Thinking Through “Baby Think It Over”: A Proposed Intervention for Teen Pregnancy Prevention--Kate Reed

Introduction

“Baby Think It Over” is a parenthood-simulation program created by Reality Works, Inc. that is used mostly in middle schools as a mechanism to prevent teen pregnancy.  Students are each given an infant simulator named RealCare Baby – a lifelike, life-size baby doll with computerized responses.  According to Reality Works, the doll is set to cry at varying intervals, cueing the students to feed, burp, diaper, or comfort it.  An internal computer monitors how often and how quickly the students respond to the crying, as well as if the doll is shaken, dropped, or otherwise handled roughly.  It even senses if the students do not support the “infant’s” neck.  The teens keep the doll over a weekend in order to experience some of the demands of infant care. 

At its peak, “Baby Think It Over” was used in more than 12,000 school districts and health and service organizations in the US (RealityWorks).  Schools that decide to participate can adjust the program to fit their needs; it is up to the individual school or program to determine which students will participate – girls and/or boys, older or younger. Some schools and programs are unable to use “Baby Think It Over” due to the enormous cost of the program; each infant simulator costs around $700, and schools must also buy baby care supplies and replace infant parts every few years (RealityWorks).  “Baby Think It Over” is unable to provide statistics showing that its doll works – the company wants to collect the data but for now it relies on “strong anecdotal evidence” (Drawbaugh).  In terms of wanted teen pregnancies, the program has been found to have either no effect on the desires of students to be teen parents or to actually increase the number who want to (Kralewski).  Infant simulators are an expensive and complex intervention for teen pregnancy, and their effectiveness is questionable.  One paper states that “simulated experiences can be a powerful strategy for effective learning about complex decisions regarding the risks of sexual activity and the realities of parenting” (Didion), while another paper argues that the “effectiveness of using infant simulators to influence the perceptions of teens about the reality of teen parenting is minimal” (Herrman). 

 “Baby Think It Over” has three fundamental flaws that prevent it from ever being successful.  First, the program has no clear goal and bases its assumptions on the Theory of Reasoned Action.  Second, the program induces psychological reactance in its participants.  Third, the program is ineffectively delivered and gives mixed messages.  The proposed intervention takes a different stance on teen pregnancy prevention, and aims to correct for the three fundamental flaws of the “Baby Think It Over” program previously discussed.

Critique 1

         A major problem of the “Baby Think It Over” program is the lack of a clearly defined goal.  It wants to prevent teen pregnancies, but it does not distinguish between wanted and unwanted teen pregnancies.  It also does not specify whether the solution to teen pregnancy is safe sex or no sex at all.  Ostensibly, the goals of the project are to help students realize the responsibility of having a baby, and presumably that they need to wait before having children.  However, Richard Jurmain, the creator of the program, maintains that the main lessons learned from the program are not about values but "sleeplessness," which as he states, "is a compelling rationale for not getting pregnant” (Cheakalos).

The “Baby Think It Over” program is also based on the Theory of Reasoned Action, and therefore makes incorrect underlying assumptions about why teens get pregnant.  According to the Theory of Reasoned Action, people have rational decision-making processes and skills, and decsions are influenced by two factors: a person’s attitude towards the heavier and their perception of social norms (Edberg).  If the goal of the program is to prevent wanted teen pregnancies, then the underlying assumptions

are that teens actively choose to become pregnant, and that they want to become pregnant because they do not understand how difficult parenting is.  If the goal of the program is to prevent unwanted teen pregnancies, then the underlying assumptions are even more ridiculous: teens choose to have sex, and choose to have unprotected sex, because, again, they do not understand how difficult parenting is.  The problem with this is that human behavior is not always rational, especially when erections are involved (Ariely).  In fact, according to Dan Ariely’s book “Predictably Irrational,” subjects were more than twice as likely to engage in risky sexual behavior and 25 percent less likely to use a condom when asked in a “hot” aroused state than a “cold” non-aroused state.  Also, the majority of teen pregnancies are unplanned, meaning that no rational decision – at least about the difficulty of parenting – was made at all (Finer).

Critique 2

 A second problem with “Baby Think It Over” is the degree to which is induces psychological reactance in its participants.  The program gives students infant simulators to convince them to wait to have children, and therefore in order to be successful the program needs its participants to fail at their parenting tasks.  In reality, some students inevitably end up scoring highly, thereby defeating the whole purpose of “Baby Think It Over” – to prove that parenting is hard.  In fact many students state that they found “Baby Think It Over” to be easier than they expected it to be, and they believe that real infant care will probably be even easier (Kralewski).  More importantly though, according to the theory of psychological reactance, giving teens a message that they “cannot” do something – for example, be a parent – will make them want to do it more.  The theory posits that when people feel that a freedom is threatened, they experience a motivational state aimed at restoring that freedom (Silvia).  “Baby Think It Over” induces psychological reactance because it is attempting to take away teens’ freedom to have sex, something which nearly-mature bodies and still-maturing minds are intensely concerned with. 

Critique 3

         A final critique of the “Baby Think It Over” program is the way it is delivered – the instructor is not effective and the program has implicit mixed messages.  Because teens as young as thirteen take part in this program as a school project, it is important for the instructor to be relatable and respectable.  The instructor is often not relatable to the students due to age and race differences.  The program is also delivered with mixed messages: the students are told to take the project seriously and reflect upon the hardships of being a teen parent, but at the same time they are given bonus points if they take lots of pictures with their “baby” and create “family” photo albums (Borr).  As previously stated, although the program is based on a premise that students will fail, this is not always the case.  Not only do students often find the project to be easy, they also find it to be fun – some students throw baby showers and birthday parties for each other and their “babies” (Borr).  The mixed messages, combined with the fact that they are coming from a non-similar, not necessarily respected adult, do not create a strong lasting impression.

