Saturday, December 15, 2012

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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