Improving the Efficacy of Condom Distribution at a Small Liberal Arts College – Katelyn Gormley
Sexually transmitted diseases are a pervasive issue that affects young
adults all over the world. According to the Center for Disease Control (CDC),
sexually active young adults ages 20-24 are at a higher risk at being diagnosed
with a sexually transmitted disease than other age groups (6). Half of the 19 million new STD’s cases a year
are among young people ages 15-24 years old (6). Additionally, young adults ages 13-29 years
old account for 39% of all new HIV infections in 2009 (6). Furthermore, sexually
transmitted diseases affect minority students more frequently than their white
peers. African American students are
disproportionally affected by HIV, accounting for 46% of new HIV/AIDs diagnoses
(22), and incidence rates for syphilis, gonorrhea and chlamydia were higher
among African Americans and Hispanic young adults (20). Although both men and
women suffer the consequences of STD’s, women tend to bear the long-term
effects such as pelvic inflammatory disease, tubal scarring, ectopic pregnancy
and chronic pelvic pain (6). Overall, college students are a particularly high-risk group for
contracting and STD or HIV due to a high rate of risky sexual behaviors and
increased incidence rates, but many college students remain relatively
unconcerned about being at risk for HIV/AIDS (10).
When it comes to wearing condoms, young adults are not always consistent
in their use. A study conducted by the
American College Health Association found that among sexually active students, they
used a condom on more or all occasions 51.6% of the time for vaginal sex, 30.2%
for anal sex, and 6% for oral sex (5).
Not consistently wearing a condom during sexual activity puts young adults
at risk for serious health consequences. One public health approach to
addressing this widespread issue of sexually transmitted diseases is condom
distribution. Studies by the CDC have
found that condom distribution programs have been shown to be cost-effective
and cost-saving, by saving up to millions of dollars in future medical costs
brought on by STD’s and HIV (7).
Additionally condom distribution interventions are successful in
increasing condom use, increasing attainment of condoms, and reducing the rates
of STD’s and HIV (7).
One
particular condom distribution program that will be focused on in this paper is
the condom distribution efforts implemented by my undergraduate campus at
Lasell College. Lasell College is a small liberal arts school in Newton,
Massachusetts with a population of more than 1,600 students. The Peer Health Education (PHE) program was
founded in September 2008, by a small group of students interested in raising
awareness on a variety of health topics. By 2012, the group has grown to a
group of 25 students who are specifically trained in sexual assault, domestic
violence, alcohol abuse and sexual health topics. The PHE program at Lasell puts on a number of
events, interactive programs, and awareness campaigns each year, but the most
popular effort by the PHE program is condom distribution. The PHE program distributes condoms at almost
every event, encouraging college students to make healthy choices and avoid
contracting and transmitting sexually transmitted diseases. Despite the great efforts implemented by the
PHE program, students are still engaging in risky sexual behavior. As of 2010, 46% of female students and 42% of
male students at Lasell were not consistently using a condom (17). As hard as the Lasell PHE program works in
preventing sexually transmitted diseases, there are a few critiques that must
be addressed to ensure that students are protecting themselves. This paper will examine three fundamental
flaws in the Lasell PHE program, including the over reliance on the health
belief model, creation of psychological reactance in students and the use of
unpopular condom brands.
Criticism of
Intervention 1: Lasell’s PHE Program Assumes Young Adults use the Health Belief
Model for Decision Making.
The Lasell PHE program’s
main goal in their condom distribution efforts is to educate students on
sexually transmitted diseases and prevent the spread of HIV and STD’s by
providing students with condoms. PHE students work hard at this goal by
distributing condoms at every event they hold, and have specific events on
sexual health, such as World AIDS day campaigns. Unfortunately, the PHE program
heavily relies on the belief that students utilize the health belief model when
making decisions on their sexual health and that student's make rational
decisions.