Proposed Intervention

         The proposed intervention aims to correct the fundamental flaws present in “Baby Think It Over” with a new intervention focused on empowerment and control.  The data is unclear on whether or not infant simulators have the potential to be effective in preventing teen pregnancy, even if the program surround the simulators is changed.  Therefore, the proposed intervention will abandon the use of infant simulators.  Also, because the proposed intervention is not assuming that teens get pregnant for lack of parenthood knowledge, an infant simulator is unnecessary anyways.

         In reality, teens get pregnant due to an interacting web of factors, but one of the most significant underlying factors is a feeling that they are not in control of their own lives.  The teenage brain is not fully developed, and teens are more likely to engage in risky behavior, think less about consequences, and focus on only immediate effects and consequences than a fully developed adult brain (Hedaya).  When teens feel that their futures are not under their own control, their inherent inability to think rationally is compounded.  In terms of sexual behavior, they are more likely to engage in unprotected sex, have multiple partners, and generally increase their risk for pregnancy (National Campaign).  The feeling of a lack of control arises from a number of factors such as low socioeconomic status, life stressors, living in an impoverished area, and community or cultural norms.  If teens live in an area where no one reaches their goals then the teens will not expect to reach their own goals either.  Likewise, if teens see their peers having children young then they will begin to think it is the norm.

         What the proposed intervention aims to do is break this cycle of learned helplessness by empowering teens.  The core value of the program is “control.”  Teens in high risk areas will be part of small focus groups, available at school or through community centers, where they will have discussions and do exercises that focus on empowerment and controlling their own lives. 

Defense 1

         The proposed intervention has a clearly defined goal: to make safe sex the natural choice in order to prevent unwanted teen pregnancies.  The intervention acknowledges that many teens will chose to participate in sexual activity, and rather than explicitly attempting to prevent that activity it will instead attempt to make it safe.  The intervention aims to prevent unwanted teen pregnancies because the majority of teen pregnancies are unwanted, and because the underlying factors in wanted teen pregnancies are far more complex and beyond the scope of the intervention.

         In order to make safe sex the natural choice, the intervention will focus on empowering teens to realize why safe sex is the best option for them.  The underlying assumption of the intervention is that unwanted teen pregnancies happen because of a lack of control.  According to Kathryn Edin’s book “Promises I Can Keep,” women who have no access to opportunities use children as validation; the unconditional love of a child and the attention they bring is a replacement for academic or professional success, intimacy, etc.  In a way “Baby Think It Over” reinforces this because other people often give participants excessive attention while they are caring for their “baby” (Borr).  To address this, the proposed intervention will empower teenagers to realize their opportunities, dreams, and desires, and that getting pregnant will reduce the control they have over their own futures.  This will be a lot more effective than patronizingly assuming that teens get pregnant because they are ignorant to the trials of parenthood. 

Defense 2

         Where “Baby Think It Over” induces psychological reactance by impeding on personal freedom, the proposed intervention will instead make teens induce psychological reactance on themselves by getting them to visualize themselves fulfilling their dreams, so if they do something that prevents those dreams, such as getting pregnant, then they are taking away their own freedom.  The intervention also aims to increase the number and kind of positive freedoms teens feel they have.  Many teens have an optimistic bias about teen pregnancy, thinking, “It won’t happen to me.”  Optimistic bias is the tendency of people to be unrealistically optimistic about their own future life events and the expectation of others to be victims of misfortune rather than themselves (Weinstein).  Even if teens do realize their susceptibility to the threat of teen pregnancy, they often have an inverse illusion of control and feel like whether or not they get pregnant is not under their control.  The illusion of control is an expectancy of personal success greater than is appropriately warranted due to an incorrect assumption of control over chance situations (Langer).  Therefore, an inverse illusion of control could be thought of as an incorrect assumption of chance in situations which one does have control over; learned helplessness in a sense (Langer).  The program will address these things by talking about different contraception choices as well as healthy relationship practices, showing teens that pregnancy is within their control and it is their freedom to exercise that control.

         It is also important that the program not increase the stigma of being a teen parent further.  Many teenagers in high risk areas have exposure to teen parents – they know teen parents, they were the child of a teen parent, etc.  Therefore, a program that is insensitive and not careful in its language and underlying messages will increase psychological reactance by angering and alienating the participants.  Furthermore, it is important for teens who are already parents to know that it is still possible, on some level, to achieve their dreams and desires.  The program does not aim to say “you cannot achieve your dreams with a baby;” it simply aims to say “reaching your goals is easier without a baby.”

Defense 3

“Baby Think It Over” struggles to leave a lasting impression on its participants due to its mixed messages and non-similar instructors.  Communications theory and the theory of psychological reactance both show that a message is more effective and persuasive if the person delivering it likeable, familiar, and similar to the target population.  Furthermore, the message itself should be clear and concise, have justification, and have positive associations.  For this reason, the program will be delivered by role-models who are similar in race and age to the target population, and likeable.  The program will also engage familiar community leaders to back the message, further increasing its effectiveness.  For example, if the program is being implemented in a school then a well-liked student body president will be involved in delivering the program.

