitude) and that other people in the social group approve of its use, as ITNs are now widespread (social norms). They also appear to assume that by providing ITNs, RBM is reducing the difficulty of performing the behavior (perceived behavioral control) and the person believes they have power to perform the behavior now that they posses an ITN (perceived power). As ownership of ITNs is presupposed to reflect these aspects of the TBM, RBM believes these individuals will intend to use the ITNs regularly (behavioral intention) and that intention will lead to behavior. However, these factors that lead to behavioral intention are not necessarily existent among new ITN owners. For example, just owning something does not mean you have a positive attitude about its intended use. Many people will take free things because they are free and may not value them for their intended use (10). In fact, regarding bed nets, a study evaluating their use in a village in Kenya found 25% of individuals used the ITNs for alternative purposes, such as fishing netting and hanging fish to dry (11).
Likewise, rational decision-making does not always result in performing the intended behavior. Other factors beyond conscious cognition motivate behavior, such as environmental and social factors (8). Many reports have shown that barriers to use exist beyond obtaining ITNs. One study revealed a statistically significant reason for lack of adherence to ITN use, among participants who were given free nets, was temperature (12). One participant stated that it was “too hot” sleeping under the nets (12). Social reasons also influence use such as the disruption of normal sleeping arrangements for various reasons such as visitors or multiple beds (12). Additionally, technical factors can be a barrier such as people stated, “cannot hang the net properly, difficult to spread net over mat, returned home too late to put up the net,” and “net is too hard to put up and take down,” (12). RBM’s assumption that ownership will lead to intended use via the TPB and ultimately result in ITN use is false. Demand does not reflect behavioral intent and there are other factors, social, environmental, and technical, that can prevent ITN use by beneficiaries of ITN social marketing.
CRITIQUE 2 – Focusing on Education Campaigns - The Fallacy of the Health Belief Model
Another error in RBM methods for increasing ITN use is reliance on the Health Belief Model (HBM) through community-based education to encourage use of ITNs. HBM, like TPB, is a theory based on cognitive decision-making about what motivates health behavior. It assumes beliefs concerning perceived risk, costs, and benefits to participate in a healthy behavior, such as bed net use, are considered in a rational way, and will influence health behavior (13). There are six factors in the HBM which will be explained in relation to malaria and ITN use: 1) perceived susceptibility – the degree to which the person feels they are at risk of contracting malaria, 2) perceived severity – the degree to which a person believes the outcomes of contracting malaria are severe, 3) perceived benefits – perception of the positive outcome of using ITNs to prevent contracting malaria, 4) perceived barriers – the negative outcomes of using ITNs, 5) cues to action – an external event, such as someone in the community dying from malaria, that motivates use, and 6) self-efficacy – a person’s belief they are able to effectively use the ITN (8).
RBM’s GMAP proposes the use of community education programs in order to target these HBM factors assuming this will result in the behavior of ITN use. In fact, in the GMAP, Bill Gates, a major donor to RBM, is quoted as saying, “I believe that if you show people a problem, and then you show them the solution, they will be moved to act. The Global Malaria Action Plan lays out an achievable blueprint for fighting malaria – now it is time for the world to take action,” (1). RBM relies heavily on the HBM in that education of the susceptibility and severity of malaria, the benefits and limited barriers to ITN use, and promoting self-efficacy through educational cues to action will result in ITN use.
Like TPB, one of the major problems with HBM is its focus on individual decisions without addressing social and environmental factors (8). An individual’s cognitive and rational processes exist within a social and environmental context in which external influences affect behavior and can counteract rational thoughts and intentions (8). A randomized controlled trial performed in western Kenya evaluated adherence to ITN use with free ITNs and extensive educational activities focusing on many of the factors in HBM (12). These educational activities taught individuals about malaria, its prevalence in the area, the outcomes if adults and/or children contracted malaria, and ITN’s effectiveness in reducing transmission (4). Despite knowledge of malaria and ITN use, as well as free ITNs, “adherence” was still only around 70% (12). Teachers also emphasized to participants that malaria is a more serious ailment in children than older people and it was very important that children are a priority in sleeping under the nets. However, one of the statistically significant findings in this study was older people were more likely to sleep under the ITNs than children (p=0.0001) (12). Another important indication of ITN use by this study was that ITN use decreased over time, a factor that was observed in other efficacy trials surrounding ITN use (12). Allaii et al. states, “That this occurred in spite of our educational campaign illustrates how difficult it is to impact human behavior…” (12). This study shows the limitations of the HBM and RBM initiatives in education resulting in behavior change. This approach relies too much on the client and fails to take into account the wider social and environmental factors that influence behavior (14). Thus, knowledge alone does not always mean behavior change.
CRITIQUE 3 – Inducing Psychological Reactance Through Education
As shown in the second critique, education is intended to teach individuals about why it is important to their health to use ITNs, but health education campaigns have not proven to be very productive in changing behavior. Whitehead and Russell reiterate the difficulty found of changing behavior in the Kenya randomized controlled trial by stating, “‘Fully’ informing individuals about health and health risk does not necessarily lead to a change in behavior” (14). In fact, sometimes it induces the exact opposite of what is intended, which in this case would motivate individuals to not use ITNs (14). Evidence that health education can sometimes be counterproductive is explained by the Theory of Psychological Reactance. This theory was developed by Jack W. Brehm in the 1960s and has been supported by a number of empirical studies, particularly those related to health behavior (15). This theory suggests that when someone is told what to do, the individual perceives a threat or reduction in their freedom, and will act in a way to restore that freedom, often doing the opposite of what was told to them (15). To explain in more detail, Brehm (16) states there are four elements fundamental to reactance theory: 1) freedom, 2) threat to freedom, 3) reactance, and 4) restoration of freedom (15). Individuals first have a perceived sense of freedom. In response to a stimulus, such as an authoritative voice, individual’s feel this freedom is threatened. Individual’s then react to the threat and are motivated to act in order to restore the freedom (17). While reactance can take many effects, often the result is a boomerang effect, in which the individual will engage in the behavior related to the challenge of freedom (18). For example, if a child is told not to eat a piece of candy, they will feel their freedom threatened and will want to eat that piece of candy to restore their sense of freedom. Education campaigns and programs are a type of social influence that often induce reactance and prompt freedom-restoring responses leading to rejection of the message, resulting in ineffective persuasion to change behavior(17).