The health belief model is a model based on a
theory of individual behavior that is motivated by four factors: perceived
susceptibility, perceived severity, perceived benefits of an action, and
perceived barriers to taking that action (11). The health belief models states
that people are ready to act if they believe they are susceptible to the
problem, they believe the condition has serious consequences, and they believe
that taking action would reduce their susceptibility to the problem or its
severity. Additionally, they believe the
costs of taking action are outweighed by the benefits (11). Lastly, it is believed that they have a cue
to action or an external event that motivates a person to act in a particular
way (15).
In terms of
condom distribution, it is believed by Lasell’s PHE program that college
students believe they are susceptible to HIV and STD’s and know of the serious
consequences of contracting a sexually transmitted disease through the
information provided to them from PHE students.
From that belief, they feel as though taking action, such as taking of
the condoms distributed by Lasell’s PHE program, would reduce their
susceptibility. Then when they are in a
circumstance when they need to use their condom, which is their cue to action,
they will use their condom due to the rational decision made through the health
belief model. This belief is flawed because studies have shown that college
students do not perceive themselves at being at risk for HIV or STD’s, which
disrupts the health belief model process from being successful.
A study conducted
by Zak-Place and Stern looking at the effectiveness of the health belief model
in determining STD and HIV preventive behavior of heterosexual college students
found that the health belief model held very little support for safe sex
behaviors and was not an efficient model to depend on for behavior change (25). Zak-Place and Stern found that although
college students understand the threat of STD’s and HIV, and see this is a
serious health concern, they were found to have an incredibly low perception of
vulnerability to STD’s or HIV for themselves (25). This can also be defined as
unrealistic optimism, which is an error in judgment that occurs when someone
does not perceive himself or herself as being victims of misfortune, especially
when it was a more undesirable event (23).
Since perceived vulnerability was not a significant predictor of condom
use, students were not equating this in their decision to use a condom when
they were weighing their perceived risk and benefit (25). This belief of low
vulnerability in turn leads to risky sexual behaviors and low preventative
measures such as not using the condoms they received through Lasell’s PHE
program. Additionally, the use of condoms could be confounded when they are
seen only as forms of contraception, instead of a method of preventing sexually
transmitted diseases. In this
circumstance, college students might not see the benefit of using a condom if
their partner is already using a form of contraception such as the birth
control pill (25).
Furthermore,
reliance on the health belief model shows that Lasell’s PHE program assumes
that young adults act rationally. According
to Dan Ariely, author of Predictably
Irrational, rationality is based off the assumption that humans are capable
of making the best decisions for themselves (1), but realistically speaking
humans are not rational because they often engage in behaviors that are
opposite what’s expected. Additionally,
he believes that understanding irrationality is important in understanding
every day actions and decisions, and understanding the pattern of irrationality
that people engage in over and over (1).
In his book he describes an experiment he conducted on college students
to examine their decision-making skills under sexual arousal, and compared those
decisions to the ones made when they were not sexually aroused. When sexually aroused students were 25% more
likely to not use a condom, than when they were not aroused, showing that
prevention and protection were not significant factors in their decision making
when aroused (1). Therefore, evidence
shows that the health belief model is not an effective model to base condom
distribution efforts on because students do not see themselves as being
vulnerable to STD’s or HIV and do not use rational decision-making skills when
sexually aroused.
Criticism of
Intervention 2: Current Condom Distribution Efforts Can Lead To Psychological
Reactance.
Psychological
reactance occurs when people feel as though their freedom is being threatened,
and as a result they work to restore that freedom (18). Individuals experiencing psychological
reactance attempt to restore their perceived loss of freedom through a number
of ways such as performing the behaviors being criticized or resisting the
behavior being advocated (24). Also,
younger adults are more likely to show higher rates of feeling as though their
personal freedoms are being threatened, making them a difficult age group to
target for health preventative measures such as condom distribution (14). This
is problematic, because the target age group for condom distribution at Lasell
is young adults. Additionally,
psychological reactance not only motivated restoration of the perceived threat
of losing freedom, but it also increased the attractiveness of the criticized
behavior and made young adults want to engage in this behavior even more (4).