This piece of the program is particularly necessary for encouraging condom usage.  Social expectation theory shows that individuals take behavioral cues from groups by observing the social norm (DeFleur).  Therefore, if the program makes condoms appear to be the social norm, they will in fact become the norm.  There are several ways in which the program will attempt to make condoms the social norm.  First, the familiar community leaders will endorse them.  Second, condoms will be readily available and free in schools, community centers, apartment complexes, and anywhere else the program is implemented.  Third, advertising for condoms that is created by the program will bear a promise of control over one’s own life and will contain popular music and images.  In this way, the program can attempt to alter social norms and make condom usage the natural choice.

Conclusion

         “Baby Think It Over” is a fundamentally flawed program for three reasons: it has unclear goals and incorrect assumptions based on rational behavior patterns, it induces psychological reactance in its participants, and it is delivered ineffectively and with mixed messages.  The proposed intervention to prevent unplanned teen pregnancy corrects for those fundamental flaws by setting clear goals based on accurate assumptions about teen sexual behavior, it is formatted to minimize psychological reactance, and it is delivered in an effective way following theories of communication and social norms.  Ultimately, the proposed intervention would enhance teens’ feelings of control over their own lives and help them to realize their life potential.  Combined with effective advertising and adjustment of social norms in the community, this would make safe sex the natural choice.

Works Cited

§  Ariely, Dan. Predictably Irational: The Hidden Forces That Shape Our Decisions. New York: Harper Perennial, 2009.

§  Borr, Mari L. “Baby Think It Over: A Weekend with an Infant Simulator.” Journal of Family & Consumer Sciences Education (2009). NATEfacts.

§  Cheakalos, Christina. “Shrieking Baby Doll Gives Jolt of Parenthood for Teenagers.” Editorial. Herald-Journal [Atlanta] (1994). Google News.

§  DeFleur, M. Theories of Mass Communication. White Plains, NY: Longman Inc., 1989.

§  Didion, J., and H. Gatzke. “The Baby Think It Over Experience to Prevent Teen Pregnancy: A Postintervention Evaluation.” Public Health Nursing (2004). PubMed.

§  Drawbaugh, Kevin. “Baby Doll Teaches US Teens about Parenthood.” Editorial. The Nation [Chicago] (1997). Google News.

§  Edberg, M. Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Sudbury, MA: Jones and Bartlett Publisher, 2007. Course Reader.

§  Edin, Kathryn, and Maria Kefalas. Promises I Can Keep: Why Poor Women Put Motherhood before Marriage. Berkeley: University of California, 2005.

§  Finer, L.B., and Kost, K. “Unintended Pregnancy Rates at the State Level.” Perspectives on Sexual and Reproductive Health (2011).

§  Hedaya, Robert. “The Teenager’s Brain.” Psychology Today (2010).

§  Herrman, J.W., J.K. Waterhouse, and J. Chiquoine. “Evaluation of an Infant Simulator Intervention for Teen Pregnancy Prevention.” Journal of Obstetric, Gynecologic, and Neonatal Nursing (2011). PubMed.

§  Kralewski, J., and C. Stevens-Simon. “Does Mothering a Doll Change Teens' Thoughts about Pregnancy?” Pediatrics (2000). PubMed.

§  Langer, E. “The illusion of control.” Journal of Personality and Social Psychology (1975). Course Reader

§  National Campaign, The. The National Campaign to Prevent Teen and Unwanted Pregnancy. Web. [http://www.thenationalcampaign.org/]

§  Reality Works, Inc. Realityworks - Experiential Learning Technology. Web. [http://www.realityworks.com/]

§  Silvia, Paul. “Deflecting reactance: The role of similarity in increasing compliance and reducing resistance.” Basic and Applied Social Psychology (2005). Course Reader.

§  Weinstein, N. “Unrealistic optimism about future life events.” Journal of Personality and Social Psychology (1980).  Course Reader

HPV Vaccine: Getting Young Men In On It Using Social And Behavioral Science Theories– Mary Buckley

Human papillomavirus (HPV) is the most common sexually transmitted disease in the United States and a known risk factor for oropharyngeal and anogenital cancers, especially cervical cancer. The US Food and Drug Administration approved Gardasil for HPV vaccination in 2006. Gardasil protects against four strains of HPV, two of which cause about 70% of cervical cancer while the other two cause about 90% of anogenital warts (1). There is enormous public health potential for reduction in negative outcomes associated with HPV infection if a large enough number of young people are vaccinated and are no longer able to acquire or transmit infection to sexual partners. Individual immunity is important, but a large enough population vaccination provides protection to those who are still susceptible. Thus, regardless of individual risk, vaccination decreases the greater risk of the general population (2)(3).  

The FDA initially approved HPV vaccination for use among young women, recommending that young women age 11-12 be vaccinated, with catch-up vaccination recommended up to age 26. The idea is to have women vaccinated long before their first sexual encounter and, in doing so, prevent future cervical cancer caused by infection. However, in 2009, Gardasil was approved for use in boys and young men age 9-26 (4) and is now recommended by the Centers for Disease Control and Prevention (CDC) for young men between the ages of 11 and 12 with catch-up vaccination recommended up to age 21 (5).

The CDC currently provides educational information on their website and in pamphlets regarding HPV in both men and women. Since the age recommendation for vaccination is 11-12, much of the information provided by the CDC is directed toward parents. However, there is information that is geared toward young adults who are learning to make their own health decisions. Furthermore, young adults will receive this information from their primary care physicians who will recommend vaccination if it has not already been administered. This paper will focus on the age group of young adults, specifically the target audience of young males for whom HPV vaccine was most recently recommended. There is no formal “campaign” directed toward this audience, but this paper will critique the current model of recommending HPV vaccination to young men. 