Psychological reactance theory may explain why some individuals do not use ITNs. When people are told to use ITNs, particularly when the source of the information are individuals from outside of the cultures of the individuals being taught, it is likely that a boomerang effect may occur. People value freedom and control and telling someone it is imperative that they sleep under ITNs violates these values by seemingly challenging their freedom to choose how they sleep and how they take care of their own families. By someone telling individuals to use ITNs at night, it is likely they feel these freedoms threatened, and in response, they may refuse to use the ITNs as a means of gaining back this challenged freedom, thus ignoring the rationale of the education campaign. RBM’s educational programs may therefore be causing individuals to not use the ITNs, by threatening their freedom through the intent of instruction – the opposite of RBM’s goals.
Proposal 1 – Market ITN Use, Not Just Ownership
As this analysis has delineated, RBM has focused on increasing uptake of ITNs through inducing demand and encouraging their use through education. But as has been shown, ownership of a net and education do not necessarily lead to the behavior of using ITNs. Instead on inducing demand of ownership of ITNs and focusing on individuals’ rational, cognitive-decision making through education about malaria and ITNs, RBM could include in their GMAP, direct marketing of ITN use. Rather than inducing demand of the product, RBM would be marketing a behavior – the use of ITNs. Using principles in marketing theory, RBM could greatly revamp their action plan to reach many more people in numbers and reach them at heart - a much greater motivator than knowledge.
Marketing is defined as “human activity directed at satisfying needs and wants through exchange processes” (19). RBM wants their beneficiaries to benefit from the use of the ITNs they provide. However, RBM needs to consider the wants and needs of these beneficiaries. Marketing theory starts by looking at the wants and needs of individuals’, and then packages and promotes products for exchange based on these values (20). Effective marketers do not try to make the target audience accept their values and beliefs, as RBM has done, but rather start from the standpoint of the audience’s wants and needs, values, and perceptions (21). While RBM claims methods of social marketing, it really is only focusing on the exchange part, ignoring the wants and needs of their consumer. Marketing theory suggests that rather than telling people to use ITNs because the educator thinks it is the right thing to do, coming at ITN use from the audience’s point of view can be much more effective.
As RBM’s focus is a global initiative, there are many beneficiaries from various cultures and subpopulations. While some values tend to be universal, such as independence, freedom, control, respect, etc., values tend to vary across subgroups and they can vary across cultures. Marketers do not rely on intuition to know what the consumer wants and needs, but rather they perform formative research in order to understand the values, wants, and needs of the target audience (20). Essentially this requires, “getting inside the heads” of consumers (21). Formative research needs to be included in RBM’s marketing approach in order to have an empirical basis for their marketing efforts and marketing campaigns.
Overall, marketing of a health behavior is different from traditional public health paradigms such as HBM and TPB, which tries to “sell” a behavior based on an individual’s desire for health and their rational cognitive processes. While health is generally valued, it is also generally misunderstood by those who possess it, and largely taken for granted. By using marketing theory and formative research in the GMAP, RBM could focus their efforts on the actual wants and needs of their beneficiaries and effectively redefine and packages the behavior of ITN use in a more effective way.
Proposal 2 – Expand on Marketing Theory - Branding ITN Use
By using marketing theory as proposed, RBM would be selling the behavior of ITN use based on the core values discovered through formative research. However, RBM needs to extend this marketing approach one step further. After performing formative research, marketers repackage, reposition, and reframe their product in a way that shows the target audience that they will benefit from its consumption in a way that reinforces their core values (20). One of the primary modes of presenting a product in this manner is through branding. Branding is a concept used by marketers that associates a product or service being sold with something the brand represents (22). In public health, generally it is a branded message to partake in a health behavior, rather than a symbol of a product (23). A branded message is a “strategic communication designed to elicit a particular set of beneficial associations in the mind of the consumer which become linked to the brand’s identity, providing…a sense of value (24). The best brands represent the core values, wants, and needs discovered through formative research (20).
Public health has co-opting branding as a means of marketing healthy behavior. Unlike commercial branding, public health does not intend to brand products or services. Alternatively a behavior is branded which leads to a benefit from engaging in or refraining from a behavior and its consequences. Whereas the HBM and TPB associate the outcome of “health”, branding a public health behavior will associate the outcome with a core value (22). These branded behaviors can then be “sold” as embodying a “lifestyle” of the healthy behavior, which will become part of the identity of those who partake in the branded behavior, such as the use of ITNs (23). Branding of a health behavior is often more effective than educating about a health behavior. This is because the purpose of healthy behavior is often abstract, complex, and it is difficult to appropriately convey the benefits to the target audience (23). In addition, healthy behaviors often do not have quick or noticeable results, thus branding a behavior with a value can be much more effective (23). In the case of ITNs, it may be difficult for people to use ITNs on a hot night, when comfort is their immediate concern, rather than use them for the purpose of preventing a disease of which they have never experienced and which they may not contract. The benefit of a net-free bed may be seen as much better in the immediate moment then preventing an abstract event such as malaria. However, by branding ITN-use, the owner of a net may partake in the use of the net because they associate the use with an “identity” and core value. Branding, therefore, can create a value-based association with the behavior that is more likely to induce “compliance” than an abstract “health” concept.