Furthermore, if
someone feels as though the person threatening their freedom is not relatable
to them, they will perceive that coercive action to be much worse and not want
to comply with the health preventative measure being introduced (18). Although students run the PHE program at
Lasell, these students can be seen as people who have a sense of authority on
campus due to the training and knowledge they have on sexual health topics and
the general population of might not relate to them when it comes to condom
distribution and safe sex practices. Consequently,
when PHE students tell students to take condoms to protect themselves from
sexually transmitted diseases, the general college population may feel as
though their freedom to make their own personal choices is being threatened and
since they can’t relate to these PHE students, they feel the need to rebel by
not taking a condom. Therefore, it is shown that current condom distribution
efforts implemented by the Lasell PHE program elicit psychological reactance in
the students they are trying to influence.
Criticism of
Intervention 3: Young Adults are Not Interested in Using Generic Brand Condoms
that Health Centers Often Provide for Free.
The condom brands
that are distributed by Lasell’s PHE program are Durex and Lifestyle condoms,
which are the popular brand often distributed in health centers across numerous
college and universities. Although these
condom brands are well known to college students, one brand that is
particularly popular among youth is Trojan, which is the number one condom in
America (8). Health officials and
consumer advocates both agree that in terms of preventing sexually transmitted
diseases, there is no difference in effectiveness between Trojans and the less
expensive Durex and Lifestyle condoms (9). But due to the fact that Trojans are
considered the better-known brand, thanks to rampant television and magazine
advertising, students continue to prefer Trojans over the condoms frequently
given by Lasell’s PHE program (9).
Scientists and
D.C health officials have found that the appeal of Trojan condoms are often attributed
to the company’s marketing strategy, specifically the shiny gold wrapper of the
magnum condoms, which can be associated with something of higher quality such
as a gold watch or gold necklace (9).
Durex and Lifestyle condom wrappers are often solid colors with the
label written all across it, which doesn’t have as strong of an appeal. A study
conducted by the Youth Sexual Health Project confirmed the appeal of Trojans by
finding that students felt Trojan brand condoms were of better quality and protection
compared to other brands (9). They also
found that the brands schools typically give out were viewed as being a cheaper
brand that was more likely to pop or break (9).
I have found this to be true through my experience of as a peer health
educator, for I have heard many complaints from students about the quality of
Durex or Lifestyle condoms. Last year on
World AIDS day, our schools Students Advocating for Equality organization
donated male and female condoms to the PHE program, and one of the brands they
donated were Trojan condoms. Interestingly enough, I had many students come to
my table to take free condoms because they recognized the Trojan condom wrapper
when they walked by and these students were very excited about this brand being
offered. Unfortunately, once the Trojan
condoms ran out, the number of students coming to take free condoms greatly
reduced, showing that brands play a role in the condoms they choose.
Furthermore, this
notion of Durex or Lifestyle being considered lower quality was proven to be
false through an experiment conducted by the New York City Health department in
2009 that took Trojan, Durex and Lifestyle condoms and repackaged them, to
distribute to students. All three condom
brands scored 100% in tests of strength, reliability, leakage and package
integrity (9), showing that there was in fact no difference in the condoms
themselves, except for the way that they were marketed to youth. As seen
through condom distribution efforts in other cities, utilizing unpopular brands
of condoms are not effective in changing student’s sexual behaviors and
increasing the likelihood of safe sex practices.
New Intervention
Proposal: Launch a Marketing Campaign to Change the Culture of Condom
Distribution and Attract More Students to Durex and Lifestyle Condoms.
In its fifth year
at Lasell, the PHE program has come a long way from obscurity to being a
leading force on campus. By 2012, the
PHE program has been able to reach out to every first year student through
presentations and in class workshops, be known as a source of information and
support among their peers, and served as the bridge between faculty and the
student population. Despite their great
success, they have put themselves at risk of joining many college peer health programs
in their unsuccessful attempts at changing sexual health behaviors through
ineffective condom distribution efforts.