Critique 1: Public Health Paradigm In Marketing

            The CDC’s current marketing of the HPV vaccine (both for young men and for young women) employs the traditional public health paradigm by using the core values of health and safety. Although heath and safety are strong core values for those working on public health campaigns at the CDC, they are not the ultimate core values of the general public, especially not of the audience of young males to whom the CDC is trying to “sell” the importance of HPV vaccination. The CDC presents “fact sheets” that provide information specifically for men (6) and general information about the vaccine and dangers of HPV infection for both genders (7).

             According to the CDC’s information, men should receive the HPV vaccine to prevent genital warts and cancers of the anus, penis, and oropharynx (6). However, a majority of the general information on HPV vaccine focuses on prevention of cervical cancer. Cervical cancer is the second most common cancer among women worldwide and its burden is strongly associated with socioeconomic disparities (1). Although cervical cancer caused by HPV is certainly a major public health concern, the use of cervical cancer prevention as the means of promoting vaccination excludes the male audience.

            To maintain use of the health core value in promoting HPV vaccination among males, the CDC provides a lot of information about the serious health effects of HPV infection experienced by males. As mentioned above, these health effects include some types of cancer in addition to genital warts. Gardasil protects boys and men against most types of HPV that can cause anal cancers and genital warts. However, the CDC fact sheet goes on to express how uncommon these health problems are among straight men and men who are immunocompetent (6). So, even if men are concerned about the health problems associated with HPV infection, they are unlikely to be motivated to request HPV vaccination solely by reading this information on a fact sheet. They might actually be dissuaded from vaccination upon learning that they are not among a group that can be seriously affected by HPV infection.

            Menashe and Siegel describe the importance of a strong frame and use of framing theory in their article “The Power of a Frame: An Analysis of Newspaper Coverage of Tobacco Issues – United States, 1985-1996.” Although their article discusses the framing battle between tobacco companies and tobacco control organizations, the concept of framing theory applies to any public health campaign. When developing a frame, core values other than health are much more compelling. Tobacco companies have been successful for so long because their campaigns consistently target very strong, human core values such as personal freedoms and civil liberties (8). These core values have kept the tobacco companies’ argument relevant despite the ever-growing wealth of information about health implications of smoking and tobacco use. As seen in the case of HPV vaccination, the core value of health does not hold up amid changes in vaccination recommendations.    

            Furthermore, appealing to the core value of health provides a platform for arguments about vaccine safety and potential side effects or risks associated with HPV vaccination. Regardless of gender, an argument exists regarding the safety of vaccines. The CDC’s fact-sheet for men directly addresses this concern by referencing the many successful studies carried out to determine the safety of Gardasil in both men and women. Researchers have not found any serous adverse events associated with HPV vaccination (6)(7). However, the concern about adverse events often gains a great deal of media coverage when it is brought up. Therefore, the health core value can be taken away from the vaccination campaign and used against it in an anti-vaccination argument about dangerous side effects.

            Social marketing has gained a lot of popularity among public health organizations and public health campaigns are using commercial marketing concepts to promote behavior change. In their overview of the use of social marketing in public health promotion, Sonya Grier and Carol Bryant describe the importance of offering benefits that the consumer (not the public health professional) truly values when developing a marketing strategy (9). As such, the most important aspect of marketing is researching what it is that people want most and then using that information to “package” the product in ways that fulfill those deepest desires. The CDC does two things in its HPV vaccine promotion that contradict the recommendations of Grier and Bryant. With health as a core value, young men who choose to be vaccinated against HPV will generally not receive a valued benefit in return for their decision. Health information about HPV does not touch at the deepest held values of young males in the United States. Additionally, the HPV vaccine campaign does not take into account the fact that it is not possible to simultaneously appeal to all types of people. Successful social marketers know “it is not possible to be ‘all things to all people’” (9). The CDC’s information sheets are not making use of marketing to the values of the specific population of interest. The “HPV and Men- Fact Sheet” has images of happy young men and provides information specific to the gender, but the message is not packaged in a way that appeals to their values.

Critique 2:

            In addition to the weakness of the core value around which the HPV vaccine message is developed, the way in which that message is given to its audience violates communications theory. Communications theory holds that the context of a message affects how persuasive that message is to its audience. The message about HPV vaccination being given to young men is not likable and does not have positive associations. When and where people encounter a message is crucial to how they respond to the information.

            In their 1965 paper “Facilitating Effects Of ‘Eating-While-Reading’ On Responsiveness to Persuasive Communication,” Janis et al. describe the tendency of people to yield to persuasion when they are engaging in a gratifying activity.  Their experiments focused on changing opinions of study participants (undergraduate students) given persuasive written communications in the setting of eating free food or no food (10). When students were eating, they were more likely to accept the messages that they were given. These study results were significant, but certainly did not elucidate a novel concept. Salesmen, businessmen, and lobbyists often use the same strategy when they “soften up” clients (10). They present their message to clients around a dinner table or at a café rather than in a conference room or office. The HPV vaccine promotion fails to take this strategy of persuasive communication into account. The CDC provides information to young men in the form of health pamphlets that are normally distributed at health care centers. Also, much of the information provided by the CDC is geared toward medical professionals who are encouraged to bring it to the attention of their patients. A doctor’s office is not an environment that is often associated with gratifying experiences. In fact, a doctor’s office may have the opposite effect because of the association with illness.