There are three basic concepts surrounding a brand: a) building a relationship b) adding value and c) beneficial exchange (22). First, the public health brand, in this case ITN use, must build a relationship with its beneficiaries to encourage the adoption of the health behavior. This is often through the development of positive associations offering a “brand promise”. The brand promise is something of value that the consumer of the health behavior will acquire if they respond to the proposed “call to action” (22). Building a relationship is essentially making the brand “promise” understood to the beneficiaries. In the case of ITNs, the call to action would be for people in malaria endemic areas to use ITNs each night for themselves and their family members. Thus, RBM would need to link this “call to action” with a “promise” that their brand represents. The promise must be something appealing to consumers, such as the values of the target audience discovered through formative research.
There are three persuasive mechanisms for making the brand appealing to consumers of the health behavior based on these values which include: a) aspiration to an appealing ideal, b) modeling of a socially desirable good, or c) association with idealized imagery (22). These mechanisms are related to the second aspect of branding: adding value. This is making explicit the relationship between the brand and the value it is associated with, linking the brand with the values, needs, and wants of the consumers. An association with an aspiration of an appealing ideal is that the brand may represent beauty, status, sex appeal, or power (22). Some examples would be “ITN use gives you control” or “ITN use is a sign of status”, thus linking the behavior with other “social goods”, though this “value” may not be directly related to the actual utility of the ITNs.
The third aspect of branding is providing a beneficial exchange. This is what the individuals actually receive from the adoption of the behavior and is generally based on the added value and the brand promise. An important factor in this aspect is the development of trust that the individual will gain the promise of status, beauty, or power, by performing the desired behavior (22). While education campaigns might use scare tactics such as teaching individuals about the biology of malaria and how it can cause morbidity and mortality, building a trusting branding relationship for promoting the use of ITNs would work much better, thus creating a positive approach. An example that RBM partners promoting ITNs could use may be, “Wrapping your family’s beds with ITNs each night makes you an excellent mother,” or “It’s sexy to use an ITN,” or “ITNs – only for high-society.” Positive associations help build trust and will induce the brand to be associated with positive social norms. As Dan Ariely suggests, “There are social rewards that strongly motivate behavior – and one of the least used…is the encouragement of social rewards and reputation,” (10). By building associations between the public health “brand” of ITN use and social values and rewards, individuals are much more likely to want to participate in the behavior in order to gain these social rewards if they understand the association of the promise and trust that the behavior will result in this reward.
Proposal 3 – Use Psychological Reactance To Roll Back Malaria– Mitigating Reactance and the Brand-Value of Freedom
While the third critique of RBM’s GMAP showed how psychological reactance could induce non-compliance with ITN use, it is possible for RBM campaigns through branding to a) mitigate psychological reactance, and b) use psychological reactance in their favor to promote ITN use in branding.
Although there is a compelling amount of empirical evidence to support psychological reactance, attempts at social influence does not always reduce compliance (16). Some studies have evaluated factors that do not decrease compliance, despite attempts at social influence that would likely induce psychological reactance. One fact that has been empirically shown to reduce psychological reactance is introducing similarity in the source of the influence. Paul J. Silvia performed a study evaluating how similarity may overcome the resistance to persuasion (25). He showed that having the message of persuasion coming from someone who is similar to the recipient in certain characteristics, such as age or gender, can increase the positive force by increasing liking and decrease the negative force by decreasing perceptions of threat, both contributing to decreased psychological reactance (24). Based on this factor, branded messages from RBM about the use of ITNs to its beneficiaries can decrease the amount of psychological reactance by delivering them from someone similar to the beneficiaries. This means that any educational campaign or advertisements involved in the branding of ITN use should come from people who are similar to the target audience. For example, if RBM partners were targeting increased use of ITNs to mothers, they would associate the brand with values of the mothers of this community, and could decrease psychological reactance by having the message come from a mother in the community and culture.
Rather than reducing psychological reactance, RBM could actually use psychological reactance to their benefit and even combine it with their brand. Because psychological reactance often induces a boomerang effect, it is possible to induce psychological reactance as a means of promoting a desired behavior by challenging individual’s freedoms in the opposite manner. As described, psychological reactance is induced as a reaction to an influence that results in a perceived threat to freedom, causing the individual to perform the opposite behavior from what was asked. One way that RBM could use this to their advantage is by focusing on the value of freedom in their brand. This would first mean the overall association between the brand and the behavior of using an ITN would be the value of freedom. The ITN brand would thus need to “promise” that using the ITN would lead to freedom. However, first the target audience would need to believe there is a threat to their freedom, which would require support from the brand. One way in which RBM could do this is to present support in the advertisements of the ITN brand that the mosquito and malaria are a threat to their freedom, and that following the “cue to action” to use ITN nets would restore this freedom. Thus, RBM could use techniques of marketing theory, branding, and psychological reactance all to promote an increase in ITN use.
Roll Out Behavior Change
Overall, RBM has done an incredible job at getting nets to those who need them. However, as was shown, owning a net does not necessarily lead to use of the net – what is ultimately necessary to prevent malaria. By changing their tactics from focusing on demand, using assumptions of TPB and the HBM, and potentially inducing psychological reactance through education programs, RBM could change minimal behavior influence into wide scale use of ITNs. Marketing theory and branding are impressive tools that have been greatly refined by the commercial sector. By co-opting these methods into public health behavior change, and utilizing psychological reactance in their favor, RBM could reach a lot more people on a much more influential level – by eliciting the core values of individuals, a much greater motivator of behavior.








