Social Marketing and HIV Stigma: The Need of Community Help with Marginalized Populations – Nicolas Karr

In 2008, 33.4 million people had a positive HIV status (1). Through out the year, 2.7 million new infections joined the tally and 2 million left because of AIDS-related deaths (1). The infection devastates low-resource populations. Prevention programs intervene to help these populations and provide the resources that could change the tide of infection. Unfortunately, while HIV/AIDS prevention programs provide the tools to fight infection, the populations do not necessarily change their behaviors. Content-rich interventions fall short when the target community does not use the resources.
In a summary analysis and critique of 21 interventions to reduce HIV/AIDS stigma, Brown, Trujillo, and Macintyre stated that HIV/AIDS stigma “undermines public health efforts to combat the epidemic” (2). They found that stigma affects the magnitude of reactions to epidemics and causes violence against infected people (2). Populations affected by stigma might fear societal attitudes and could deny their risk of infection. This denial could lead to inaction and ignoring risk factors; inaction could manifest as not using condoms, not testing for HIV, and not disclosing HIV status (2). Stigma can trigger actions to avoid a loss of a job, health benefits, or social ostracism (2). These actions on the part of the stigmatized could cause harm to themselves and the surrounding population. Acting in fear, marginalized populations experiencing HIV/AIDS stigma could endanger their relationship networks.
Stigma has prevailed throughout generations as an impediment to public health. When confronting disease, stigma causes negative views and reduces access to care. Stigma embeds itself within a population and breeds a culture of fear. In order to reduce infections in high-risk populations, interventions need to address stigma. In a meta-analysis of twenty-four studies, occurring between 2000 and 2007, of people living with HIV/AIDS in North America, Logie and Gadalla found that marginalized populations experienced higher stigma levels (3). Specifically, the researchers found stigma highly associated with low social support, poor physical health, poor mental health, lower income, and younger age (3). Consequently, according to Herek and Capitanio, who looked at behaviors towards people living with HIV/AIDS, stigma causes reduced access to care due to discrimination through violence and exclusion (4).
Marginalized populations endure the most stigma and these misunderstandings lead to low resources, poor funding, and inconsistent interventions and treatments. In order to help these populations the current interventions need to make changes. This paper focuses on three specific sub-populations at high-risk for HIV/AIDS and stigma: young black men, female substance abusers, and young men who have sex with men (MSM). The first section presents critiques on interventions targeted at each group and the second section provides ideas for improvements upon the current interventions. To stop the spread of HIV/AIDS, health interventions need to reach the high-risk, marginalized populations; interventions need to mitigate stigma to facilitate proper care.
Young Black Men: Bearing the Brunt of New Infections
According to the Centers for Disease Control and Prevention (CDC), African-Americans make-up 13% of the U.S. population, but account for 50% of all new HIV/AIDS cases, demonstrating a highly prevalent, yet underserved population (5). Along with high prevalence among the entire population, African-American men continue to acquire more infections than their female counterparts (5). HIV/AIDS prevention programs tend to show effectiveness in controlled settings, but the transfer to the real world has less than promising results.
When developing improvements for a current intervention to target young black men, O’Donnell et al. found that interventions have too many requirements and attrition sets in(6). This issue arises specifically with stigmatized populations who choose to avoid over exposure in HIV/AIDS programs. Dworkin, Pinto, Hunter, Rapkin, & Remien found that research tested the efficacy of prevention programs, but failed to design programs acceptable, affordable, sustainable, and adaptable to the population (7). HIV/AIDS has greatly affected young black men, but interventions have failed to address this issue. In order to reach the population O’Donnell et al. stressed the importance of tailoring the intervention for population penetration (6). The prevention programs fail to address barriers to care; HIVS/AIDS stigma limits accessibility to care and the interventions fail to reach the high-risk population.
O’Donnell et al. noted that a significant level of HIV/AIDS stigma develops from internalized and externalized homophobia (6). This stigma leads young black men to test late or avoid testing at all (6). O’Donnell et al. found that African-American females would seek medical care while young black males, more commonly, self-treat (6). This could explain why interventions fail to reach young black males, due to the medical services involved with HIV/AIDS testing. In addition, issues of stigma related to medical services inhibit access to care. Stigma of medical services among the population interacts with HIV/AIDS stigma and makes seeking care significantly less likely.
In order to overcome these obstacles, interventions need to address these issues of avoiding care. If evaluations of these prevention programs only focus on the efficacy in controlled settings, they fail to deal with issues of adaptability. The population at risk avoids medical services and HIV/AIDS care because of stigma. Until the interventions acknowledge this stigma surrounding the access to care, the programs cannot effectively reach those at high risk for infection.
HIV/AIDS interventions have many flaws, but simple changes in approach can lead to greater success. Evaluations of prevention programs need to address the dynamics within each high-risk population. Without adjustments to target different contexts, interventions cannot reach the populations. As stipulated, population penetration remains an important factor in all HIV/AIDS interventions (6); interventions must change to understand their population or fail in trying to reach them.
Female Substance Abusers: Inequality and Instability
HIV infection might come directly from sharing needles, but injecting and non-injecting drug use has developed as a risk factor for risky sexual behavior, a risk factor for HIV/AIDS. Among female substance abusers, risks for violence and HIV increase. Due to gender-specific inequality and violence, female substance abusers need interventions tailored to their issues.
Interventions of the past failed to address the gender-based issues of substance abusers. Wechsberg found, through a survey of past and present HIV/AIDS interventions for women, that past interventions did not account for low status in the culture and community, low education levels, and high rates of unemployment among female substance abusers (8). These factors significantly stigmatized the population. The interventions never reached the people because they could not access medical services. Beyond low access to health care caused by these factors, the high unemployment rates led the women to sell sex (8). The factors that increased stigma also increased the likelihood of acquiring HIV/AIDS.
With the increased stigma surrounding female substance abusers, the difficulty in reaching them increases. Wechsberg noted that failed interventions did not provide knowledge and personal enhancement training specifically targeted to changing behaviors (8). These behavior specific interventions could change behaviors when issues such as substance abuse, violence, and sexual risk arise (8). Culturally specific interventions targeted at females could improve the success of the programs. Unfortunately, the failed interventions did not acknowledge cultural specificity. The women find themselves without any power to act. The interventions fail to reach women who cannot make the decisions themselves or fear losing social support.
Interventions have low compliance to condom use because the programs ignored community context. In the case of sex worker interventions, Evans and Lambert, through an ethnographical study of HIV/AIDS community interventions, found that their noncompliance stemmed from lack of control over their work and social conditions (9). If prevention programs cannot change the dynamics within high-risk populations, distributing condoms makes no difference.
Evans and Lambert also observed that government policy and bureaucrats often disrupt interventions (9). Interventions unable to adapt to changing political tides must confront possible failure; police raids due to changing political temperaments could easily ruin months or years of community-building (9). Prevention programs must adjust to the changing political, cultural atmosphere in order to succeed.
The dependence the women have on the men controlling their lives continues to impede interventions. Failure to address gender inequality means more unsuccessful prevention programs. In order to aid female substance abusers, interventions need to provide ways to increase access to care. The women need to have feelings of safety and support if they choose to seek medical services. Without stability, predominant stigma and fear prevents access to care.
Young MSM: New Generations Facing Decade Old Problem
Stigma has been an impediment to care for all people living with HIV/AIDS. Among men though, internalized and externalized homophobia has led to fear of negative social consequences (10, 11). Valdiserri noted in his review of HIV/AIDS stigma literature that internalized homophobia led to lower self-esteem and consequently, a reduced sense of self-protection (10). This lack of self-protection leads to higher risk sexual behaviors and increased susceptibility to infection (10). These factors impede public health interventions that provide tools for safer sex, but ignore the inaction by participants.
The stigma surrounding young MSM and HIV/AIDS interact and result in negative self-feelings. According to Valdiserri, young MSM experiencing self-doubt seek validation through multiple partners (10). The environments where these encounters occur also facilitate alcohol and drug use and reduced inhibitions to practicing unsafe sex (9). Interventions fail to address young MSM dealing with negative self-feelings. Prevention programs do not work if the participants assimilate information, but make different choices in the heat of the moment.
Dowshen, Binns, and Garofalo studied the effects of HIV/AIDS stigma on four psychosocial measures among MSM. The measurements included depression, self-esteem, loneliness, and social support (11). They found some correlations between perceived stigma level and psychosocial measures, but due to a small sample size, could not declare significance (11). Among their study participants though, they found a correlation between perceived levels of stigma and discovery of a positive HIV status; both of these measures highest at the beginning and reducing with time (11).
Current interventions targeted at young MSM fail to change behaviors because they do not acknowledge how MSM incorporate stigma into their decisions (10). From sexuality to gender identity to HIV/AIDS, these young men deal with multiple levels of stigma (10). Until current interventions address how MSM deal with all levels of stigma, the ability to change behaviors significantly drops.
Prevention programs fail when they ignore the needs of the population. Many programs plan interventions based on best practice protocol. In the case of people living with HIV/AIDS, the programs focus on distributing prevention tools and education. The ethnographical research of Evans and Lambert found that different dynamics influence the decisions individuals make (9). These dynamics include context, practice, agency, and power (9). The researchers found that intervention evaluations review content and the relationship to the results (9). This traditional critique leads evaluations to base success on effectiveness of distributing project resources; grading the efficacy of interventions based on the number of condoms distributed or the prevention classes taught does not demonstrate the true intervention results.
Many problems dealing with population dynamics develop from transferring intervention models from one context to another. Evans and Lambert found that evaluations of efficacy for HIV/AIDS interventions lead to best practice protocols that ignore the context and dynamics of populations (9). Best practice guidelines fail to account for distinct circumstances of marginalized populations (9).