               In her chapter “Thinking Positively: Using Positive Affect When Designing Health Messages,” Jennifer Monahan describes “heuristic appeals” as the “first step in enhancing the likelihood that individuals will engage in thoughtful processing” (11). So, unlike the Janis et al. experiment affecting students’ acceptance of messages at one point in time, Monahan emphasizes that repeated exposure to the positive heuristic cue leads to a positive feeling toward the message (11).  HPV infection is not something that necessarily affects most people’s everyday lives, so it would make sense that young men would not seek out and evaluate information on HPV vaccination. Therefore, only receiving information from a doctor or in a health information setting can make the initial association with the message negative or, at best, neutral.

            A primary exposure to a message that can be associated with a mood or feeling influences subsequent decisions related to that message. The CDC does not take advantage of the possibility to harness the primary exposure and associate it with a positive mood or feeling.

Critique 3:

Not only does the CDC choose the wrong setting to communicate the message to young males, but also the person delivering the message violates the communication theory concept of similarity. The HPV vaccine message to young men comes primarily though patient/health care provider counseling. Therefore, there is a lack of similarity between the messenger and the target audience that can foster psychological reactance. Psychological reactance emerges when individuals feel that their freedom is threatened. Social psychologist Jack Brehm, who developed the theory, explains that when people sense a threat to their freedom, they try to reestablish that freedom by acting in the opposite manner of that being directed (12). Although it might not seem as though doctors are threatening the freedom of young men regarding HPV vaccination, the message coming from a person of authority does create reactance in an audience. Young adults like to consider themselves “worthy of determining their own health outcomes,” and they receive numerous messages “prescribing and prohibiting many of their prospective behaviors” (13). So, the doctor-patient conversation about the benefits of HPV vaccination could have the opposite effect of that desired by proponents of vaccination. Young men might seek to restore their “threatened freedom” by refusing vaccination solely on the basis of the messenger. 

Paul Silvia’s research on reducing resistance identifies similarities between messenger and audience as a way to reduce or “deflect” reactance (14). Silvia’s experiments found that interpersonal similarity reduces resistance even in the context of a threat to freedom. A threatening message given to his undergraduate research participants by a similar communicator was still persuasive despite jeopardizing freedom. In these experiments, similarity was as simple as a shared birthday, first name, gender, year in school, or shared values reported on a scale of importance (14). However, the CDC does not take this importance of similarity into account in its promotion of HPV vaccination for young men.

It is probably difficult for young men to establish similarity with their physicians and, although there are pictures of young people on information brochures, those young people are not the ones providing the message. For example, one CDC HPV brochure contains five pictures of young people (both men and women) with tattoos and dressed in sexy, age-appropriate clothes. Most pictures portray couples in intimate positions. It is possible that young men relate to the individuals in these pictures; however, none of the pictures show peoples’ faces (15). This stylistic choice might have been made for a reason, but it makes it difficult relate to the people in the photographs. It also makes it especially challenging to establish that these young people are the ones giving the message detailed in the brochure. Therefore, including these pictures does little to reduce psychological reactance.

Suggested Intervention

            I suggest that the CDC invest in a targeted advertising campaign promoting HPV vaccination in young males. Although there are literature and brochures available for young men, there is no effective communication that frames the topic favorably for this target audience. The recommendation for male HPV vaccination is relatively new and is preceded by the recommendation for young women as prevention of cervical cancer. So, understandably, there has not been the same amount of time and research invested in promotion of vaccination for young males. However, their vaccination is crucial in the development of herd immunity to HPV strains that cause cancer and genital warts. The message needs to reach young males outside the context of a health care setting. Although an advertising campaign for HPV vaccination among women exists, it cannot be tailored to “fit” the young male population. An entirely new advertising campaign is required that makes use of extensive research of the target audience, associating the message with a positive mood or feeling, and communication through people who establish similarity with the target audience. 

Intervention 1: Research The Target Audience

            To develop an effective marketing strategy for HPV vaccination among young men, the CDC needs to appeal to a stronger core value than that of health. It is important to provide specific information about disease and health, but investing in research for a marketing campaign could make the target group much more receptive and reach those people who would have had no interest in reading or talking about HPV. Investing in research about the values of the target group would involve developing an understanding of the target audience’s “needs, aspirations, values, and everyday lives” (9). Grier and Bryant suggest that such research does not need to be expensive or complex. Consumer data may already exist for that target audience. Also, it can be beneficial to involve consumers (young men) as partners in the planning process.

            A great example of successful marketing research for a  young adult audience is the “Truth” campaign that effectively reduced youth tobacco use in Florida between 1998 and 2000 (16). This campaign had a lot of money available to afford cutting edge marketing resources (17), but the same strategy can be successful in any public health campaign. The marketing team for “Truth” spent a great deal of time on research and conducted hundreds of interviews with members of their target audience (17). Thus, they were able to develop a youth-guided marketing campaign with an effective “brand” for anti-tobacco.

            One very important aspect of marketing theory that “Truth” addressed is focusing the message and not trying to apply it to too broad of an audience. It can be tempting to use resources to try to develop a marketing campaign that reaches the largest number of people, but this is not the intention of marketing. It is important to establish the specific target group and let research on that group dictate the direction of the marketing campaign. Therefore, an HPV vaccine marketing campaign needs to be developed for young men independent of a campaign for young women or parents. This may seem obvious, but having different campaigns does not just mean different literature. It requires targeted research and the creation of a marketing team with input from the intended audience.       

In their study of motivations for exercising, Segar et al. look at the connection between goals and behavior. Women in their study were more likely to adhere to exercise goals related to daily quality of life than healthy aging, despite reporting equal value attributed to each. Segar et al. affirm, “immediate payoffs motivate behavior better than distant goals” (18). So, an HPV vaccination marketing message needs to appeal to young men with a core value that is stronger than health and promise to fulfill the immediate goals associated with that core value.

