Saturday, December 15, 2012

Ideology versus Practice: Why Abstinence Promises Prevention but Guarantees Failure in Social Context, and How to Revamp HIV/AIDS Behavioral Change Campaigns – Abigail Williams

The HIV/AIDS Epidemic
            HIV/AIDS: The greatest affront to public health and human security of modern times. PEPFAR: The largest commitment by any nation to combat a single disease in human history (1). Considering the unparalleled international awareness of the HIV/AIDS epidemic and the unprecedented assistance offered in response, it’s somewhat surprising how much criticism surrounds the PEPFAR initiative. Although the program has significantly reduced mortality and has revolutionized affordable and sustainable treatment, the struggle to permanently reverse the rate of infections still persists. This essay describes one particular aspect of the PEPFAR initiative, evaluates some of its strategic flaws in affecting behavior and reducing transmission, and offers suggestions for achieving better outcomes, particularly in developing settings in Sub-Saharan Africa. It is important to keep in mind that the ABC strategy described in this essay is only one component of one sector (prevention) of PEPFAR, although the opportunities for influencing preventative behavior is probably the most important contribution to an HIV/AIDS-free future.
The American Response
            The President’s Emergency Plan for AIDS Relief (PEPFAR) was introduced in 2003 as a 5-year commitment from the United States government to countries in Africa and the Caribbean to treat and prevent HIV and AIDS. The program’s goals included preventing new infections, treating people living with HIV/AIDS, and providing assistance for vulnerable children affected by the epidemic. In 2008, the initiative was renewed for another 5 years of funding with regional expansions to Central Asia, Eastern Europe, and Latin America and revisions to the program for fund approval and distribution. Despite critics’ calls for more evidence-based and arguably more culturally appropriate approaches, PEPFAR administrators continue to assert abstinence-focused prevention strategies.

            The ABC approach adopted by PEPFAR simplifies HIV/AIDS prevention into a convenient message; Abstain, Be faithful, and practice correct and consistent Condom use. The campaign targets the young and unmarried, including some at-risk and vulnerable populations as well. It emphasizes abstinence, uses monogamy and partner reduction as a tool for sexually active adults, and offers condoms as an option for people whose “behavior places them at risk for transmitting or becoming infected with HIV(2)”. The campaign emphasizes the severity of HIV/AIDS, framing the problem of the HIV/AIDS epidemic as a problem of disease – a disease which can be prevented by individual actions, and furthermore, the deliberate avoidance of risky actions.

            The approach is outlined for communication to multiple audiences, the most direct of which is the public at risk for HIV/AIDS. The second audience is the implementing partners that design strategies to address the public health problem of HIV/AIDS. Herein lies a major weakness of the PEPFAR strategy with regards to the ABC approach; this message should not have been directly transmitted to the public and should instead have been a guide for organizations—organizations who care about the core value of health, sickness, and risk—to develop strategies to address the public. If this was PEPFAR’s intention, it wasn’t clear. PEPFAR initially made it very difficult for implementing partners to translate this message in an adaptive and culturally appropriate way. PEPFAR has introduced several mandates over the last decade that supported direct implementation of the ABC strategy in the community. These policies, specifically the publically-dubbed “Anti-Prostitution Pledge” and the 33% abstinence-only mandate relate to funding eligibility (15, 16). The ABC approach was therefore intended for implementation in the population, and this is unfortunate because there are a lot of theoretical fallacies undermining the behavioral approach ingrained in ABC.
            The problems plaguing the ABC approach can be categorized into the what, the who, and the how of the campaign. These categories overlap substantially; the target level (individual versus group) impacts how and to whom the message is communicated and the content of the message causes dysfunction with its dissemination and acceptance. The content of the message, and the framing strategy employed to achieve the goal of reduced HIV/AIDS transmission and addressing the public health problem itself, contains critical flaws. The strategy for targeting the message, for example encouraging individual actions versus addressing the environment and social contexts that surround individual behavioral decisions and attitudes, is unrealistic and often unsuccessful. Finally, the strategies employed in communicating the message to the public would be considered ineffective by many social theorists and would benefit from more audience-directed adaptation and the inclusion of aspects of certain communication models in order to prevent classic reactance responses from the audience. The issues of communication are integrated throughout the entire critique and summarized in a conclusive recommendation near the end of this essay.