A New Design: Ideas for Change in HIV/AIDS Interventions
Stigma involves many different issues and they affect all facets of an intervention. However, interventions that deal with stigma can change the behaviors of high-risk populations. Valdiserri states that HIV/AIDS interventions need to empower people about health issues, mobilize communities to solve the health problem, develop policies and plans in support of individual and community health, and conduct research to find innovative solutions to health problems (10). By accomplishing these health services public health can mitigate the effects of stigma and effectively reach populations (10).
Behavioral theory remains an important part of affecting change among HIV/AIDS populations. Interventions that focused only on distributing resources to combat infection need to adjust for population-level behavioral dynamics. In a review of the AIDS Community Demonstration Projects, Yzer, Fishbein, and Hennessy found that behavioral theory plays an important role in designing HIV interventions; theory identifies thoughts and feelings that can determine behaviors (12). The researchers also determined that evaluations of interventions need to measure effects of behavior change associated with the variables the intervention modified (12); evaluations should look at how the intervention changes behaviors based on the targeted variables. This way the evaluation determines how the methods of intervention truly affected the population (12).
In their ethnographic study of community HIV/AIDS interventions, Evans and Lambert found that success developed from peer education, community mobilization, and structural interventions (9). These key points emphasize the importance of involving the target community in the intervention. Community involvement ensures individual empowerment and this leads to behavior changes. Brown, Trujillo, and Macintyre note that many of the successful interventions in developing countries utilized community-based approaches opposed to the individual level approaches employed in the U.S. (2). They speculated that the use of community-based approaches reflects an understanding that confronting stigma involves both collective and individual level action (2).
With these factors in mind, new HIV/AIDS interventions should utilize social marketing campaigns within high-risk communities to find opinion leaders and start programs for peer education, community involvement in promoting prevention techniques, and individual enhancement to mitigate HIV/AIDS stigma. An important focal point involves finding respected community leaders to lessen the fear of stigma. With proper influential leaders among the intervention, the programs can more effectively reach the target population. In the following sections, this paper focuses on specific techniques for intervening with young black men, female substance abusers, and young MSM.
Lessening the Burden of Young Black Men
In developing a new HIV intervention for young black men, O’Donnell et al. found that successful interventions must overcome barriers to disseminating information (6). The researchers also stated that the failure of medical services remains the inability to link young black men with needed medical services (6). Available resources do not translate to effective interventions.
O’Donnell et al. stresses the importance of a community review of program components before implementation of the intervention (6). This step makes sure the community understands the intervention approach and, more importantly, the design fits with community dynamics. The next step in a successful intervention includes social marketing. O’Donnell et al. used the community meetings to identify potential spokespersons that have influence (6). Along with recognizing leaders in the community, the discussions identified people young black men would listen too. The discussions determined peers had the greatest impact (6). Utilizing opinion leaders helped get young black men to seek medical services, but the next step involves reducing the requirements of the screening test. If the men find the screening test invasive, time-consuming, or overly demanding they might avoid testing (6). O’Donnell et al. noted the value of using context-pertinent learning models. The intervention utilized computer-based modules that the men found interesting and engaging. The learning module incorporated videos, games, and an overarching storyline that kept the interest of participants (6). Lastly, O’Donnell et al. stressed the importance of developing individual risk reduction plans. This allotted for population dynamics and allowed the men to voice their concerns (6).
Overall, the intervention proposed by O’Donnell et al. focuses on the effects of social marketing. Without the social marketing element, the men would never reach the screening test, learning module, or individual risk reduction plan. Most importantly, the social marketing approach involved the community. The community discussed each approach and component and aided in the successful implementation of the program.
Providing Stability and Equal Footing for Female Substance Abusers
In situations where a person living with HIV/AIDS has dependency issues, interventions fail to change behaviors. This problem stems from a persons’ inability to give up control, but interventions focus on their unwillingness to change. Resources do not aid those who need stability to utilize prevention methods. HIV/AIDS interventions focusing on female substance abusers need to incorporate personal enhancement programs into their prevention methods.
Commercial sex work, violence, and substance abuse usually intersect and complicate the issue of HIV/AIDS infections. Wechsberg found that interventions incorporating knowledge enhancement and hands-on skills training strategies could change behaviors in this population (8). The intervention needs to focus on empowering the woman to make assertive decisions.
Sex facilitates a main conduit for infection and improved condom use could come from enhanced negotiation skills (8). The women of this marginalized population tend to deal with inequality issues. This inequality leads to contexts with high risk of infection. Wechsberg notes that the ability to empower and enhance negotiation skills increases the likelihood of assertiveness with sex partners (8). The disparate contexts these women live in causes dependency and lack of power. In order for prevention resources to find use, the women need a feeling of stability. Effective enhancement and empowerment interventions could overcome the treatment barriers.
Utilizing community support in these situations could prove difficult. If the women do not have a network connecting them, peer influence might have little effect. With the right approach, communities could develop for these women. Sometimes, the health workers need to think creatively to piece together a network or community. If possible, this social support could improve the chances of behavior change after empowerment and enhancement training strategies.
A New Solution for Young MSM
The stigma surrounding MSM develops from both HIV/AIDS and sexuality. The issues intertwine and result in added fear of negative social consequences. In order to address MSM, interventions need to mitigate the stigma surrounding both HIV/AIDS and sexuality. Valdiserri noted that young MSM might avoid clinicians because of fear of judgment (9). If public health officials expect at-risk men to screen for HIV, they must account for worries of social ostracism. Brown, Trujillo, and Macintyre state that information, counseling, coping skills acquisition, and contact demonstrated effectiveness in interventions (2). The researchers also found that different approaches to coping skills acquisition occurred in several interventions and each showed effectiveness in the specific population (2). This point demonstrates the importance of tailoring the intervention to the community. The prevention program must work with the community to reach the target population.
Brown, Trujillo, and Macintyre present a different concept for interventions: contact. This method involves combating stigma through inducing empathy for people living with HIV/AIDS (2). They saw positive results associated with the contact method, but overall the method failed to provide lasting reductions in stigma overall (2). However, a community-based approach provides a means of utilizing contact (2). The influence of opinion leaders in a community and the use of community discussions on interventions could lead to changing attitudes towards infected people.
As with the other high-risk populations, interventions need to employ the power of the community and social networks. The community can help develop effective programs that target the at-risk populations. In order to affect a difficult to reach group the intervention needs to utilize the community to adapt to the group dynamics. No individual health official understands the community as well as the members.


Conclusion and Discussion
While many factors affect the behaviors of at-risk populations, perceived levels of stigma can predict possible behavior change. The presence of stigma has negative effects on public health interventions and leads people living with HIV/AIDS to avoid health services. Sivaram et al., when looking at social capital and HIV stigma in consideration for HIV/AIDS prevention intervention design, stated that stigma manifests from “social norms that render an attribute or condition inferior or inappropriate” (13). These social norms lead to reactions of fear and perceived threat (13). Under this perceived threat, people living with HIV/AIDS find difficulty in seeking health and medical services.
Beyond perceived threat, Sivaram et al. found situations where clinicians refused care to infected people (13). When an example such as this happens, stigma finds a new hold among the population. Trepidation can cause victims of stigma to avoid health and medical services. This not only makes intervention efforts ineffectual, but also creates a high risk dynamic. Stigma leads people to develop negative self-feelings and these feelings lead people to seek validation. Engaging in high-risk behaviors because of feelings of low self-worth not only puts the individual in danger, but the rest of the population. Sivaram et al. speculates that individuals hesitate to engage in prevention and care-seeking behaviors because they anticipate discrimination and possible violence (13).
HIV/AIDS interventions need to focus on community-level approaches. Most importantly, interventions should involve the community in the development of prevention programs. In this way, the program can identify key community members and opinion leaders. These influential leaders can help adapt the intervention to the group dynamics. Outside of opinion leaders, the community can help develop proper implementation methods for the intervention. Community members understand how the population digests information and ideas; their ideas can help the intervention penetrate the population (6). Key to intervention success, social marketing helps open the door for prevention programs. Without social marketing, the key components of a successful intervention cannot find their audience.
In summary, interventions need to utilize opinion leaders, peer education, enhancement training, and prevention techniques to change behaviors in people living with HIV/AIDS. These techniques help to mitigate stigma among the population and surrounding community. The interventions must involve the community every step of the way to reduce fear of exposure. Stigma exemplifies a real fear of people living with HIV/AIDS and a true deterrent to successful interventions. Prevention programs can reach marginalized populations if confronting stigma becomes a focal point of HIV/AIDS intervention.
References
1. UNAIDS. (2009). AIDS Epidemic Update 2009. UNAIDS. http://www.unaids.org/en/KnowledgeCentre/HIVData/EpiUpdate/EpiUpdArchive/2009/default.asp
2. Brown, L., Trujillo, L., & Macintyre, K. (2008). Interventions to Reduce HIV/AIDS Stigma: What Have We Learned? Horizons Program Tulane University.
3. Logie, C., & Gadalla, T. (2009). Meta-analysis of health and demographic correlates of stigma towards people living with HIV. AIDS Care, 21(6), 742-753.
4. Herek, G.M., & Capitanio, J.P. (1999). AIDS stigma and sexual prejudice. American Behavioral Scientist, 42(7), 1130 – 1147.
5. Centers for Disease Control and Prevention. (2008). HIV/AIDS Surveillance Report, 2006. Atlanta, GA: U.S. Department of Health and Human Services. http://www.cdc.gov/hiv/topics/surveillance/resources/reports/
6. O'Donnell, L., Bonaparte, B., Joseph, H., Agronick, G., Leow, D., Myint-U, A., et al. (2009). Keep It Up: Development Of A Community-Based Health Screening And HIV Prevention Strategy For Reaching Young African American Men. AIDS Education & Prevention, 21(4), 299-313.
7. Dworkin, S., Pinto, R., Hunter, J., Rapkin, B., & Remien, R. (2008). Keeping the Spirit of Community Partnerships Alive in the Scale Up of HIV/AIDS Prevention: Critical Reflections on the Roll Out of DEBI (Diffusion of Effective Behavioral Interventions). American Journal of Community Psychology, 42(1/2), 51-59.
8. Wechsberg, W. (2009). Adapting HIV Interventions For Women Substance Abusers In Internationalsettings: Lessons For The Future. Journal of Drug Issues, 39(1), 237-243.
9. Evans, C., & Lambert, H. (2008). Implementing community interventions for HIV prevention: Insights from project ethnography. Social Science & Medicine, 66(2), 467-478.
10. Valdiserri, R.O. (2002). HIV/AIDS Stigma: An Impediment to Public Health. American Journal of Public Health, 92(3), 341-342.
11. Dowshen, N., Binns, H., & Garofalo, R. (2009). Experiences of HIV-Related Stigma Among Young Men Who Have Sex with Men. AIDS Patient Care & STDs, 23(5), 371-376.
12. Yzer, M., Fishbein, M., & Hennessy, M. (2008). HIV interventions affect behavior indirectly: results from the AIDS Community Demonstration Projects. AIDS Care, 20(4), 456-461.
13. Sivaram, S., Zelaya, C., Srikrishnan, A., Latkin, C., Go, V., Solomon, S., et al. (2009). Associations Between Social Capital And HIV Stigma In Chennai, India: Considerations For Prevention Intervention Design. Aids Education & Prevention, 21(3), 233-250.