Intervention 2: Associate The Message With A Positive Mood

            To effectively utilize communication theory for HPV vaccination, the CDC needs to find a new context for the message. When, where and with what associations the topic is addressed all need to be taken into account. Taking the message of HPV vaccination for young men outside the doctor’s office would be the first step in this intervention. Finding a setting in which it would reach young men while they are in a favorable mood is the key. Not all of the information that is covered in the CDC’s brochures needs to be included in the advertisement message. It is most important that the audience is primed to consider the topic in a favorable light.

            Television and radio advertising provide a great way to reach the target audience outside the health care context. Advertising time slots during sporting events can take advantage of a positive mood, especially for the target audience of young men. Considerable funding behind the Florida “Truth” campaign allowed them to run advertisements on channels and at times with high teen viewership like on MTV and during broadcasting of the Superbowl (17). But even without significant funding, one can develop an advertisement that creates its own association with a positive mood. Monahan writes that heuristic appeal can come from the use of a popular song or visual imagery, providing a cue for positive feeling toward the message (11).

                Gerald Gorn conducted experiments to determine the relationship between hearing liked or disliked music and product preference (19). Apart from just music, his study question is whether or not “background features” of advertisements affect attitudes. His results indicate that the presence of “liked” music can cause people to choose a certain product when there is very little product information provided (19). Gorn mentions that people are often exposed to commercials when they are not considering buying the advertised product, and it is in those situations that background features are most important. In the case of HPV vaccination, young men are not considering the “product” of vaccination, so product information is not as influential as background stimuli that can arouse emotion. Very little specific information about HPV actually needs to be in the advertisement because such information will be presented by a physician once an individual has developed a positive attitude toward the “product.”

Intervention 3: Establish Similarity

The  “One Less” advertisement put out by Merck, the pharmaceutical company that makes Gardasil, is a good example of establishing similarity between the messengers and the target audience. Merck’s “One Less” campaign has designed its website to include pictures of young men since Gardasil is now recommended for them (20), but the advertising message is still directed toward young women. The same advertising campaign cannot be tailored toward young men because the message specifically empowers women to be “one less” statistic of cervical cancer (21). However, the use of similarity in this advertisement is a good example of a way to reduce reactance. The advertisement starts out with a young girl skateboarding. She says that she could be “one less” woman to learn that she has cervical cancer. Other young women join in with the same statement while they are playing basketball, horseback riding, playing drubs, and dancing (21). The people portrayed effectively identify with strong, independent young women. The target audience of the advertisement will likely find interpersonal similarity with these young women and identify them as embodying ideals of their age group.

An HPV vaccine campaign for men could benefit from a similar approach. The focus of an advertisement would be young men engaging in activities to which their audience can relate while providing their own reasons for receiving HPV vaccination. The primary goal in the development of the advertisement would be to make the actors likable through similarity. Silvia writes that similarity “creates liking” which is the “positive force towards compliance” (14). Rather than coming from a doctor or health care provider, the message would be from a more likable figure who would not inspire the same reactance. 

Conclusions

            There are certainly challenges facing the CDC in any HPV vaccination campaign targeting young men. As I mentioned before, the CDC does not currently have a formal HPV vaccine campaign for men, nor does the pharmaceutical company that produces Gardasil. However, the CDC does provide a good amount of information (in the form of brochures and recommendations for physicians) intended to motivate young men to get vaccinated. An advertising campaign by the CDC could make young men more receptive to information about HPV vaccination. However, HPV vaccination affects men differently than it does women; so, consumer research and effective use of communication theory will be crucial to successfully influence the vaccination decision of young males.    

References

1.     Fernández ME, Allen JD, Mistry R, Kahn JA. Integrating Clinical, Community, and Policy Perspectives on HPV Vaccination. Annu Rev Public Health 2010 Apr 21; 31:235–52.

2.     Giuliano AR. Human papillomavirus vaccination in males. Gynecologic Oncology 2007 Nov; 107(2, Supplement):S24–S26.

3.     Villa LL. Prophylactic HPV Vaccines: Reducing the Burden of HPV-Related Diseases. Vaccine 2006 Mar 30; 24, Supplement 1(0):S23–S28.

4.     U.S. Food and Drug Administration. Approved Products > October 16, 2009 Approval Letter – Gardasil. Silver Spring, MD: Division of Communication and Consumer Affairs, Food and Drug Administration, 2009. http://www.fda.gov/BiologicsBloodVaccines/Vaccines/ApprovedProducts/ucm186991.htm

5.     Centers for Disease Control and Prevention. Vaccines and Preventable Diseases: HPV Vaccine- Questions & Answers. Atlanta, GA: National Center for Immunization and Respiratory Diseases, 2012. http://www.cdc.gov/vaccines/vpd-vac/hpv/vac-faqs.htm

6.     Centers for Disease Control and Prevention. HPV and Men – Fact Sheet. Atlanta, GA: Centers for Disease Control and Prevention, 2012. http://www.cdc.gov/std/hpv/stdfact-hpv-and-men.htm

7.     Centers for Disease Control and Prevention. HPV, also known As Human Papillomavirus. Centers for Disease Control and Prevention, 2012. http://www.cdc.gov/vaccines/vpd-vac/hpv/downloads/dis-HPV-color-office.pdf

8.     Menashe CL. The Power of a Frame: An Analysis of Newspaper Coverage of Tobacco Issues-United States, 1985-1996. Journal of Health Communication 1998; 3(4):307–25.