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More African Americans Dying from Cancer: A Critique and Modification of the Approach to Cancer Prevention in the African American Community

—Brandi Vaughan

Introduction

Cancer is one of the top ten leading causes of death in the United States and has been for a number of years (4). Many technological advances have been made to assist with early diagnosis for cancer by screening patients in order to detect cancer, prevent further stage progression of the disease and to prolong life. These advances include the mammogram which is used to detect breast cancer, the colonoscopy and fecal occult blood test to detect colorectal cancer, and the PSA test to detect prostate cancer. Even with the uncertainty of the accuracy of the PSA test because of high false-positive rates, all of these screening tests have been successful in reducing the prevalence of cancer cases in this country (4,5). Interestingly enough, these cancers, as well as lung cancer, are the top leading causes of cancer deaths in both African American men and women (4).

The incidence of all sites of cancer in African Americans had substantially increased during the 1990s and significantly decreased between the years of 2000 and 2006 (5,6). This has significantly narrowed the gap between the incidence of cancer in Whites and African Americans. However, the major concern regarding African Americans is based on the mortality and survival rates of this ethnic group compared to Whites. According to the American Cancer Society, the survival rate of African Americans compared to whites in the four cancer types at all stages respectively are: 77% vs. 90% for female breast, 55% vs. 65% for colon and rectum, 12% vs. 16% for lung and bronchus, and 95% vs. 100% for prostate cancers(5,6). The mortality rate of African American men and women with cancer is 313.0 and 186.7 per 100,000 respectively, which is higher compared to those of their white counterparts which is 230.7 and 159.2 per 100,000(5,6).

Some studies indicate that the reason for the high mortality rate in African Americans is due to the lack of taking preventive measures by getting the appropriate screening tests on a regular basis when prompted by their physicians(3,7). In this case, the disease is detected later when the cancer is no longer local and has progressed in stage. This has a direct effect on how responsive a patient will be to treatment, and how likely they are to survive. As a result, interventions were designed to reduce the incidence of cancer in the African American community. These interventions had two main focuses, exposure to information and education.

By using the Health Belief Model in conjunction with other models, they exposed African Americans to information about the mammogram, PSA and colonoscopy tests in hopes of increasing the number of those that understood the importance of these tests.(1,2) For example, The Targeting Cancer in Blacks (TCiB) intervention, conducted as early as 1994 to 1996 in Georgia and Tennessee, intervened by means of Historically Black College and University medical schools (Morehouse School of Medicine and Meharry Medical College) , churches and other institutions. These community institutions were used to spread the message of the importance of regular screenings and living a healthy lifestyle (1). Another intervention that was done from 2001 to 2003 was the randomized prostate cancer intervention conducted by Georgetown University. It was done in conjunction with the National Cancer Institute on the effects of print and video exposure to information on the PSA test to African Americans (2). Both interventions had the same approach which would allow African Americans to take the information and independently decide whether they should get screened regularly in the future (2).

Based on the data provided by the Surveillance Epidemiology End Results (SEER) and the American Cancer Society, the cancer mortality rate and survival rate of the African American population are a cause for concern. These rates not only magnify the problem, but they also reflect the effectiveness of the overall approach to the problem. This paper will critique the approach to cancer prevention in the African American population. It will present the existing problems in the interventions of the past and what changes can be made to future interventions of the approach to eliminate racial disparity of cancer mortality and survival with regards to the African American community.

A Critique on the Approach to Cancer Prevention in African Americans

There are three main setbacks to the previous interventions designed to promote cancer prevention in the African American population that will be discussed. The first one is that these interventions have relied on the Health Belief Model to assure that people will get screened. Secondly, the previous interventions do not significantly take social, cultural and environmental factors with regards to the African American community into account. Lastly, these interventions have not intervened past education nor do they allow the community institutions to get involved past education on the screening tests.

Previous Interventions heavily rely on the Health Belief Model.

The previous interventions that have been designed to reduce the incidence of cancer in African Americans are flawed because they have consciously used the Health Belief Model which implies that human behavior is rational. Furthermore, it assumes that if information is provided to people, they will automatically weigh the perceived benefits and barriers which will prompt them to act accordingly to prevent disease. The TCiB intervention purposely used this model with the assumption that it would help to promote unity and a community effort by promoting self efficacy and developing “cues of action” (1). This was attempted by displaying messages that would cause unity such as, “Get a pap smear once a year” and “Don’t wait too late, check the prostate”(1). This would then prompt intention which would lead to everyone acting as the intervention expected.