Oversimplification of a Complex Problem : A Critique of the Boston Public Health Commission’s New SexED Campaign

I. Introduction:
There are over two dozen infections and diseases that can be transmitted through sexual contact. (1) In the United States there are approximately 65 million people with one or more viral sexually transmitted infections (STI) and there are approximately 19 million new cases of STIs every year.(1,2) There are 56,000 new HIV infections each year and currently 1-1.2 million people in the United States live with HIV/AIDS. (1) In 2009, 56 percent of Boston Public High School students reported having sex and 40% of students younger than 16 reported being sexually active. (2) Only 71% of those reporting sexual activity indicated that they had used a condom during their previous sexual encounter. (2) One in two sexually active persons will contract an STI by the time they turn 25 (3) and nearly ½ of all STIs occur in people ages 15-24(4,2). A 2008 report indicated that 1 in 4 female teens has an STI/STD and half of all African American teen girls has an STD. (4) Condom use has been shown to significantly reduce the risk of many STIs. (3,5) Contrary to popular belief, being at higher risk for contacting an STI does not necessarily indicate risky behavior. The risk of contracting an STI increases in areas with high levels of poverty, unemployment, social and economic discrimination and poor access to healthcare. (1,6,7)
The Boston Public Health Commission (BPHC) has recognized the threat that STIs and teen pregnancies have on Boston youth. In an attempt to lower the STI incident rates in Boston teens, a new campaign called “SexED in Boston” has been introduced. (7) This is the first time major funding from BPHC has been spent to target STI prevention in sexually active teens. (2) The campaign includes print ads that can be seen in Massachusettes Bay Transportation Authority (MBTA) buses, trains and stations and in newspapers. (2) BPHC has produced TV ads that have run on local cable stations and can also be viewed on Youtube and on the SexED facebook page. (2,8,7)
The print ad consists of two teen girls leaning on a desk and the words “A prefect score on the SATs might be hard, but preventing STIs isn’t. Do your homework. Protect yourself. Don’t get infected”. (7) In the background is a chalkboard with the words “Mrs. Tinkleberry Health 101”. (7) A different ad simple says “Don’t confuse the SATs with STIs” (7) Below are examples of some of the print advertisements with Mrs. Tinkleberry in the glasses and Janay in the t-shirt.