Lasell’s PHE has come so far, and has a strong foundation of committed
and thoughtful students that could truly make change in the Lasell community
with the right tools in place. This
paper will now propose a new intervention that will utilize the strong
foundation that Lasell’s PHE program has built in its five years of existence
on campus, but address the shortcomings and create an effective condom
distribution marketing strategy that could change the culture at Lasell.
To begin,
Lasell’s PHE program could distribute surveys or conduct short interviews with
students from the Lasell community to find out what students are looking for in
relationships or in their own personal lives.
From this information, the PHE program will have a better understanding
of the values that students find important and the beliefs they hold about
personal success and relationships.
Utilizing this information from the Lasell community, PHE’s could create
new marketing strategies for Durex and Lifestyle condoms on their Facebook and
Twitter pages that frame the message of the condoms around the core values that
Lasell students find important, instead of framing the message around the
dangers of unprotected sex. For example, if one of the core values was personal
happiness, Lasell’s PHE program could create an ad with a young couple in a
romantic relationship looking happy while spending time together in a dorm room
or with a group of friends, with the Durex or Lifestyle logo in the background. This could demonstrate that this couple has
what Lasell students strive for which is personal happiness, and the couple in
the ad achieved this through using Durex or Lifestyle condoms. Additionally,
this could help students feel as though they have the freedom to choose their
condom brand and that choosing Durex or Lifestyle is their personal choice.
From there,
Lasell’s PHE program could also use the information collected about the communities’
values and select a small group of influential students in the Lasell community,
not affiliated with the Peer Health program, to help market Durex or Lifestyle
condoms. These influential students
could include people who obtain these values and goals that Lasell students
found important and could be represented from popular organizations on campus
ranging from the Rugby team, student government council, the radio station, or
campus activities board. A common approach to condom distribution for Lasell’s
PHE is to distribute condoms outside the cafeteria during peak lunch and dinner
hours to reach a wide spread of students. During these peak lunch and dinner
hours, have members from this small group of influential students individually
take the Durex or Lifestyle condoms from PHE students around other students,
while making small comments such as “these are my favorite kind”, to influence
students to take and use these condoms as well.
This will help build up a buzz about Durex and Lifestyle condoms and
spread the word of their new popularity.
By doing this, the marketing of Durex and
Lifestyle condoms would slowly start to spread among the Lasell community, until
it reached “The Tipping Point”, which would be the moment of success for Durex
and Lifestyle condoms. To sustain this
success, the PHE program should briefly cut back on the distribution of condoms
to create a demand and make students feel as though they have to act fast when
they do see PHE’s distributing condoms.
Once this demand has been established, Lasell’s PHE program could resume
its normal condom distribution frequency, but when they do distribute condoms,
only put a small amount of condoms out at a time so students can continue to
feel as though these are desired items that many people want.
Defense of New
Intervention 1:
The current
condom distribution program implemented by Lasell heavily relies on the assumption
that students use the health belief model in decision-making and that student’s
act rationally. Instead, this proposed
intervention emphasizes self-efficacy, which is an important part of the health
belief model that was added, and was initially left out in Lasells PHE
program’s condom distribution efforts. Self
Efficacy can be described by Bandura as an “individuals'
belief and confidence that they are capable of successfully performing a given
behavior” (2). Additionally, the study by
Zak-Place & Stern, found that self-efficacy is incredibly important in
predicting behavior, and that a college students belief in their own abilities
to make safe sex choices is crucial for decisions they make (1). Also, condom
use self-efficacy is found to be one of the strongest and most consistent
predictors of condom use for heterosexual relationships (3). Lastly, there is a
stronger link of health knowledge and behavior change for individuals with high
self-efficacy, meaning that those individuals are more likely to make better
health decisions (16).