The “What”: Guaranteed Prevention, Inevitable Rejection
            As previously mentioned, the ABC strategy places a heavy emphasis on the abstinence component of the prevention model, frequently asserting that abstinence is the best and only certain way to prevent HIV.  A primary objective of this assertion within the overarching HIV transmission reduction goal is to delay the first sexual encounter of young adults aged 15-24 (2).  It’s not difficult to discern the rationale behind the abstinence-as-HIV-prevention approach: HIV/AIDS is a deadly disease, the burden of which is well known in many Sub-Saharan African regions, and abstinence is guaranteed to prevent sexual transmission. Following this logic, an individual who believes that HIV/AIDS is severe and desires to avoid this outcome would likely be willing to take steps to protect themselves, especially if the risk of infection is relevant and realistic. Abstinence is a risk-aversion decision individuals can make with very few barriers, and it seems rational that a risk-averse individual would agree with and internalize this logic. The structure of this behavioral decision making process is embedded in the Health Belief Model (HBM), which states that health behavior is motivated by perceived susceptibility of the outcome in question, perceived benefits of the action required for avoidance, and perceived barriers surrounding that action.  An additional element of the HBM is that of self-efficacy, which is a person’s belief in his or her ability to take action (3). This feature was a later addition to the HBM and is also an integral part of Alfred Bandura’s Social Learning Theory. In many health behavior interventions, self-efficacy has proved to be an often pivotal predictor of success (4). There are some fundamental problems with this approach that render it not only ineffective but in some cases, counterproductive.
            The abstinence approach itself is undoubtedly debatable in terms of effective prevention of HIV/AIDS transmission. Likewise, the HBM is a widely criticized model in the field of public health, and many of those criticisms are relevant to this specific application. But first, we will look at how the approach fails to meet even the basic HBM criteria. The concept of self-efficacy is overlooked in the PEPFAR abstinence strategy. The message conveyed by PEPFAR educational campaigns is that individuals should refrain from engaging in sexual activity, for a number of reasons, but specifically for protecting themselves from HIV/AIDS infection. Again, this logic makes sense. The reality, however, is that culture and nature place pressure on individuals in such a way that young adults may not truly believe they have the power to remain abstinent, even if they decidedly commit to this. PEPFAR program strategies frequently include classroom-based educational programs that incorporate a promise to oneself to pursue abstinence until marriage (2).  The issue with self-efficacy here is that even an individual who has the intention to remain abstinent may doubt that their preliminary decision about how they feel will remain constant over their developmental transition from youth to adulthood – in other words, there are challenges surrounding confidence in terms of commitment to abstinence.
            There are other interpersonal factors that impact the belief in self-efficacy as well within the ABC strategy. The abstinence message is directed at young, unmarried individuals. The PEPFAR strategy employs the Be Faithful component of HIV prevention to encourage married individuals to practice fidelity, thereby reducing the number of sexual encounters (2). A severe flaw in this application of the health belief model is the lack of control an individual has over the actions of their partner, thus undermining the perceived positive outcomes expected from faithful behavior and threatening self-efficacy in performing the risk-reduction activity (3). For example, a woman may commit to a monogamous relationship with a partner who a) has not been tested for HIV/AIDS and could possibly be infectious or b) does not intend to practice fidelity or c) uses coercion or violence (5). These external and internal influences on self-efficacy are detrimental to theory driving the effectiveness of abstinence, as self-efficacy is often reported as an extremely important aspect of successful behavioral interventions, particularly in sexual decision making (4, 6, 7, 8).
Recommendation: Ownership of Sexual Health

            Abstinence is and has always been a challenging health intervention to implement; it works where it works and it doesn’t where it doesn’t. Because it is such an inexpensive tool that carries a level of certainty if used effectively, abstinence will likely remain a central part of HIV/AIDS prevention strategies. Social and behavioral experts have suggested, however, that there are alternative messages – alternative methods, even – that work towards the same goal of reducing the risk for contracting HIV/AIDS. The problem with the abstinence message is that there are barriers to completing and maintaining the action, not to mention all the people that are excluded from the prevention strategy in the first place because of an existing sexually-active life style. The abstinence message does not necessarily fit in the immediate and exploratory world of today’s youth, where preventative health choices based on long term ramifications are somewhat unreasonable to expect. In a world where youth are often inundated with information and instructions, the good intentions of the messages can sometimes be lost. Abstinence, while intended to be a personal decision teens make for themselves, has the potential to be received as an instruction, a rule. Instead of empowering individuals through offering them control of their bodies, the ABC approach dictates what a person should or should not do, thereby removing the freedom of choice, of action, of lifestyle that an individual feels and observes in their cultural environment. Empowerment is of course a valuable tool, but the empowerment needs to be appropriately directed. Rather than encouraging teens to control their risk of disease, the prevention strategies should adopt a more person-based (rather than disease based) ideal that gives teens the opportunity to control their sexual health.
            The PEPFAR initiative suggested list of activities includes promotion of testing, and in fact testing promotion is loosely affiliated with the Be Faithful component of the ABC equation. It is not, however,  asserted or encouraged in any way comparable to abstinence, delayed first sexual encounter, and partner reduction (2). A campaign to learn your HIV status provides people, of all risk levels, with a tool to help prevent HIV/AIDS infection. The empowerment principle has been discussed in the academic world in the setting of HIV/AIDS, although more often in the context of injection drug users and sex workers (9). Expanding the message and integrating it more prominently within PEPFAR objectives could be successful for achieving the ultimate goal of PEPFAR, which is to reduce the transmission of HIV/AIDs.  By suggesting that there are steps you can take to reduce HIV/AIDS and showing you what TO do, rather than what NOT to do, PEPFAR implementers might avoid some of the challenges that reality places on abstinence. Furthermore, if teens are aware of their HIV status, they will likely feel that HIV-free is something they own and there will be a stronger incentive to protect that state of good health. The strategy here is to convince young adults that good health is theirs and that protecting it is easy, rather than informing them how to avoid a state of poor health. Positive reinforcement for responsible sexual decision making has the potential to work more effectively in youth populations (10). The positive tones, empowerment tools, and ownership incentives help discourage that natural feeling of encroached freedom that the commanding abstinence-only assertions invoke.
The “Who”: Beyond Individual Intention