When weighing the perceived benefits, The Health Belief Model also takes the perceived susceptibility and perceived severity into account. This indicates that a person will consider how likely they are to get a disease (susceptibility) and how bad it would be if they got the disease (severity) which leads a person to act. Evidently, this model assumes that individuals are able to make a knowledgeable decision to act in order to prevent themselves from getting a disease. This is suggested in the prostate cancer screening intervention. In this intervention African Americans were randomly assigned into three groups (2). Two of the groups were given information about prostate cancer and the PSA test in two forms, one in print and the other as a video. The third group was on a waiting list to set a control (2) The measure of the exposure types was tested based on how many people reported knowing of the information (2).

The complete disregard to test if the exposure had an effect on the number of people that would get screened regularly leads to the assumption that the decision to get screened is dependent on the individual. This interaction is flawed because it only measures the exposure, not the effectiveness of the exposure on the subjects (1,2). Providing people with information suggests that they will weigh the benefits, followed by intention and then acting on preventing disease by getting screened (1,2). However, this will not necessarily cue them to act as expected because it depends on how they perceive their susceptibility to getting prostate cancer and how severe it would be for them. In addition, there are many factors that could have an effect on a person’s action and prevent them from getting screened such as fear of the screening test or potential diagnosis.

Previous interventions have not paid substantial attention to the social, cultural and environmental factors that exclusively affect the African American community.

The main aspect that is observed when studying different cultural groups is the difference between them and their white counterparts. Clearly there is a difference between these groups in terms of their environment, as well as social and cultural standards which are taken into consideration when intervening with other ethnic groups. Earlier interventions that target cancer prevention in African Americans have completely overlooked these differences which have affected their overall approach and have proven why they are flawed.

When intervening with African Americans, previous interventions recognized that there is a necessity for cultural sensitivity (1) and that community involvement has a positive effect on administering information to this ethnic group (1). However, these interventions fail to discuss in detail what other differences exist between African Americans and Whites and how to overcome those differences to intervene effectively in the future. They accounted for educational differences by producing reading material from less than 6^th grade to 8^th grade levels (1) assuming that some African Americans aren’t on the same educational level as their white counterparts. They also understood the importance of getting community institutions involved and presented visual and culturally accurate print and video material in attempt to gain acceptance of the intervention’s message (2).

The incidence of cancer in African Americans was at its highest in 1993 at 567.6 per 100,000 people compared to 496.6 per 100,000 in Whites (6). During this period, an insufficient amount of attention was paid to social, cultural and environmental factors when promoting screening tests to African Americans. It is only recently, particularly in the past couple of months that researchers are beginning to acknowledge these other factors that have affected the incidence and mortality rate of African Americans with cancer (3,7).

Recent studies have shown that there are social, cultural and environmental factors that have affected the mortality rate of African Americans. One study reveals that there are cultural factors that affect the prevalence of colorectal screening among the African American population such as medical mistrust, perception of group susceptibility and strong traditional cultural orientation (7). Another study that focuses on African American women with breast cancer suggests that there are external social factors that exist such as lack of access to high quality care and the opportunity to participate in clinical trials (3). Other factors include inadequate mammography screening and difference in tumor characteristics in African American women due to late detection of the disease (3). Presently, it is evident that there are strides being taken to tackle these environmental and external social factors, however, the mortality and survival rates of African Americans with cancer proves that there is still progress to be made.

Previous interventions were discontinued after exposure to information and education.

Since it is noted that recent studies have discussed that social, environmental and cultural factors should be considered when studying the mortality rates of African Americans with cancer, it can be predicted that future interventions will be extensive. However, previous interventions were not extensive in nature. These interventions were implemented with the preconceived notion that education and exposure to information were sufficient to increase incidence of appropriate screening in the African American population.

As previously stated, the interventions of the past focused on educating African Americans about the importance of regular screening. They incorporated community institutions to educate them on the importance of getting screened, and they introduced print materials such as flyers, posters and brochures (1), as well as video material (2). Educational lectures and workshops took place at different community events, public health clinics, small businesses and churches (1). The measurement point of exposure to the information by means of educational workshops and different media materials marked the end of these interventions.

Studies suggest that they were unable to determine the effects of education and the community outreach on the mortality rate of African Americans with cancer because their interventions only involved a cross-sectional survey (1,2,3,7) This type of study examines the relationship between the disease of interest and other existing variables that have affected a population at a specific point in time (10). In this case, previous interventions conducted by cross-sectional survey provided substantial information on different exposures which measured knowledge of the screening tests. However, it prevents follow up with subjects over a course of time (10). This did not permit the interventions to study how their efforts affected the African American population because they did not track the incidence over a given time period. Therefore, the approach to this problem is flawed and more appropriate measures need to be taken to assure that the efforts of the intervention are measurable.

“Yes We Can”: the introduction of social sciences to cancer prevention in African Americans

Given the fact that the majority of previous interventions conducted to prevent cancer in African Americans are based on individual health models, the proposed approach will be unique due to implementation of social sciences models. This approach will be explained and will show how the introduction of social science models can positively affect the cancer mortality and survival rates in the African American population.

The Proposed Approach

This approach will maintain the promotion of regular screening and will continue to inform African American men and women of the benefits of getting mammograms, PSA tests and colonoscopies on a regular basis. It is important that screening continues and increases in the African American population in order to decrease the mortality rate (3,7). In addition to the screening promotion, this approach will continue to use community institutions as channels to emit the message (1). Lastly, this approach will implement the advertising theory as well as the psychological reactance theory to motivate people to live a healthy lifestyle by getting screened.