9.     Grier S, Bryant CA. Social Marketing in Public Health. Annual Review of Public Health 2005; 26(1):319–39.

10.     Janis IL, Kaye D, Kirschner P. Facilitating Effects Of “Eating-While-Reading” On Responsiveness To Persuasive Communications. J Pers Soc Psychol 1965 Feb; 95:181–6.

11.     Monahan JL. Thinking Positively: Using Positive Affect When Designing Health Messages (pp. 81-98). In: Maibach E and Parrott RL, ed. Designing Health Messages: Approaches from Communication Theory and Public Health Practice. Thousand Oaks, CA: SAGE, 1995.

12.     Brehm JW. A Theory of Psychological Reactance (pp. 377-390). In: Burke WW, Lake DG, Paine JW ed. Organization Change: A Comprehensive Reader. John Wiley & Sons, 2008.

13.     Miller CH, Lane LT, Deatrick LM, Young AM, Potts KA. Psychological Reactance and Promotional Health Messages: The Effects of Controlling Language, Lexical Concreteness, and the Restoration of Freedom. Human Communication Research 2007; 33(2):219–40.

14.     Silvia PJ. Deflecting Reactance: The Role of Similarity in Increasing Compliance and Reducing Resistance. Basic and Applied Social Psychology 2005; 27(3):277–84.

15.     Centers for Disease Control and Prevention. The Facts – HPV. CDC Publication No. 99-8822. Atlanta, GA: Centers for Disease Control and Prevention, 2011. http://www.cdc.gov/std/hpv/the-facts/default.htm

16.     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):723–8.

17.     Hicks JJ. The Strategy Behind Florida’s “Truth” Campaign. Tobacco Control 2001 Mar; 10(1):3–5.

18.     Segar ML, Eccles JS, Richardson CR. Rebranding Exercise: Closing the Gap Between Values and Behavior. International Journal of Behavioral Nutrition and Physical Activity 2011; 8(1):94.

19.     Gorn GJ. The Effects of Music in Advertising on Choice Behavior: A Classical Conditioning Approach. Journal of Marketing 1982 Jan 1; 46(1):94–101.

20.     Merck Sharp & Dohme Corp. Information About Gardasil. Whitehouse Station, NJ: Merck & Co., Inc. gardasil.com

21.     Merck & Co. (2006, Nov 13) Gardasil Commercial [Video file]. Retrieved from: http://www.youtube.com/watch?v=hJ8x3KR75fA&feature=youtube_gdata_player

Critique of an STD/HIV Prevention Intervention: Safe in the City – Kristin B.

Introduction

            Sexually transmitted diseases (STDs), including Human Immunodeficiency Virus (HIV), are one of the biggest public health issues facing the United States today. Left untreated, STDs can pose serious and oftentimes irreversible health threats, and in the case of HIV, can lead to death. A 2011 Centers for Disease Control and Prevention (CDC) report estimated that there are 19 million new STD infections in the U.S. annually, of which half are among young people (1). STDs cost the health care system over 17 billion dollars a year (1). In addition, a March 2012 CDC report estimated that 1.2 million people in the U.S. are living with HIV and there are 50,000 new infections annually (2). Among these new infections, African American and Latinos are disproportionately affected (2). The same report also determined that one in five HIV-infected individuals is unaware of their status (2). Because STDs and HIV are transmitted overwhelming through sexual contact, getting tested and knowing one's status is imperative in reducing the number of new STD/HIV infections. Research shows that knowledge of one’s status increases the likelihood that infected individuals will decrease risky sexual behaviors (3).

            Abstaining from oral, vaginal, and anal sex, practicing monogamy with uninfected partners, reducing one’s number of sex partners, and using condoms correctly for every sexual encounter can reduce one’s risk of contracting STDs/HIV (4). Because using latex condoms is the most efficient way to reduce the risk of contracting an STD/HIV among those who do not abstain from sexual activity (5), many STD/HIV infection reduction interventions focus on giving people the knowledge and skills to use condoms effectively. Risk factors for not having protected sex include a lack of knowledge and perception of STD/HIV risk, negative attitudes about using condoms, a lack of knowledge about using condoms correctly, a lack of intentions to use condoms, a lack of self-efficacy and skills to get tested, and a lack of self-efficacy and skills for practicing safer sex, including acquiring condoms and negotiating their use. A majority of STD/HIV prevention interventions target these risk factors.

Overview of Safe in the City

            Safe in the City is a 23 minute video designed to reduce HIV and other STD infections by increasing condom use. The video is shown in public STD clinic waiting rooms and has no staff involvement and does not require any counseling or group facilitation – the video is simply shown on loop to those in the waiting room. The video’s goals are to increase STD/HIV knowledge, increase the perception of risk of getting HIV or another STD, promote knowledge of correct condom use and positive attitudes toward condom use, increase intentions to use condoms, build self-efficacy and skills for getting tested and facilitating partner testing, and build self-efficacy and skills for acquiring condoms, negotiating the use of condoms with their partner, and increase actual condom use (6). After watching the video, clients of the STD clinic are expected to use condoms correctly and consistently.