The television commercial opens with a young teen pretending to be a strict and obnoxious teacher; Mrs. Tinkleberry. This teacher proceeds to ask the students what an STI is and no one answers. In an angry and accusing voice she calls on “Janay” and the student incorrectly answers that “Isn’t it that test you take when you want to get into college?”. (7) Everyone in the class laughs at her and Mrs. Tinkleberry explains in a condescending voice that that is the SATs. Mrs. Tinkleberry proceeds to explain what an STI is and that it may not cause symptoms and that to prevent this you should always wear protection and then she holds up a condom. The class is dismissed and Janay confronts “Jeffrey” who is clearly a teen girl dressed in drag pretending to be a teen boy. Janay says “Jeffrey you said we didn’t need no condoms”. He says “Ya but it was good though. It was worth it right?”. Janay says “No I didn’t know you were going to give me the SATs”. Mrs. Tinkleberry was listening and says in an exasperated voice as she rolls her eyes “STI Janay”. The commercial end and the words “Do your homework. Protect yourself. Don’t get infected” appear.
This critique is on the BPHC SexED campaign as a whole but focuses on the print and TV ads since they are the most prevalent part of this campaign. The second section of this paper outlines three fundamental flaws of this campaign. The third section of this paper focuses on what could be done to improve on this campaign and provides support for why these changes could improve the campaign’s success.
II. Critique of the Theories, and Lack of Theories, Used in the SexED Campaign.
There are three fundamental errors that the BPHC made when creating this campaign. The first is that they used the Theory of Planned Behavior to model a behavior that cannot be captured using this theory and ignored visceral influences. (9) The second critique is that BPHC did not follow any advertising or marketing theories when creating their advertisements. Instead, they relied on assumptions and guesswork which can be fatal to any campaign. (10) Finally, this paper will critique the BPHC for failing to consider important environmental and social factors that influence teen’s decision to have safe sex since research has shown these factors put a teen a greater risk for infection. (6)
A. BPHC Uses the Theory of Planned Behavior to Explain Irrational/Spontaneous Actions and Ignores Visceral Influences:
The BPHC clearly used the Theory of Planned Behavior to guide their campaign. The Theory of Planned Behavior says that before people change their behavior they weigh their attitudes and the importance of those attitudes and then weigh what people think and the importance of what those people think. This leads to an outcome expectancy and if they think they can do the behavior they will intend to and then they will follow through with the behavior. (9) When used to understand STI prevention the Theory of Planned Behavior would predict that to get teens to use condoms they must have negative attitudes about the outcomes and must strongly weigh the importance of that outcome. The teen must also consider what other people think and consider how important that person’s opinion is to them. Finally, this will lead the teen to develop an outcome expectancy. If the STI is considered very bad, they are deeply concerned about the negative consequences and the people they care most about think using condoms is good they will want to use condoms and practice safe sex. However, they must have self efficacy and really believe they can adopt that behavior. The teen would then decide they would intend to use condoms and then they would use condoms. (9,11,12,)
The BPHC uses this theory and attempts to influence the attitudes about condom use by giving facts. This is done both on the website, and in the TV ad. (7) This is an attempt to make teens understand that the outcomes for STIs can be very bad and very serious and that they are at risk. The BPHC uses the influence of what others think by using teens to deliver the message and using a Facebook page to show that their peers think using condoms is good. (7) The self efficacy is reinforced in the sexED slogan “A prefect score on the SATs might be hard, but preventing STIs isn’t”. (7) This slogan hopes to encourage teens to adopt the belief that they can do things to prevent STIs.
On the surface there doesn’t appear to be anything wrong with the message. However, in one study they found that 97% of adolescents had reported receiving STD education. (13) What can explain the high infection rates of teens if all they need are the facts? Theory of Planned Behavior is an individual level model that assumes the decision whether to use condoms is rational, it assumes this choice is also planned and that it is static. (9) Unfortunately, because of optimism bias – people’s tendency to feel that bad things are unlikely to happen to them and more likely to happen to other people, it may be easy to convince teens that STIs are dangerous and severe, but very hard to convince them that they will get one if they are not careful. (14)
It is also true that people often believe they are at risk, can do something to prevent that risk, fully intend to do it, but then do not follow through with the behavior. (15) There are many reasons that a teen might choose not to use a condom. There could be pressure from their partner to not use one. A condom might not be readily available in the heat of the moment. They may simply prefer not to use one because they feel it could interfere with pleasure. (15) At the moment when a condom is actually needed both parties involved are reacting to those visceral influences. A visceral influence is a natural human urge such as hunger, pain, thirst, sexual desire, etc. (15) When faced with these visceral factors people tend to ignore all else and their attentions and behaviors are focused at satiating that hunger, pain, sexual urge etc. (15) It makes people act in seemingly irrational manners. It has been found that people often will act against their own self-interest and fully know that they are doing so when visceral factors are involved. (15) Unfortunately, we underestimate the power of these visceral factors on both our behaviors and the behaviors of others. (15)
The Theory of Planned Behavior and other commonly used theories in public health do not take these natural human drives into account. In the case of condom use, teens are making a short-sighted tradeoff of sexual pleasure even though they know that it could lead to an STI tomorrow. This is an example of how visceral factors produce attention-narrowing.(15) These visceral factors also tend to make people selfish. (15) With that in mind, why would someone mention that they have an STI to their partner in the heat of the moment? The Theory of Reasoned Behavior would ignore these visceral factors and assume good information and good intentions would work. However, because of this very important issue, this campaign is missing the real problem entirely and setting the teens up for failure. The BPHC assumes condom use is a rational behavior when in fact it is irrational but in a predictable way. (16)
B. BPHC Violates Marketing and Advertisement Theories:
One of the most important rules that has been learned from research done on how to build a good campaign is that “The selection of the right promise is so vitally important that you should never rely on guesswork to decide it” (10) BPHC did do some research before embarking on the campaign but did not research the promise. In an interview with the Boston Globe Margaux Joffe, who was involved in the campaign, she said “They told us, ‘We don’t want some old 40-year-old woman telling us about sex and STIs…We laughed, but it makes sense. You may not trust the advice of an adult as much as you would someone in your peer group.’’(17)
The results from their research were easily explained by Reactance Theory. This theory outlines that using a communicator that is as similar to the target audience as possible can increase compliance and reduce resistance. (18) BPHC did take into account who would deliver the message but instead of an adult they used a teen dressed as “some old 40-year-old woman” named Mrs. Tinkleberry who acts condescending and scoffs at Janay’s stupidity. BPHC also made the fatal error of trying to sell health. Ogilvy was clear that a large promise that appeals to people’s core values is the key to any successful advertisement. (10) Although it may seem counterintuitive, health is not a core value. It has been shown that often the deepest distress that illness causes is due to loss of control and the loss of independence. (19) These core values can differ slightly by age and culture but for American teens some of the most powerful core values that they hold are freedom, rebellion, control, and independence. (19) These are the “products” that the teens want to buy into.
The ads done in the campaign were done by a 16 year old girl who had her video chosen out of submissions done by local students. (2) To me, it is clear that this is a better example of how we have failed the students than it is an example of an advertisement for condom use. The teen produced a scene that is an exaggeration of the way sexual education is taught in school. It was a groundbreaking idea for BPHC to have students give input and become involved because they have knowledge about Boston teens that no adult does. However, a successful campaign involves using advanced Psychology, Marketing and Advertisement theories that students at this age group could not be expected to know.
C. The BPHC Ignored Important Social and Environmental Factors
Teens in Boston are influenced by their peers, teachers, parents, the community, socioeconomic status, ethnicity/race, and many other external factors. These environmental and social factors have a tremendous impact on the likelihood of a teen becoming infected with an STI. In fact, socioeconomic status, race/ethnicity, unemployment and discrimination are risk factors for STIs. (1,6) While white Americans generally get STIs through risky sexual behaviors, black Americans tend to get them from both high and low risk sexual behaviors. (1) This can be attributed to the fact that the levels of infections are much higher in blacks. (1,6) The infections rates are also higher in areas with poverty, high unemployment, poor access to health care, and social and economic discrimination etc. (1,6) The simple fact is that many of Boston’s schools are in neighborhoods where these environmental and social factors are prevalent. The BPHC did not attempt to address any of these problems. The focus of the campaign was to relay information and impress upon them the importance of practicing safe sex or abstaining altogether.
It has long been understood that teenagers can succumb to peer pressure. One study investigating this notion found that females were more strongly influenced by peer pressure and that peer pressure influenced both males and females attitudes about sexual activity. (20) It is not trivial that it was females most affected by peer pressure. Condoms are worn my males and despite requests, it is the male who decides if he will wear one. Female condoms are available but they are more expensive and less well known. The BPHC uses females in their video and ads to promote condom use when it is males who must wear them and they must do so in that “hot” state and we have seen that people tend to be selfish in that state. (15) This gives the male the option of trying to pressure the woman into sex without condoms. There is the additional problem of being viewed negatively by your partner/peers if you have a condom because Social Outcome Expectancy could lead your partner to wonder why you were carrying one with you and wonder if you anticipated casual sex. (21) This could be particularly damaging for women who would carry a condom because wanting lots of sexual partners is seen as a “male trait” and women are viewed negatively if they appear to be promiscuous. (21)
III. Proposed Intervention