The proposed approach will implement a community effort to increase the incidence of screening tests with the help of community institutions across the nation. Churches, black-owned businesses, hospitals, clinics and Historically Black Colleges and Universities (HBCUs) will be the institutions that will collaborate in order to host weekly community events. These events will provide educational workshops on the four cancers that are the main causes of cancer death in the African American population: breast, prostate, colorectal and lung cancers. They can also provide free screening tests, informational and Q&A sessions with African American physicians who would discuss the issues surrounding the cancer mortality rate among African Americans.

This approach will also implement the psychological reactance theory by including prominent figures in the African American community who can help in the efforts to eliminate the racial disparity. This theory suggests that messages are more accepted when they are given from someone of high similarity (11). The community events present the opportunity for African American politicians, physicians, nutritionists, nurses, community organizers, and Greek social organizations to get involved in the efforts. This would also mark the inclusion of African American celebrities, Colin Powell, Richard Roundtree, Ruby Dee and Marsha Hunt who survived cancer by means of participating in the community events and the advertising theory. In this case, the advertisement will not be selling health. Instead it will sell the core values that are associated with a happy and healthy life such as family, unity and freedom.

Support for the Proposed Approach

The Proposed Approach assumes that others’ opinions can affect human behavior.

The proposed approach does not rely on the Health Belief Model which assumes that human behavior is rational and dependent on the individual. This approach utilizes the psychological reactance theory to demonstrate how a group of people can be motivated to act in response to a message that causes a threat to one’s freedom (11). It administers the message by means of the communicator. The presence of the communicator will determine how the group will act based on similarities between the communicators and the members of the group (11). This assumes that human behavior is irrational and is dependent on other factors.

In this approach, the communicators are the prominent figures of the African American community which include cancer survivors. The male survivors include the former Secretary of the State, Colin Powell, who was treated for prostate cancer in 2003, and the actor Richard Roundtree who was diagnosed with breast cancer in 1993 (8,9). The female survivors include the actress Ruby Dee who was diagnosed with breast cancer in 1974 and former singer Marsha Hunt who was diagnosed with breast cancer in 2004 (8,9) Under the psychological reactance theory, these communicators would be able to present a strong threatening message such as, “you will die unless you get screened”. This threatens the groups’ freedom and self control in which people are either prompted to behave in compliance or to not conform (11). However, since the communicators have physical and cultural similarities with the group, they are more likely to comply to the expected action and get screened regularly.

The Proposed Approach uses the Advertising Theory to reinforce core values

American core values are very important to the people of this country because they are one of the factors that separate the US from the rest of the world. Many of these core values such as love, family, unity, hope, and freedom are universal across the nation. The advertising theory is regularly used to persuade people to like a product or it used to change their attitude about a product in order to make them purchase it.(12) The proposed approach would use this model to persuade African Americans to get screening on a regular basis by showing images that represent these values. This is done through means of printed advertisements and television commercials.

The phrase “Yes We Can” was borrowed from the Barack Obama campaign for the proposed approach for this purpose. The inauguration of the first African American president in this country and the pride that was felt among the African American community was immense. President Obama has been in office since January, and there are still people, including African Americans that continue to proudly wear the “Yes We Can” apparel. If African Americans were shown a commercial that showed the accomplishments that African Americans made in this country that ranged from freedom to President Obama’s inauguration, making a connection to screening methods would persuade African Americans to get screening because they are connected to that experience and screening would be connected to a sense of pride in making a positive difference in the community.

The Proposed Approach accounts for environmental, social and cultural factors that have affected cancer mortality in the African American population.

Aside from the theories and models that are used, the main aspect that separates this approach from the previous approach to reduce cancer mortality in the African American population is the consideration for environmental, social and cultural factors. This approach has accounted for these factors by implementing community efforts by introducing education, access to services and strong clinical and community leaders in the African American community.

This approach takes a few steps ahead of the previous interventions which discontinued after education. In addition, by involving African American celebrities who survived the disease and are currently in remission, it is evident to the community that the disease does not discriminate and it is possible to obtain. However, with getting the proper screening and following up with treatment if diagnosed with the disease, it is possible to live a healthy life and to live longer than anticipated.

Conclusion

The mortality rate in African Americans with cancer is likely to continue to rise if the lack of attention to the different external factors that affect access and quality of care in this population are not taken into account. While I initially found interventions that only focused only on the education factor, it appears that there are upcoming interventions that will begin to take these factors into account. This provides a very promising future for the African American community, and hopefully future interventions will reduce and eventually eliminate the racial disparity that exists.

REFERENCES

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D. Schwartz, Jon F. Kerner, and Chikarlo Leak

Educating African American Men about the Prostate Cancer Screening Dilemma: A Randomized Intervention

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7. Purnell, Jason Q., Mira L. Katz, Barbara L. Andersen, Oxana Palesh, Colmar Figueroa-Moseley, Pascal Jean-Pierre, and Nancy Bennett. "Social and cultural factors are related to perceived colorectal cancer screening benefits and intentions in African Americans." Journal of Behavioral Medicine (2009). SpringerLink. Web.

8. "Touched by Breast Cancer - AOL Black Voices." Black Entertainment and Sports, African American News, Culture, and Community - AOL Black Voices. Web. 10 Dec. 2009. .

9. "Celebrities With Cancer." About Cancer. Web. 10 Dec. 2009. .