Promoting self
efficacy is instrumental in creating behavior change, and it could be
incredibly beneficial for Lasell’s PHE program to help students use their own
self-efficacy and feel confident in their decisions to make healthy safe sex
choices, by allowing them to feel as though using Durex or Lifestyle condoms is
their personal choice.
Defense
of New Intervention 2:
Currently, the
current condom distribution efforts are implemented by a group of students who
are highly trained in sexual health topics, and may not appear that relatable
to some students. To remove the perceived loss of freedom felt by Lasell
students after having a group of highly trained students tell them to use
condoms, it would be helpful to have non-PHE students help initiate spreading
this message. According to Silvia, interpersonal similarity can help enhance
the health communicator’s credibility, which will result in the likelihood of
compliance by the audience being more likely to agree with a communicator that
they have more in common with (18). Therefore
people may interpret coercive actions, such as condom distribution, as being
less coercive if someone those students feel as though they are connected to
due to similarities is providing that message (18). A study conducted by Valente and Fosados found that targeting a media campaign at a social
network comprised of young adults who hold negative safer sex norms, such as
not using a condom, could help change these norms and increase condom use since
the social network is comprised of
people with similar traits that influence one another (21). Having those similarities can help move the
flow of information and persuade people more easily.
Therefore,
utilizing Lasell students who are not affiliated with the peer health program
to help create the initial buzz about condom distribution could be an effective
solution because the general population will feel more likely to connect with
students who have not received the training a PHE student has and be more
attracted to the idea of using condoms.
Defense
of New Intervention 3:
A common flaw of many public
health programs and Lasell’s PHE program is that they market products that they
think people will want, such as condoms to protect themselves from STD’s and
HIV. D.C Council member and chairman of
the health committee that implemented the use of Trojan condoms into Washington
D.C schools said “we thought making condoms available was a good thing, but we
never asked the kids what they wanted” (9).
Therefore, it would be beneficial for Lasell’s PHE program to distribute
surveys and conduct short interviews to find out what students in the Lasell
community would want for their personal lives and relationships, along what
they want from their condom brands, and then frame the new campaign to hit
those core values. Framing is the way in
which many public health programs have been able to steer their targeted
population to the desired behavioral intervention by using the core values that
population holds (13). Also, the framing
message in the proposed intervention would help influence the public opinion on
condom use and change individual behavior.
Additionally, the
benefits of building up a buzz about Durex and Lifestyle condoms can be seen
from a popular example of a shoe brand that came back to popularity through
similar techniques. The popular example is
the case of Hush Puppies, a shoe brand that almost went out of style, until a
small group of young adults started wearing them out to clubs in New York (12). This trend quickly spread by word of mouth,
and influenced a whole culture of young adults to start wearing this particular
brand of shoes (12). Similar to the
spread of popular shoe brands, no advertising company would be telling students
to use Life style or Durex condoms because they were “cooler” or “better” than
Trojans. Instead a small group of influential
students would expose other people to this brand by openly taking the condoms
by PHE’s and discussing causally how they enjoy using this brand. By doing
this, the marketing of Durex and Lifestyle condoms would slowly start to spread
among the Lasell community, until it reached the tipping point, which is a
dramatic moment of critical mass where it officially is a widespread phenomenon
(12). Lastly, it’s been found that massive social changes that can influence
the culture of a market, or in our instance a college campus, start with a
small social nudge. This small social
nudge seen in the proposed intervention, is the small group of influential
students nudging students to take condoms from the PHE program (19). This is
found to be effective due to the fact that humans like to conform to what is
the popular choice at that point in time, such as taking and using condoms, and
are influenced by their beliefs of what other college students do, therefore
changing the culture of condom use. (19).
As a result of
this proposed public health campaign, Durex and Lifestyle condoms would become
a much more popular brand and Lasell’s PHE program would have a much more
successful at influencing students to take condoms and make better sexual health
choices.
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Labels: Adolescent Health, Health Communication, Platinum, Sexual and Reproductive Health
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