The first part of the intervention I propose is also the most controversial. I propose that condoms not only be readily available to teenagers free of charge but that there be a campaign to encourage teen boys to use condoms to masturbate. I have heard in popular culture of men using lubricated condoms for masturbation because it is pleasurable and convenient.(22) These would seem like something a teen boy might be curious about. This could be included on a “fun tips” card that comes with a condom goodie bag. It could also be made into print ads or TV ads but that must be carefully thought out, considered, studied and planned to avoid any unforeseen problems. If these advertisements were done tastefully and with tact, they could have the potential to be widely influence this behavior in teens.
In order for this to work condoms should be freely available in many places that teens go and can access privately. They could be in locker rooms, bathrooms, the nurse’s office, youth centers, etc. To make it more successful there might be variation with the type of condom that is provided. There are dozens on the market and each one promises a different pleasurable benefit.
The intervention would also need to create a better advertising and marketing campaign. My goal is to re-frame and re-package the “product” of sexual health. I would use teens as the communicators in all of the advertisements but while they would provide important insights, they would not write the actual advertisements. I would also attempt to use famous teens to support these ads in the hopes that they would be viewed as early adopters of the messages in the campaign and create a tipping point. (23) The overall messages would be simple. “I am in control”, “I am independent”. I would also backup these promises with stories, symbols, and images that reinforce the promise. (19)
I am impressed by BPHC’s use of a Facebook page. I would create a Facebook page and use it to build the brand and to better the chances that the campaign would reach that critical tipping point. (19,23)
The campaign that I would plan would also be particularly unusual because part of it would put a focus on programs not normally associated with lowering STIs. In addition to the free condoms, encouragement of condoms for masturbation, and ad campaigns with a big promise, I would try to improve the environment that the teens in Boston must live in. I would put aside money to pay for after school programs. One program would be an empowerment program designed to encourage teen girls to be active members of the community and go to college. The program would also encourage empowerment among all teens. I would also put an effort into literally cleaning up the neighborhood with a special focus of keeping the mile radius around the school very clean. The teens would be encouraged to help in this effort to help increase pride in the community.
Other social/environmental programs would include a course on how to improve on the SAT’s. These SAT preparation courses are currently offered but at a high cost at private tutoring centers. I would also offer courses that specialize in practical advice on how to get into college. They could receive help on their entrance essays, resumes, applications and with scholarship searches. The hope of this program is that it would lead to more students going to college and then getting jobs and lessening unemployment and poverty in the community.
i. Support For Using Visceral Influences
The purpose of encouraging condoms for masturbation is that it has been found that interventions done when in a “hot” state were more effective than an intervention done in a “cold” state. (16) If a teenage boy always reaches for a condom when he is in that hot state he would probably be more likely to associate that hot state with condoms and think of it when he was with a partner.(16) This is one way to actually provide an intervention when the teen is influenced by visceral factors. This is particularly important since males are the ones who must wear it. The Social Learning Theory (9) would predict that the teen would use a condom and if they have a positive reinforcement of a pleasurable experience they would be more likely to reach for a condom again. The environment would be conducive to acquiring a condom because they would be in many places free of charge. It would likely cause a buzz and if a teen thinks others might be trying or doing it he would be more likely to try it because people base many behaviors on social norms (Social Expectations Theory). (24) It is a simple step and since another partner is not involved they would have a great deal of self-efficacy. (9) The simple fact that the teen used it once for masturbation is in itself a reinforcement of the behavior and makes it more likely that he will use it again. (9)
This would do many things. It would mean that teen males might seek out condoms and possibly have condoms with them or in their room. This greater accessibility to condoms would mean that if in a hot state with a partner the condoms would already be there. This easy accessibility, even when visceral influences are at play, leads to, not perfect, but better condom use. (16) It allows for irrational behavior and creates a positive reinforcement between sexual pleasure and putting a condom on. It also gives teens experience with how to put a condom on. It can require some planning (getting the condom) but hopefully that will be less of an issue if they are free. (9)
ii. Support that investing in Marketing Theory and Advertising Theory pays off.
I do not pretend to know what slogan would resonate most with Boston youth but this is why I would invest heavily in research. This use of Advertising Theory, Marketing Theory and framing is a subtle but important difference in this campaign. It re-frames the issue so I am no longer selling health. (19) I am selling control and freedom. I would also work towards making images of condoms be closely associated with core values.
These core values in teens have been studied and teens care most deeply about are rebellion, control and independence. (19) The Truth campaign was hugely successful in re-framing a public health issue and creating a valuable brand. (22,23) The Truth campaign team did research and discovered that what teens valued most was rebellion. They then used this to encourage teens to rebel against the tobacco industry and they had amazing results. (25) In just two years current cigarette use dropped in teens from 18.5% to just 11.1%. (26) A 7.4% decrease is tremendous in such a short period of time. Although it is difficult to rebel against a disease it is easy to reframe sexual health to be about control and independence. I would use Advertising Theory and Marketing Theory and make those three core values as my big promise. (10,19) I would also try to use symbols and hopefully make condoms a symbol of rebellion, control and independence.
iii. Support for Social and Environmental Interventions:
My hope is that this project would extend beyond what traditionally would be thought of as a “sexual health intervention” but at the same time be uniquely successful. There is only so much that condom use can do. If a community has a high level of infected adults it puts everyone at risk, including those practicing low risk sexual behaviors. (1,6,21) The after school programs are aimed at making the community better and stronger as a whole. This should decrease poverty and unemployment which tend to lead to communities with higher STI rates. (6,21)
The Theory of Gender and Power postulates that inequalities between genders are due to divisions of power, labor, and the structure of cathexis. (6,21) Some of these disparities and inequalities produce certain exposures that increase women’s risk for diseases such as STIs. (6,21)
As discussed earlier, Black teens are more likely to become infected with an STI and also more likely to give in to pressure from peers. (1,20) Socioeconomic status, discrimination and unemployment are just a few more environmental factors that actually increase risk. (1,6) My program would address some of these problems with after school programs to encourage college educations. This is important because social and environmental issues are at the root of the problem and no amount of harping about condom use can influence these problems.
The Theory of Broken Windows would predict that garbage, graffiti, etc would create a general sense of disorder. (9) This method of cleaning up to prevent crime was used successfully in NYC subway stations. (9) The physical cleaning of the community should create a sense of order and stability. It should discourage the idea that “anything goes” and again, work towards the promotion of a healthy community and thus, healthy teens.
IV Conclusion:
One of the main strengths of the proposed intervention is that it is multifaceted and uses strategies that are rarely, if ever, used in STI/STD interventions. The new campaign avoids common pitfalls that the SexED campaign bought into and uses emerging theories based on the understanding that behaviors are not always, planned, static or even rational. This program has the ability to be tweaked and then implemented in other cities. The underlying issues outlined in this paper must be realized, understood and addressed before any progress can be made in the fight against STIs in teens.
References:
1. Guttmacher Institute. Washington, DC. Facts on Sexually Transmitted Infections in the United States. http://www.guttmacher.org/pubs/FIB_STI_US.html
2. The Boston Public Health Commission. Top Stories View. Boston, MA. http://www.bphc.org/Newsroom/Pages/TopStoriesView.aspx?ID=101
3. American Social Health Association. STD/STI Statistics > Fast Facts. Research Triangle Park, NC. http://www.ashastd.org/learn/learn_statistics.cfm
4. National Public Radio. Study: 25 Percent of Teens Have STDs : NPR. http://www.npr.org/templates/story/story.php?storyId=88140117
5. Crosby RA., DiClemente RJ., Wingood GM., Lang D., Harrington KF. Value of consistent condom use: A study of sexually transmitted disease prevention among African American adolescent females. American Journal of Public Health. 2003 Jun;93(6):901-902.
6. Wingood GM, DiClemente RA. The Theory of Gender and Power: A Social Structural Theory for Guiding Public Health Interventions. In: Emerging Theories in Health Promotion Practice and Research: Strategies for Improving Public Health. Jossey-Bass; 2002. p. 313-346.
7. Facebook. sexED in Boston | Facebook. http://www.facebook.com/bostonsexED
8. Youtube. Health 101: STIs. San Bruno, CA. http://www.youtube.com/watch?v=0JC8ijpW5iI&feature=youtube_gdata
9. Siegel, M. Class Lecture, Session 5. 2009 Oct 1;
10. Ogilvy D. Confessions of an Advertising Man. Revised. Atheneum; 1988.
11. Edberg M. Individual health behavior theories. In: Essentials of Health Behavior: Social and Behavorial Theory in Public Health. Jones and Bartlett; 2007. p. 35-49.
12. Theories and applications. In: Theory at a Glance. National Cancer Institute; 2005. p. 147-160.
13. Lane T. Despite having received relevant education, youth lack knowledge of STDs. Perspectives on Sexual and Reproductive Health. 2003 Feb;35(1):51-52.
14. Neil d. Weinstein. Unrealistic optimism about future life events. Journal of Personality and Social Psychology. 1980;39(5):806-820.
15. Loewenstein G. Out of control: Visceral influences on behavior. Organizational Behavior and Human Decision Processes. 1996;65(3):272-292.
16. Ariely D. Predictably Irrational: The Hidden Forces That Shape Our Decisions. 1st ed. HarperCollins; 2008.
17. Smith S. The Boston Globe. Cautions for and from teens. Boston, MA. http://www.boston.com/news/health/articles/2009/08/04/safer_sex_campaign_makes_use_of_peers_on_facebook_youtube_cable/
18. Silvia PJ. Deflecting reactance: The role of similarity in increasing compliance and reducing resistance. Basic and Applied Social Psychology. 2005;27(3):277.
19. Siegel M, M.D, Doner L. Marketing Public Health. Jones & Bartlett Publishers; 2004.
20. Brown BB. The extent and effects of peer pressure among high school students: A retrospective analysis. Journal of Youth and Adolescence. 1982 Apr 1;11(2):121-133.
21. Raj A. Class Lecture, The Theory of Gender and Power. 2009 Dec 3;
22. Hamburg J. I Love You Man. DreamWorks; 2009.
23. Gladwell M. Introduction. In: The Tipping Point. Back Bay; 2002. p. 3-14.
24. Siegel M. Class Lecture, Session 9. 2009 Oct 29;
25. Hicks JJ. The strategy behind Florida's “truth” campaign. Tobacco Control. 2001 Mar 1;10(1):3-5.
26. Bauer UE, Johnson TM, Hopkins RS, Brooks RG. Changes in youth cigarette use and intentions following implementation of a tobacco control program: findings from the Florida Youth Tobacco Survey, 1998-2000. JAMA. 2000 Aug 9;284(6):723-728.