10. Aschengrau, Ann, and George R. Essentials of Epidemiology in Public Health. New York: Jones & Bartlett, 2003. Print.

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12. "Advertising theory: How to get people to think, feel and take action." Creative advertising ideas, techniques, example ads and workshops. Web. 10 Dec. 2009. .

Health Belief Model and HIV Prevention Programs: A Failure to reach Black Men Who Have Sex With Men

-- Beatrice C. Martin

Introduction

HIV/AIDS has become one of the major public health problems during the twentieth century. Because of the high Incidence of HIV infection in the gay community, much effort to reduce risky sexual behaviors has been targeted at gay men. Nearly half of the people living with HIV in the United States are MSM (10). Moreover, MSM are the only group in the United States in which HIV infection is steadily increasing every year, they account for more than half of new HIV infection each year (10). Public health intervention efforts to educate gay men about safer sex practices have been proven quite successful at the beginning. Gay men reported to have been engaging in sex with fewer partners and have been using condoms more frequently during sex (8).

Despite many public health HIV prevention programs targeting the gay community, there is a concern of the reemergence of the epidemic. Evidence suggests that although rates of new HIV infections declined between the years of mid- 1980 to mid-1990, rates of HIV infections are starting to increase (5). Moreover, black MSM are disproportionally hit by the epidemic compared to any other race and ethnicity. According to Wolitski et al., in 1999 the AIDS incidence rates among African American were more than five times that of the white MSM. Recent trends indicate that black MSM are at greater risk of contracting HIV infection compared to white MSM. Between the years of 1990 and 1995, black MSM AIDS cases increased among African American MSM by 45%, while AIDS cases decreased by 2% among white MSM(5).

One theory widely used to guide HIV prevention interventions is the health belief model. The health belief model is applied in the development of prevention programs to modify health behavior. It elucidates the relationship between individual health beliefs associated with a disease and the likelihood of engaging in preventive health actions (1). A number of studies of AIDS-preventive behavior have been based, in part, on the health belief model (1). The main components of the health belief model to HIV prevention are as follow: AIDS preventive behavior is a function of perceived vulnerability to HIV infection, perceived severity of HIV infection, perceived costs and benefits of HIV/AIDS preventive behavior, and cues to action (1) and self- efficacy, which is defined as the conviction that one can successfully execute the behavior required to produce the outcomes (12). HIV-preventive programs based on theoretical frameworks like the health belief model has not proved to be effective among the black MSM as the rise of HIV incidence rate is higher than the white MSM population. The efforts of HIV risk reduction strategies were not effective in decreasing the rate of HIV infection among the African American Population (11). The health belief model is an individual-focused model that has limitations in addressing the historical, social context of black MSM living in African American communities.

Failure to address the historical context of Black MSM as African Americans in the country

A limitation of the health belief model is the implication that people exist in similar cultures and have similar degrees of control over their environment (12). As an individual -focused model, the health belief model fails to address the historical and social context of HIV/AIDS among the black MSM communities. The experience of African American in this country is unique due to their history of racism and slavery. A lack of mistrust in the government makes it more challenging for public health messages to effectively reach African Americans. According to Bogart et al. article, a handful of studies shows evidence that a significant group of African American hold conspiracy beliefs that HIV/AIDS is a form of black genocide. Hereck and Glunt conducted a national telephone survey in which they found that two third of blacks (67%) agreed that the government is not telling the truth about AIDS, and another national telephone survey conducted by Hereck and Capotino found that twenty percent of black Americans believe in the statement that the government in using AIDS as a way of killing minority groups (7). The revelation of the Tuskegee Syphilis study confirms long held beliefs among the black communities that the government should not be trusted. After the study has been exposed, charges surfaced that the experiment was part of a governmental plot to exterminate black people (3). Thomas and Quinn argued that the legacy of this experiment with its failure to educate the study participants and treat them adequately, laid the path for today’s pervasive sense of the black distrust of public health authorities (3). The belief of genocide and the distrust of the health authorities are foundation for opposition to many strategies that will directly reduce transmission of HIV. Intervention programs framed by the health belief model to modify the individual’s health behavior will not be effective if the targeted black MSM hold beliefs of genocide and if they mistrust health authorities. They will not take into consideration information and messages they receive about AIDS. This mistrust will get in the way of AIDS education strategies that use theoretical framework like the health belief model to target black MSM within the black communities.

Failure to approach Homophobia in black communities

The HBM model views the individual as devoid of emotion and has the capacity think rationally (1). However, the interaction of the individual and the social environment may bring about situational and emotional difficulties that affect HIV risk behaviors (1). In the United States, HIV- related stigma and discrimination are closely related to negative thoughts surrounding homosexuality (9). African American communities often condemn homosexual behavior, and being homosexual is seen as weakness and embarrassment. As a result, African American men who have sex with men are more “closeted” than white men who have sex with men (9). Research shows that African American gay men and MSM are likely to experience prejudice, discrimination and even threats of physical violence based both on their status as gay and MSM in the black community (9). Therefore, Black MSM who fear discriminations and who do not want to be perceived as weak homosexuals in their community hide their sexual orientation. They stay “in the closet” in order to avoid prejudice and threats of physical violence. They tend to identify themselves as heterosexuals, while secretly having sex with other men. Black MSM who hide their sexual orientation are more likely to engage in risky sexual behavior.