            The criticisms of the ABC approach in regards to self-efficacy are similarly rooted in the innate problems of only targeting an individual’s behavior. Just as self-efficacy is violated because the individual is not fully in control of an activity that involves two people, the approach is flawed by failing to recognize the influence that social norms and peer pressures have on intention and action. The Health Belief Model mentioned previously assumes that people are rational and make decisions internally based on the severity of the health problem, among other things (3). A widespread critique of the model, and therefore its applications in PEPFAR’s ABC approach, is this failure to consider the attitudes and practices at the relationship level and at the community level as well and how those interactions and environments can influence behavior. Social norms are customary codes of a behavior in a group or culture that incorporate beliefs and attitudes as well (3). Based on statistics about premarital and unprotected sex in young adult populations, the cultural norms do not mesh well with the abstinence message. Following the logic of the Theory of Planned Behavior, intention is not enough to predict behavior (3). The attitudes of the individual and of those that they interact with are a key construct in rational behavior. In the case of youth, the opinions of peers carry a heavy weight in influencing attitudes and behaviors, especially in topics concerning drug abuse and sexual behavior (10, 11). The ABC strategy certainly acknowledges the social and cultural context that challenges abstinence, but the response is to equip teens with the skills to resist peer pressure. While this is certainly an important and undoubtedly valuable tactic, it is a mistake to refuse to try and change the social environment that perpetuates risky sexual behavior.
            The Diffusion of Innovations (DOI) theory explains how social pathways and networks play a role in the adoption of an idea or activity (12). There have been many challenges surrounding HIV/AIDS prevention that have impacted the effectiveness of this model for influencing behavior change. The United States government has taken a socially conservative position on condom, family planning, and reproductive services strategies for HIV/AIDS prevention, fearing accusations of “encouraging premarital sex (5).”  Part of this political opinion evolves from the financial and programmatic support from faith-based organizations with a strong presence in Africa and in the HIV/AIDS relief efforts. In addition, African governments consider the topic of sex, and HIV/AIDS in general, to be sensitive and damaging to national reputations, so it’s not uncommon for national leaders to adopt an abstinence-only stance (5). There seems to be an opportunity for diffusion here, considering the national attention, however the problems with the abstinence message itself hinder effective diffusion of innovation.
             In order to successfully employ the Diffusion of Innovations model, the message must exhibit certain attributes. These include relative advantage to existing mechanisms, compatibility with current values and needs of potential adopters, limited complexity, good trial-ability, which is the degree to which an innovation can be experimented with, and observable results (12). The ABC approach conflicts with several of these elements, but most critically it is not compatible to current norms nor does it offer a relative advantage to sex for those who are already sexually active. It is also difficult to measure the non-event associated with the non-action of abstinence.  Studies have shown that using members of a defined population (for example, youth) to reach that particular population have been successful in HIV/AIDS prevention (12). In other areas of public health, celebrities and athletes have been engaged in the communication of important messages as well. These tactics fit with the DOI framework by raising awareness and persuading others to accept. While these tactics are not totally absent from the PEPFAR strategy, their effect seems limited. The flaw here is the failure to use channels of communication to diffuse a more positive reinforcement message and a better “innovation” that blends with cultural activity.
Recommendation: “Social Norms Are People Too” – and can be influenced!