Turning The Tide On HIV In Young Men Who Have Sex With Men – Steven Ralston

One hates to begin paper with a cliché, but sometimes a picture really is worth a thousand words:

This graph comes from the Centers for Disease Control and Prevention (CDC) and clearly demonstrates the failure of Human Immunodeficiency Virus (HIV) prevention strategies to reach young men who have sex with men (MSM) (1). From 2001-2006, the incidence of HIV/AIDS cases in every other age group decreased, but in the adolescent age group, the number HIV cases continued to rise. Sadly, we see this trend despite clear indications and predictions that this group was particularly vulnerable to such a resurgence (2).
Traditional HIV prevention programs aimed at young MSM have usually involved advertising and educational campaigns encouraging one of three behaviors: abstinence, condom use, or HIV testing. And while some of these campaigns may have been more effective than others, and while some interventions have been based on sound theoretical bases (3-5), the overall result has been a dismal failure as the CDC data demonstrate: HIV infections continue to rise in this age bracket (1). I posit that these campaigns have failed in this demographic because behavioral change in this group cannot be achieved through traditional rational choice models of health behavior for several reasons: the young men who are the targets for these campaigns have a sense of invulnerability and a natural distrust of authority and they are making decisions about condom use at the wrong time, i.e. when they are already having sex; the messages we send young men are inconsistent and contradictory; and, finally, the stigma of being gay or having sex with other men is so great that it renders ineffectual any public health campaign that is based on a supposed rational framework that adolescents might use to make decisions.
Promoting Abstinence, Condom Use and HIV Testing: The Traditional Public Health Approach
Attempts to change the sex behaviors of men at risk of acquiring HIV have not been very successful overall. Even very intensive interventions aimed at preventing risky behaviors have achieved only modest changes that tend to dissipate with time (6). Young men, especially, are likely to be resistant to such interventions due to their self-perceived invulnerability and their distrust of authority. Condom ads exhorting them to “Respect Yourself, Protect Yourself” may have catchy rhyme, but probably do not resonate with young men who perceive themselves as invincible (7). And abstinence-only education has been a dismal failure for this demographic (8).
In addition, young men do not make sound decisions in the heat of passion. This is compounded in a particularly problematic fashion by the well-documented fact that risky behavior in MSM is directly tied to alcohol and substance abuse (10-11). It is not clear, therefore, how effective the rational framework based models can ever hope to be in affecting behavior at the time of a sexual encounter that is so patently wrought by emotion and irrationality.
The Problem of Mixed Messages
Other salient aspects of the public health thrust for abstinence, greater condom use, and HIV testing are the inherent contradictions in these campaigns. On the one hand, condom use is promoted as the means of protecting oneself from HIV and other sexually transmitted infections (STIs); however, this information is often couched within the context of an abstinence-based curriculum. There is a striking incongruity between being told that “waiting is best” and that condom use is crucial.
In those campaigns targeting at-risk youth, the reason often given to make HIV testing seem worthwhile (the theory being you are more likely to spread HIV if you don’t know you have it) is that there are now effective treatments for HIV available. This seems to be saying at once that HIV is bad (i.e. you don’t want to spread it), but actually, not so bad because there are good therapies. In fact, it may be this perception (i.e. that HIV can be avoided with post-exposure prophylaxis and that HIV is now a treatable illness) has contributed to the increase in unsafe sex practices and HIV rates in young MSM (12). It is no wonder, therefore, that the messages of abstinence, condom use and testing have become diluted or lost amidst these contradictory messages from educators, politicians, and public health authorities.
The Problem of Stigma
My final argument as to why the traditional behavioral changing models and public health campaigns have failed to adequately reach young MSM is that the context within which these men are living in the world is one of stigma and discrimination and this makes it difficult for them to perceive a rational basis for their behavioral change. In many of the individual change models (e.g. the Health Belief Model or the Theory or Reasoned Action), there is a rational calculation required of the actor – a balance of needs, inputs, risks, benefits, etc. – that results in the behavior modification towards greater health. But, MSM are growing up in a world replete with unequivocal messages – both overt and covert – that their lives will be miserable: full of loneliness, social isolation, and perhaps even eternal damnation. Any campaign to convince these men that abstinence or condom use or HIV testing is worthwhile will fail unless these perceptions can be changed and they can believe in a happy future for which saving themselves is desirable.
Stigma theory was originally described in the 1960s by Erving Goffman (13) and has been used to explain behaviors and health outcomes in disease ranging from psychiatric illness (14) to epilepsy (15) to STIs (16). Goffman defined stigma as an attribute that discredits persons who possesses it; these individuals are seen as different and deviant. Stigmatization thus leads to discrimination and internalized self-hatred which both act as barriers to healthy behaviors. Later theorists moved to “reframe our understanding of stigmatization and discrimination to conceptualize them as social processes that can only be understood in relation to broader notions of power and domination” (17). Stigma theory, as it applies to people with HIV or those at risk for getting HIV explains the difficulty in effecting behavioral change in these oppressed populations.
And while some programs to promote safer sex practices have been framed as empowering MSM, this is usually within the narrow context of a particular sexual encounter or a particular health behavior being promoted, and not as broad-based notion to combat a systematic pattern of discrimination and marginalization in society. And without addressing these more far-reaching aspects of stigma, public health initiatives to promote healthy behaviors may be hampered as intimated by Parker and Aggleton:
“Precisely because they are subjected to an overwhelmingly powerful symbolic apparatus whose function is to legitimize inequalities of power based upon differential understandings of value and worth, the ability of oppressed, marginalized and stigmatized individuals or groups to resist the forces that discriminate against them is limited”. (19)
Thus, without addressing the underlying world of stigma and discrimination in which young MSM find themselves, public health authorities are left with a panoply of cognitive-behavioral or social-cognitive models for behavioral change which will only be marginally effective at best.
A New Path: Empowerment as a Precursor to Change
My proposal for a strategy to combat increasing HIV infections in young MSM is not to reject the behavioral change models that have been used in the past, but to continue them in a context in which change is more likely to occur. This context is one in which being gay or bisexual or having sex with other men is less stigmatized and that the message of having healthy sexual relationships is equated with having both healthy loving relationships and fulfilling lives despite being gay or bisexual.
My vision is one of a public health campaign whose goal is to bolster the self-esteem of young MSM by providing them a framework in which to see their lives as having purpose and a bright future. Instead of a life of isolation, fear, misery and disease, we should be offering them a future of professional and personal success. Such a campaign might consist of a series of ads that highlight the lives of successful gay or bisexual men. (Success in this context could be financial, professional, or personal.) These could be men playing sports, or graduating from college, or running their own businesses, or flourishing in supportive relationships, or having families of their own. The promise would be one of access to the American Dream, one of possibility, one of acceptance. If there were even a hint of traditional behavior modification in these ads, I would certainly not specifically mention condoms or HIV testing, but would favor keeping it vague: e.g. “I take care of myself, and those I care about, so I can keep my future safe.”
I also envision a series of more political ads which highlight the successes of the gay rights movement from discrimination law to civil rights and, now, even to marriage rights. This part of the campaign may need to come from private sources of funding, through foundations and gay-rights groups (e.g. the Human Rights Campaign), but is yet another means of shifting the context in which our public health messages are heard.
Now, I am not so naïve to think that the stigma of being gay, or bisexual, or being a MSM can be eliminated with a public health campaign, but I believe the effects of discriminatory societal pressures can be ameliorated through well-planned communications, marketing, and public relations strategies. And that without a change in how young MSM perceive themselves and their futures, any effort to change individual behavior will likely be ineffectual.
A Move Away From Individual Change Models
One of the strengths of this strategy is that the target is not necessarily an individual, but a group or social network of individuals. Attitudes about sex and safer sex practices may be largely influenced by the social networks in which individuals find themselves, as Fisher states:
“A social network theory approach to STD/HIV prevention suggests that individuals function within social networks that establish norms for behaviour [sic], including safer sexual behaviour [sic] and that these social networks enforce adherence to these norms”. (3)
If young men see themselves as part of a group that has a future worth staying healthy for, then they are more likely to make choices that will protect that future. And this will only be reinforces as they see others around them making similar choices.
Similarly, the use of gay leaders as a focus for the campaign will help to create role models for young MSM. But at the risk of seeming elitist, I would steer the campaign towards featuring role models that seem accessible to the target audiences: not just movie idols and star athletes, but regular guys who happen to be gay or bisexual and have managed to build successful lives. Such role models can be a source of opinion that can influence the behaviors of those men in similar social networks, as intervention models have used “community popular opinion leaders” to help propagate new ideas and behaviors (20). I think this strategy will be especially crucial in trying to reach the young men in the African American community whose HIV rates have increased the most in recent years.
A Consistent Message
A second strength of my proposed campaign is that its message is both clear and consistent. There is no incongruity between the promise of a better life and the facts presented: decent, admirable role models; broadening legal protections for gay and bisexual men; and increasing societal acceptance of these lifestyles. The message is clear, on point, even redundant. But consistent. In contrast to the many ads and campaigns promoting condom use and HIV testing, there is no waffling on the bottom-line message being sent to the target audience: protecting your future is important, because you have a future. The details of how the future is protected – whether by safer sex, or delayed intercourse until marriage – are less important than the promise of the future itself. It is the possibility of a future that is being sold, not the HIV test, not the condom, and certainly not the delay of sex until marriage. The product – the future – needs to be one that young men will want.
Challenging Stigma as Inevitable
Finally, the ultimate goal of this campaign is to shift the context of these young men’s lives and thus improve their self-esteems. And, the enduring power of improving these young men’s self esteem cannot be underestimated. Or, conversely, the adverse effect of continued discrimination will be immense. If MSM experience the world as one where marriage and committed relationships are impossible or stigmatized, how can they ever be motivated to protect themselves for such a bleak future? But in a world where gay marriage, civil unions, and committed monogamy are not just European curiosities, but part of mainstream – (think Iowa ) – American ideals, these young men might be motivated to reframe their decisions and choose healthier alternatives to unprotected sex.
Caveats
My campaign poses several challenges for any organization that seeks to implement it. The political and public discomfort with addressing issues of sex and sexuality are readily apparent in reviewing the difficulties public health authorities had in addressing the AIDS crisis during the 1980’s and 1990’s (21). Civic equality for homosexuals is far from mainstream in many parts of the country. Because of this, it may be that much of the funding for this program will need to come from private sources or begin in some of the more liberal parts of the country.
Finally, the difficulty in reaching African American youth needs to be addressed. One explanation why African American men seem to have been left behind especially by our current educational tools is that they are already stigmatized and marginalized by their race. And this compounded with the stigma of homosexuality (especially harsh in many African American communities) will likely make the young African American MSM a particularly intransigent population to be affected by this campaign. So, great effort will need to be made to include and keep this group in the sights of any agencies or organizations addressing this issue.
Nevertheless, despite these challenges, the long-term benefits of this campaign could be profound and long lasting. Establishing the legitimacy of gay and bisexual lifestyles in our society is crucial to enabling young men to see themselves as having futures in which they have more choices available them than short-term sexual conquests in the context alcohol or drug use. These men need the promise of a brighter future and the accessibility of the American Dream; the need a reason to stay healthy.


REFERENCES

1. www.cdc.gov/healthyyouth
2. Wolitski RJ, Valdiserri RO, Denning PH et al. Are we headed for a resurgence of the HIV epidemic among men who have sex with men? Am J Public Health 2001;91:883-888
3. Fisher WA. A Theory-Based Framework for Intervention and Evaluation in STD/HIV Prevention. Can J Hum Sexuality 1997;6(2).
4. Eke NA, Mezoff JS, Duncan T, et al. Reputationally Strong HIV Prevention Programs: Lessons from the Front Line. AIDS Education and Prevention 2006;18(2), 163-175
5. DiClemente RJ, Crittenden CP, Rose E, et al. Psychosocial Predictors of HIV-Associated Sexual Behaviors and the Efficacy of Prevention Interventions in Adolescents at-Risk for HIV Infection: What Works and What Doesn’t Work? Psychosomatic Medicine 2008;70:598-605
6. The EXPLORE Study Team. Effects of a behavioural intervention to reduce acquisition of HIV infection among men who have sex with men: the EXPLORE randomized controlled study. Lancet 2004:364:41-50
7. www.advocatesforyouth.org
8. Santelli J, Ott MA, Lyon M, et al. Abstinence and abstinence-only education: A review of U.S. policies and programs. Journal of Adolescent Health 38 (2006) 72– 81
9. Ariely D. Predictably Irrational New York: HarperCollins, 2008.
10. Koblin BA, Husnik MJ, Cofax G, et al. Risk factors for HIV infection among men who have sex with men. AIDS 2006, 20:731-739
11. Koblin BA, Chesney MA, Husnik MJ, et al. High-Risk Behaviors Among Men Who Have Sex With Men in 6 US Cities: Baseline Data from the EXPLORE Study. Am J Public Health 2003;93:926-32
12. Morin SF, Vernon K, Harcourt JJ, et al. Why HIV Infections Have Increased Among Men Who Have Sex With Men and What to Do About It: Findings from California Focus Groups. AIDS and Behavior 2003;7(4):353-362
13. Goffman E. Sigma: Notes on the Management of Spoiled Identity. New York: Prentice Hall, 1963.
14. Yang LH. Application of mental illness stigma theory to Chinese societies: synthesis and new directions. Singapore Med J 2007;48(11):977
15. Westbrook LE, Bauman LJ, Shinnar S. Applying Stigma Theory to Epilepsy: A Test of a Conceptual Model. J Ped Psychology 1992;17(5):633-649
16. Breitkopf CR. The Theoretical Basis of Stigma as Applied to Genital Herpes. Herpes 2004;11(1):4-7
17. Parker R and Aggleton P. HIV and AIDS-related stigma and discrimination: a conceptual framework and implications for action. Social Science & Medicine 2003;57:p16
18. http://www.aids.gov/takecontrol/factssheets/nhmtc_flyer.html
19. Parker and Aggleton, ibid. p.18