Fear of being perceived as gay in their communities may cause Black MSM to avoid expressing any concerns about the HIV epidemic and discussing condom use. This group is less exposed to HIV prevention messages targeting the gay community. They are not aware of the risk factors associated to HIV transmission and how they can reduce their risk of getting infecting. Relative to white men who have sex with men, African American men has less accurate knowledge about HIV risk reduction steps (6). Moreover, AIDS education campaigns targeting the gay community have not successfully reached black MSM who are not open about their sexual orientation (6).

Failure to approach poverty and HIV risk behavior

From an ecological perspective, understanding HIV risk behaviors means understanding how the environment shapes the choices and opportunities available to the individual (12.). The rational presumption that individuals have resources to make preventive HIV risk decisions and that they have control over their environment to change their risk behavior can be challenged. The health belief model does not address the interaction of individuals and their environment. Individuals living in poor neighborhoods have limited resources and are mostly under stressed. When African American men have a prolonged exposure to stress, it may result in individuals denying the threats of a stressful situation or refusing to think about it. African American males denying their risk of contracting HIV may engage in higher risky sexual behavior; they may also deny the realty of HIV/AIDS in the African American community (12). Black MSM living in poor neighborhoods are more likely to have sex with men in exchange for money or drugs. A study found that homosexual and bisexual men with low income who had been paid to have sex with men are less likely to use condoms (11).

An effective approach to HIV prevention among black MSM: Community-Level Intervention.

Research potentially helpful to African Americans has been severely limited because of the exclusion or underrepresentation of this specific group in prevention intervention research or the lack of focus on African Americans at higher risk for HIV infection like the MSM (12). Effective intervention programs to HIV prevention among black MSM should take into account the cultural, historical and socio-economic factors of that group. Public health efforts to change black MSM sexual risky behaviors should promote positive views and acceptance of homosexuality among the black community. Moreover, the messages of HIV prevention programs that target black MSM population should be culturally sensitive in order to successfully reach that community.

Community- level interventions to HIV prevention can be an effective approach to decrease HIV-risk behavior among the black MSM community. Community-level interventions are those that target communities often defined by sex, geography, sexual orientation, risky behaviors and sexual orientations rather than a specific individual. This intervention includes the involvement of community members in the actual design and delivery of the intervention. Community-level intervention aims to change community norms about high risk behaviors. An important aspect of this intervention is the involvement of the target population in formal or informal activities, programs, group discussions, to come up with planned improvement and change in community life, resources(4).

This intervention approach to HIV prevention among black MSM can be effective in addressing the experience of African Americans in this country with discrimination, racism and the mistrust that they hold against public health professionals. The intervention should first choose one or more black MSM leaders within a black community. The involvement of black gay men in the design and study of the intervention may have more positive response to HIV prevention messages targeting black MSM. Black MSM may listen and trust one of their peer leaders rather that a white counterpart. Kelley and colleagues recruited opinion leaders from communities of gay men, trained them in HIV prevention messages and message delivery, and asked them to take these messages back to their communities. Controlled studies showed that these interventions changed community norms, and self-reported risky sexual behaviors among these communities (6). CDC study’s findings provide evidence that HIV prevention endorsement messages, modeled and delivered in outreach fashions by members belonging to the same social group can reduce risk behavior levels in community population (2).

Community-level intervention is mostly founded in the effort to influence individual behavior by changing the social context of communities. In this view, widespread and enduring reduction in risky sexual behaviors among black MSM will not be achieved without new norms governing condoms, and an increased tolerance of homosexuality by African American communities and organizations (4). With an increased acceptance of homosexuality in the black community and changing community norms about HIV-related stigma, black MSM may be able to be open about their sexuality and seek HIV prevention messages. An important factor of the community level in reducing risk behavior among black MSM is the involvement of black gay men members who are conveying the message of condom and promotion of safe sex within their communities. Social theory tells us that peers are important behavioral role models who can establish and redefine population norms, including those of condom use (2). Unemployment may encourage some black MSM to have sex in exchange for money. This situation increases risk behavior because this group has no control over the use of condoms. Community-level interventions find the need for communities to pursue economic and political development, to help men in their community find jobs (4). Trained MSM leaders or peers can work in African American neighborhoods to address common problems such as unemployment and drug abuse.

Conclusion

As shown, the health belief model approach to HIV prevention among black MSM fails to address the social, economic and historical context in which individuals interact. Moreover it assumes that individuals control over their behavior. However, individuals with low social economic status have no control over choosing to use condoms if they engage in sex for money. The community-level approach to HIV prevention addresses the social context of individuals by trying to change the community norms and decreasing homophobia in the black community. Community- level HIV prevention interventions must grow from and be owned by the target population one wants to reach in order to be successful.

References

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2. Kelley AK. Community-Level Interventions Are needed to prevent New HIV infections. American Journal of Public Health 1999; 89: 299-300.

3. Vanessa NG. Under The Shadow of Tuskegee: African American and Health Care. American Journal of Public Health 1997; 87: 1773-1777.

4. Kraft JM, Beeker C, Stokes J et al. Finding The “Community” in Community-Level HIV/AIDS Intervention: Formative Research With Young African American Men having Sex with Men. Health Education and Behavior 2000; 27: 430-441.

5. Wolitski RJ, Valdiserri RO, Denning P, Levine W. Are We headed for a Resurgence of the HIV Epidemic Among Men who Have Sex with Men? American Journal of Public Health 2001; 91:883-885.

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7. Bogart LM, Bird ST. Exploring the Relationship of Conspiracy Beliefs About HIV/AIDS to Sexual Behaviors and Attitudes Among African American Adults. Journal of National medical Association 2003; 95:1057-1065.

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