            Considering the flaws of individual-focused behavior challenge models, especially in the face of a problem that involves so many external factors, the PEPFAR strategy’s success would likely improve with the expansion of the intervention target from individual to societal. Some of the main issues that challenge abstinence intervention programs are the susceptibility of teens to social pressures and the inability to have full control over one’s own sexual health. PEPFAR strategies should target the roots of these problems, rather than trying only to arm individuals against the environment. Campaigning for safe sex and encouraging testing through the channels of social adoption is an example of how to nudge cultural norms and attitudes in the right direction. The difference between this and simply changing the HIV/AIDS prevention method is that abstinence may perhaps have been overplayed and devalued over the years of prevention efforts, and a campaign for wider acceptance of testing and communicating status may be an idea that is perceived as new. DOI theory has been cited as an effective method for changing social norms in HIV/AIDS prevention (12). Abstinence is something that is difficult to model, and thus does not fit as well with the DOI model as other activities do. In practice, an activity that requires action rather than deliberate inaction is more likely to gain rapid acceptance in a community, especially in the quick-adopting youth group. In the United States, voting is endorsed by an “I voted” sticker, although it is considered taboo to ask a person about their vote. While of course HIV/AIDS status is a much more sensitive topic, the concept of socially accepted, encouraged activity and the public announcement of participation similar to the American voting culture could potentially translate well into HIV/AIDS interventions.
            Another strategy PEPFAR could mimic from the U.S. voting campaign is the involvement of popular public figures promoting the cause and reporting their own intentions to participate. “Popular” here means liked and relatively relatable, rather than just well-known and revered. These concepts will be further explored in the recommendations for improved methods of communication. The relevant aspect here is the goal of these communication techniques to effect change in the social context. By involving something directly from the culture in the cultural norms evolution, an intervention can influence those factors that predestine individually focused behavioral change models for failure. The importance of environmental and social influences on attitudes, beliefs, intentions, and achievements are supported explicitly by the Theory of Planned Behavior (3) and Bandura’s Social Learning Theory (4).
The “How”: Discouraging Reactance
            So far, the recommendations for improved behavioral interventions related to HIV/AIDS risk reduction have included a new or additional message, an expanded focus that includes social and environmental influences, and better use of the Diffusion of Innovations model for planting the message and fostering widespread acceptance. While the goal of risk reduction to stabilize and reverse HIV/AIDS transmission is still the same, the approach of safe and responsible sexual decision making joins abstinence as a prominent dispatch. The success of these recommendations depends not only on the interaction of the described components, but also on an appropriate, well-designed communication strategy.
            One of the most concerning risks when structuring a communication approach for a public health message is the inducement of psychological reactance. The Psychological Reactance Theory (PRT) is the conditioned reaction of deliberate disobedience to the sensation of threatened freedom and autonomy. The result of authoritative, explicit “advice” is the attraction to the perceived “forbidden” behavior and a somewhat irrational skepticism of the informative source (13). The type of message that generates reactance is that which commands a “don’t,” that which imposes upon the audience an authoritative source, and that which requests a great effort, a serious commitment (14). No matter how the abstinence message is transmitted, the inducement of reactance following this logic seems unavoidable. Information about sex and refraining from sex can be communicated through peers, but the source of information is always understood to have originated from the “adults”, the “don’t” component inevitably overshadows the “engage in abstinence” frame, and the commitment, in the minds of many, is enormous. After incorporating the recommendations about message content, audience, and adoption; intervention strategy should strive to ensure the success of the message through deliberate reactance avoidance. This requires careful selection of a relatable and likable source, aiming to transmit positive feelings, and presenting the recommended activity as desirable and attainable (14).
            The PEPFAR initiative has been instrumental in bringing life-saving treatment to the devastated populations stricken by the HIV/AIDS epidemic. Over the last decade, treatment-focused interventions have transitioned to include sustainable, preventative activities that have curtailed the once rising mortality rate and prolonged the lives of those living with HIV. While scientific evidence drives much of the treatment strategy, the behavioral component underlying prevention efforts leaves more room for interpretation, and PEPFAR’s particular interpretation induces significant criticism.
            The ABC approach to reducing HIV transmission is driven by a powerful message, but there are a number of flaws with the communication, targeting, and even the foundational content of this message that prevent its true adoption in society and thus its effectiveness. Even the PEPFAR ABC strategy guide itself acknowledges the cultural resistance to abstinence, reporting that “40 percent of women in Sub-Saharan Africa have had premarital sex before age 20; among young men, sex before marriage is even more common (2).” The idea that the abstinence strategy itself might contribute to this continued environment seems completely absent as PEPFAR programs continue to push abstinence as the core component of all educational programs. This essay has demonstrated through social behavioral theories and models why certain aspects of the ABC strategy have failed and furthermore, why they will likely never be successful. In addition, this essay has made arguments for the reconstruction of the ABC approach in regards to the “what,” the “who, “and the “how” aspects of the maiden message.  The adoption of an empowering rather than restrictive campaign, the consideration of social norms and how they can be altered, and the cohesive incorporation of the Diffusion of Innovations theory as a communication tool could be influential in changing risk-taking behavior that perpetuates HIV/AIDS.

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