20. The NIMH Collaborative HIV/STD Prevention Trial Group. The community popular opinion leader HIV prevention programme: conceptual basis and intervention procedures. AIDS 2007, 21(suppl 2):S59-S68
21. Shilts R. And the Band Played On: Politics, People, and the AIDS Epidemic. New York: St. Martin’s Press, 1987

The Misuse of Behavioral Theory in Abstinence-Only Sex Education: Why Abstinence-Only Curriculum Fails To Prevent Sexual Activity, Pregnancy, and STI

--Emily Hyman

Abstinence-only education, which promotes abstinence from sexual activity until marriage and does not provide information on contraception besides failure rates (1), has received federal support since 1981 under the Reagan Administration. From 1996 to 2008, abstinence-only education received more than $1.5 billion through both federal and state matching funds and, during the 2009 fiscal year, more than $160 million was allocated to abstinence-only education (6).

Although national Youth Behavior Risk Surveys show that teen sexual activity decreased by 7 percent from 1991 to 2007 (2), teen birth rates increased significantly between 2005 and 2007 (3) and today, U.S. teens experience the highest birth rate and one of the highest rates of sexually transmitted infections (STIs) compared to all other industrialized nations (1). The CDC estimates that, by age 24, at least one out of every four Americans will contract an STI (4).

Clearly, effective public health interventions are needed to help lower rates of STIs and unintended pregnancies; however, abstinence-only education is not the answer. A large body of evidence consistently shows that abstinence-only education fails to reduce risky sexual behavior among teens (7), identifying few short-term benefits and no lasting, positive impact on student’s sexual behavior over time (1).

Although Obama's 2010 budget cut the Title V grant program, a major source of abstinence-only funding for U.S schools, it is necessary to examine why abstinence-only curriculum is flawed so as not to repeat these tactics in future sex education curricula.

As an example, this report will focus on “Choosing the Best,” (www.choosingthebest.org), a popular and widely-used abstinence-only curriculum for 6^th -12^th graders that has been produced since 1993 by Choosing the Best Publishing, LLC. based in Atlanta, Georgia. Using videos, case studies, role playing exercises and group discussions, Choosing the Best aims to “transform attitudes and behavior of teens about premarital sex” by showing why abstinence is “the best way to show respect for yourself and others (8).”

Choosing the Best is flawed in that it relies on behavioral science theories that are counterproductive and unlikely to impact teens abstaining from sex including: fear-based tactics which distort facts and create scenarios unlikely to repeat in a real-life situation; assumptions that teens will act rationally when making emotional decisions about sex (9); and failure to account for the power of social norms to change the context of sex. The misuse of these tactics demonstrates how Choosing the Best is not adequately preparing students to make safe decisions about sex. However, by applying modern behavioral science principles, both the methodology and content of the curriculum can be improved and made more effective.

Fear –Based Tactics

Nobel-prize winning chemist Marie Curie once said, “Nothing in life is to be feared. It is only to be understood.” Contrary to this sentiment, Choosing the Best uses techniques that may cause students to fear sex, rather than understand it. All stages of the curriculum use framing to accentuate the risk of STIs and teen pregnancy and paint a negative picture of the effectiveness of birth control, thus inciting fear or making students feel threatened.

For example, Choosing the Best presents the following statistic on virginity in their 6^th grade curriculum: “Nearly 1 in 10 kids reports losing virginity before age 13.(8)” Upon reading this, a child may feel like his or her chance of losing their virginity before turning 13 is high and something to fend against. Alternately, this statistic could be re-worded to say, “Approximately 90 percent of teens have not had sex before age 13.” The latter example presents the same information as the first; however, it does not trigger fear to the extent of statistic used by Choosing the Best.

Another example of distorting facts to elicit fear can be found in Choosing the Best’s 7^th- grade curriculum. The statistic states, “One in 5 Americans aged 12 and up contract genital herpes (9). In this statistic, “Americans aged 12 and up” could include any American age 12 to 100; however, 12 is the only age mentioned in the statistic and is likely to build fear among 7^th graders about herpes, instead of presenting curriculum in as straightforward a manner as possible.

Although fear can serve as a powerful motivator, it may also distort the truth, as in the examples above, and skew facts to create an extreme scenario unlikely to repeat itself in a real-life situation. This distortion could make it confusing for students to make decisions about sex. Also, if students feel the message is so exaggerated that it is disproportionate to the risk, they may rebel or ignore the source of the message (similar to how youth decided to mock the anti-drug commercials with a dog as a spokesperson instead of accepting the messages as truthful).

Fear-based tactics are also used in Choosing the Best’s HIV/AIDS curriculum which shows a video where students travel to a health clinic to learn about HIV and meet with Lisa, a 33-year old woman with AIDS. In the video, students are introduced to a severely ill woman who is gaunt and visibly suffering. After describing her drug regimen and the pain she is going through, she says the following to the students:

“I don’t want you to think that 40 pills a day is going to make it go away. I am in prison and I can’t get out. There is no parole. I have been 80 lbs and bald for three years.

This will rob every dream that you ever had. It will take everything away. Do me a favor if you could just hold off and make that pact than I feel like my life on earth has been served. "

By using a severely ill AIDS patient to deliver messages about the risk of HIV-AIDS, students are likely to grasp the severity of the threat of HIV/AIDS and the deadly risks associated with unprotected sex. However, the AIDS example presented is extreme, and students are likely to remember this spokesperson as a caricature of AIDS instead of a person they are likely to come across in their own lives and social situations, leaving them unprepared to judge the risk of HIV and AIDS when people appear just as healthy and vibrant as they do. According to Nicholas Christakis and James Fowler’s study on social network theory, people are more likely to be influenced by people who resemble them. It is also possible that exaggerating the risks of a behavior could be perceived as melodramatic to program participants, causing health professional to lose credibility as kids make fun of or distance themselves from the curricula since it is difficult to relate to and easier to mock.

Assumption of Rational Behavior

Choosing the Best and abstinence-only education in general assumes students are rational, or in “cold states,” when it comes to making decisions about sex (5). Using the methodology behind the Health Belief Model, Choosing the Best provides students with a clear picture of the risks associated with sex (STDs, pregnancy, negative view of themselves) in the hopes that students will feel so threatened by these risks that, when it comes time to decide whether or not to have sex, students will view the benefits of abstinence as outweighing the consequences, and therefore, choose to abstain. In reality, decisions about sex are frequently made in hot states where the likelihood of rational decision-making quickly falls by the wayside (5).

As demonstrated in the sexual questionnaire experiment in Dan Ariely’s book Predictably Irrational, rational thinking is diminished when participants are in a hot state. The following excerpt from Predictably Irrational explains how emotions caused by sexual arousal make it extremely difficult to control ones behavior:

Many parents and teenagers, while in a cold, rational, Dr. Jekyll state, tend to believe that the mere promise of abstinence – commonly known as “Just saying no” – see no reason to carry a condom with them. But as our study shows, in the heat of passion, we are all in danger of switching from “Just say no” to “Yes!” in a heartbeat; and if no condom is available, we are likely to say yes, regardless of the dangers (9).

One example of Choosing the Best’s assumption of rational thought is the program’s use of one-on-one interviews with an assortment of students describing first-hand why they regret having sex and felt the experience was negative. These interviews are hoping to steer students towards abstinence by showing them the negative emotional consequences of sex. Similarly, in a video for 9^th and 10^th graders titled, “Why do I hurt inside?” students relay their experiences having sex and describe how it made them confused, used and unloved. One teenage male student tells the following story in the video:

“After the act, I felt dirty like, well, actually I felt guilty. After riding my bike back home, inside I was like… I didn’t know what happened since I had lost my virginity. All week, I had this stressful thing in my mind because I had lost my virginity. I was emotionally unstable. I couldn’t think straight. If sex was supposed to make me feel like a man, it didn’t. I took a bunch of showers and still felt dirty inside. It just makes more sense to abstain than to not abstain.”

Another teenage female has the following anecdote:

“I ended up having sex when I was in 8^th grade, it was a horrible experience, I felt I lost a part of me, my identity. I was looking to him to define who I was.

Both anecdotes show how Choosing the Best is hoping to change student’s attitudes towards sex by stressing the negative emotional consequences of sex, such as feeling “dirty,” “guilty,” “emotionally unstable” and “horrible.”

As suggested by the Theory of Reasoned Action, one’s intention to act is a determinant of behavior. Intention is a function of a person’s attitudes towards the behavior and their judgment about whether the behavior is good or bad (10). By showing easily-relatable, age-appropriate students speaking candidly about how they felt remorseful, embarrassed and confused by their decision to have sex, Choosing the Best may certainly succeed in changing a student’s attitude towards sex or succeed at demonstrating how susceptible teens are to negative emotional consequences of sex, but, the question remains: is this enough to prevent sex? The answer: most likely not.

By painting sex as an unfortunate mistake made by people who are too weak to control their impulses, Choosing the Best assumes students will use rational decision-making processes when considering sex. Knowing the tremendous power arousal has to impact behavior and quickly uproot previous attitudinal preferences, it is clear that birth control methods such as condoms are essential to protecting students in the heat of the moment, when students in hot states are likely to discard messages of self-control, forget about perceived risks, and give in to emotion.

Ignoring the Power of Social Norms

Finally, Choosing the Best fails to account for the ability of social norms to impact teen behavior. Similar to the reasoning previously stated, abstinence-only curriculum does not account for the considerable social variables teens are likely to come across when making decisions about sex. Different environments, situational contexts, and peer groups will likely present teens with a variety of social norms they will need to navigate. In step with the Health Belief Model, Choosing the Best curriculum focuses on the personal orientation of an individual and their level of readiness to take action (10); however, it fails to consider how individuals will act when part of a variety of social systems. As the perceived benefits and risks of an action begin to change around an individual, i.e. if a student moves to a new school or changes friend groups, behaviors may begin to shift depending on those who surround them and those whose opinions they value. In other words, their perception of “normal” is likely to change.

Social learning theory as outlined in the book, Effects of Mass Communication (11), demonstrates the power of society and mass media to affect behavior. According to authors DeFleur and Ball-Rokeach, social learning theory explains how people acquire new forms of behavior by observing other people’s actions, and how people come to adopt those patterns of actions as personal models of response t0 problems, conditions or events in their own lives (11).

Choosing the Best tries to set social norms in their curriculum, i.e. teens that have sex will be looked down upon by their peers or sex makes teens confused. But, what if this dynamic changes when the student is in another social context and sex all of a sudden becomes something rebellious and fun teens should try. According to the social learning theory, people are likely to model their own behavior on what we see others doing and thinking.

Instructing students how to use a condom or other birth control methods will help protect teens from STDs and pregnancy in a much wider spectrum of social norms. An effective sexual education intervention needs to consider the power of social norms to dictate behavior and fluctuate throughout a teen’s life.

Proposal for Alternative to Abstinence-Only Intervention

As stated above, Choosing the Best abstinence-only until-marriage curriculum currently used in U.S. middle and high schools is flawed in that it frames information about STDs, teen pregnancy and sexual activity in negative and exaggerated ways so as to evoke fear among students. The program also assumes students will maintain rational behavior, even in the midst of emotional situations involving sex. Finally, Choosing the Best and other abstinence-only-until-marriage curriculum ignore the power of social norms to influence decisions and the likelihood that changing social norms will alter what teens consider to be acceptable or “normal” forms of sexual behavior. Using modern behavioral science theory, these three main criticisms can be addressed and both the methodology and content of the curriculum improved.

Instead of fear, inspire control

The notion that freedom is the antidote to fear is a concept that can be applied to improve abstinence-only education. As described earlier, Choosing the Best uses techniques that may cause students to fear sex, instead of understanding the nuances and complexities of adolescent sexuality. As we can see throughout Choosing the Best curriculum, birth control, such as condoms, are framed negatively to exaggerate their ineffectiveness and make teens feel that the only way to gain control of their lives and their sexuality is through abstinence. This narrow view about the consequences of sex and limited options for control distorts reality and could result in rebellion or confusion among teens. Instead, Choosing the Best should present a broad range of options available to teens to limit their risk of STIs and pregnancy and, therefore, control their destiny.

The idea of control is already portrayed positively within Choosing the Best, when the program provides teens with positive messages about relationships, such as the importance of feeling loved and respected by a partner and the importance of being in control of your body. To improve the program, these positive messages of control could be expanded upon to include information about other birth control options besides abstinence. Through this increased knowledge, teens would feel more in control of their futures and the program would be less likely to lose credibility since it would be empowering students to consider all of the options and make their own decision. To help “sell” birth control as a viable option to prevent STIs and pregnancy, advertising theory could be employed and campaign could be created around the “promise” of freedom from the risk of STIs and the security of knowing you are capable of protecting yourself from becoming pregnant (12).

Convey sex as irrational

In order to be effective, Choosing the Best and abstinence-only education curriculum in general must accept that people are not rational beings, especially when it comes to making decisions about sex. Although there is certainly value in showing students the benefits of abstinence and the risk of sex, it is unrealistic to assume that students will remain reasonable and even-keeled every time the opportunity for sex presents itself. By preparing students to make decisions about sex in a hot or irrational state, Choosing the Best would become more effective.

This could include teaching students to use birth control such as condoms, thus providing them with an option for protection, even in the heat of the moment. Second, the educational program could also include realistic, detailed stories or videos that show two people being intimate but then stopping and deciding to use protection. These videos could use humor to make them more relatable to teens but still convey the powerful emotions behind sexual behavior. Generally, abstinence-only programs could be more honest about the psychology behind sex and sexuality and explain the science behind sexual feelings and how our bodies go into overdrive during sexual experiences. Having as much information as possible to prepare students for what the experience will be like could help them prepare mentally and emotionally for what is in store and why their decisions will be so difficult to make.

Acknowledge the power of social norms

In order to prepare teens for the multitude of situations and corresponding social norms they will face throughout their lives, it will be necessary for Choosing the Best to acknowledge the strength of these unknown and changing variables and their power to impact teen behavior. Similar to the reasoning previously stated, abstinence-only curriculum does not account for the considerable social variables teens are likely to come across when making decisions about sex. Different situations, social networks and experiences will present teens with a variety of social norms they will need to navigate.

One force that is particularly good at setting social norms among today’s teens is mass media, especially television, film and radio. As described by DeFleur and Ball-Rokeach in Theories of Mass Communication, modeling theory, similar to social learning theory, presents the idea that “the acquisition of new behavior” comes “from media portrayals.” The authors go on to state that the “media are readily available and attractive sources of models” and “provide a symbolic modeling of almost every conceivable source of behavior… literature has shown that both children and adults acquire attitudes, emotional responses, and new styles of conduct from all the media, and especially from films and television.”

Therefore, if Choosing the Best and other abstinence-only programs were to create or identify a celebrity who embodied the abstinence-only values they are trying to impress upon their students, perhaps such a high-profile person in the media would have the power to override the more typical models we see constantly in the media, including stars such as Brittney Spears whose music promotes the pleasure, power and satisfaction that come from sex. Nearly every major female and male pop star popular among teens today portrays an image of being sexually active. Would it be possible for the media machine to create the same star power for someone with abstinence-only values? For instance, if Taylor Swift announced she was in favor of abstinence-only-until-marriage, many social norms among teens would undoubtedly shift towards favoring abstinence. Of course, there is great risk placing so much power on the shoulders of one high-profile model, but the ability of mass media to shift social norms and create behavioral change should not be underestimated.

In conclusion, Choosing the Best uses behavioral science theories that are ineffective at making teens abstain from sex including fear-based tactics which skew reality, assumptions that teens will act rationally when making emotional decisions about sex, and a failure to acknowledge the power of social norms to change the context of decisions about sex. By addressing these issues and accounting for the power of irrational behavior and group dynamics, Choosing the Best would be closer to becoming an effective at lowering pregnancy and STI rates among teens.

References

1. Advocates for Youth. Five Years of Abstinence-Only-Until-Marriage Education: Assessing the Impact. Washington D.C.: Title V State Evaluations, 2008.

2. Centers for Disease Control and Prevention. Trends in HIV- and STD-Related Risk Behaviors Among High School Students --- United States, 1991--2007. Atlanta, GA.: Morbidity and Mortality Weekly Report, 2008.

3. Centers for Disease Control and Prevention. Adolescent Reproductive Health: Preventing Teen Pregnancy. Washington D.C. Centers for Disease Control and Prevention. http://www.cdc.gov/reproductivehealth/AdolescentReproHealth/

4. The Henry J. Kaiser Family Foundation. Fact Sheet: Sexually Transmitted Diseases in the U.S., Menlo Park, CA: 2003.

5. Inclusion Of Abstinence-Only Funding In Senate Health Reform Bill Surprises Advocates On Both Sides. Medical News Today, 2009. http://www.medicalnewstoday.com/articles/172556.php

6. The Sexuality Information and Education Council of the United States (SIECUS). Federal Abstinence-Only-Until-Marriage Funding. Washington D.C. SIECUS. http://www.siecus.org/index.cfm?fuseaction=Page.ViewPage&PageID=1158

7. The Future of Abstinence-Only Sex Ed. http://www.newsweek.com/id/219818

8. Choosing the Best, Inc. Curricula. Atlanta, GA: Choosing the Best. http://www.choosingthebest.org/curricula/index.html

9. Dan Ariely. Predictably Irrational: The Hidden Forces that Shape our Decisions. New York, NY: Harper Collins Publishers, 2009.

10. Salazar MK. Comparison of Four Behavioral Theories: A Literature Review. AAOHN Journal 1991; 39: 128-135.

11. DeFleur ML, Ball-Rokeach SJ. Theories of Mass Communication (5^th Edition), Chapter 8 (Socialization and Theories of Direct Influence),pp. 202-227. White Plains, NY: Longman Inc., 1989.

12. How to build great campaigns (Chapter 5). In: Ogilvy D. Confessions of an Advertising Man. New York: Atheneum, 1964, pp. 89-103.