            The video is made up of five parts: three vignettes about negotiating condom use in various relationships and two animated portions about different types of condoms available and proper condom usage. As the video begins, the following words appear on the screen: “Remember, not having sex is the most reliable way to prevent getting an STD. Please talk to your healthcare provider for more information or if you have any questions.” The first story begins with Paul pressuring Jasmine to have sex without a condom, but Jasmine insists on using one. Later, Paul hooks up with an ex-girlfriend, Theresa, but only uses a condom for the end of the sexual encounter. Theresa calls Paul to tell him that she went to a clinic and was diagnosed with an STD and encourages Paul to get tested. Paul gets tested and decides to hold off on any further sex until his test results are back (7). An animated portion about properly putting on and removing a condom follows the story and emphasizes the fact that condoms should be used consistently and correctly for them to be effective (8). The next story shows Luis and Theresa beginning to get intimate and Theresa asking Luis if he has a condom, which he does not. He gets offended and Theresa explains that pulling out is not always effective and doesn’t protect against STDs, and that condoms make her feel safe and free. The scene ends with Luis running to a convenience store and returning to his apartment with a condom (9). The following animated segment is about different types of condoms and emphasizes the idea that there is a condom just right for everyone's needs (10). The final story picks up after Ruben has sex with Tim, who notes afterward that he had a condom with him but they got carried away and ended up not using it. Ruben later has sex with Christina and she finds out that he gave her an STD. The video ends with them going to the clinic together to get treatment for their STD (11).

Flaws of the Intervention

            Findings from the CDC's 2008 evaluation of Safe in the City show that the intervention did indeed significantly reduce new STD infections by 10% among patients attending the clinics where the intervention was provided (12). However, this reduction was seen only in males. Among females who viewed the video, there was neither a beneficial nor harmful outcome found which indicates that the intervention was ineffective among this population. Safe in the City, as the current intervention now stands, is not only flawed for the purpose of increasing condom use and reducing STD infections among females, but is also flawed as a standalone intervention that does not fully take into account social and behavioral science principles, theories, and research.

Critique #1 – Lack of Group-Level Component

            Safe in the City is an individual-level intervention that requires no contact or discussion with healthcare providers. The video is played in STD clinic waiting rooms where patients may choose to actively watch the video or not. In addition, the video is just over 20 minutes long, so the viewer might not have the chance to see the entire video or may only see the end of it. The viewer knows that the people in the video are actors and what is happening on the screen is not real even though it may depict real events. There is no opportunity for discussion or questions, though the video passively lets the viewer know that they should ask their healthcare provider if they have any questions. A short video cannot possibly cover all scenarios that are likely to come up, and because it is scripted, does not allow for spontaneous questions to lead to discussion. Most importantly, the video does not allow the viewer to practice the skills depicted.

            Simply watching a video intended to change behavior without being given the opportunity to practice the skills demonstrated or even discuss what was viewed is deemed less effective than pairing the video with another component (13, 14). In a study that examined the effectiveness of video-based patient education interventions on promoting condom use among men and women in public STD clinics in New York City, researchers looked at results from a control group, a group that only viewed the video, and a group that viewed the video and then participated in an interactive group session led by a trained facilitator (13). Subjects who participated in the interactive group session showed increased STD/HIV risk perceptions, greater self-efficacy, and higher rates of condom acquisition than the control group or the video-only group, however those in the video-only group demonstrated greater STD and condom knowledge and more positive attitudes about condom use (13). Another study, also conducted in public STD clinics in New York City, looked at the impact of a video-based educational intervention on condom acquisition among African American and Hispanic men and women (14). Findings show that compared to the control group and video-only group, subjects who experienced the video in conjunction with a group discussion were significantly more likely to acquire condoms (14).

            An important aspect of social cognitive theory, one of the theories Safe in the City is based on, is observational learning or modeling. Observational learning/modeling is the theory that people do what they see others do, not what people tell them to do (15). However, observational learning/modeling is not complete with just behavior imitation, it must also involve learning skills and retaining those learned skills for future use (16). This connection is made through aspects of the theory known as behavioral capability and self-efficacy, which emphasize the execution of observed skills and address performance and confidence barriers. Without also incorporating these other aspects, the social cognitive theory will come up short when put into practical use. While the stories portrayed in Safe in the City successfully show modeling by depicting bad outcomes occurring when one or one's partner does not wear a condom, the individual-level intervention does not take into account the importance of developing skills and collaborating on strategies for safer sex behaviors, which a group-level component could provide.

Critique #2 – Theoretical Basis in Rationality

            Safe in the City is theoretically based in the Information-Motivation-Behavioral Skills (IMB) Model, Social Cognitive Theory, and the Theory of Planned Behavior. The IMB Model holds that there are three fundamental determinants of risk reduction: information, motivation, and behavioral skills. Information, including facts about STD/HIV transmission and information regarding specific methods to prevention, is seen as the precursor to risk reduction behavior, then comes motivation to reduce risk, which entails attitudes toward prevention, social norms, and intentions to practice preventive behaviors, and finally behavioral skills are seen as needed in order to perform specific preventive acts (17). However, because this particular intervention does not develop behavioral skills, it is only based in the informational and motivational aspects of the model.

            Social Cognitive Theory is built on the understanding that behavior change is based on self-efficacy, goals, and outcome expectancies. It involves reciprocal determinism (the interaction between the individual, the behavior, and the environment), behavioral capability (the knowledge and skills to perform a behavior), expectations (anticipated outcomes of a particular behavior), self-efficacy (confidence in one's ability to take action), observational learning or modeling (deciding to perform a behavior based on watching someone else perform that behavior and seeing the outcome), and reinforcements (responses to the behavior that increase or decrease the likelihood of reoccurrence) (18).

            The Theory of Planned Behavior states that a person's attitude toward a specific behavior and that person's perception of the subjective norms (whether or not the behavior is likely to be approved or disapproved by one's social groups) associated with that specific behavior come together in an intention to perform a behavior (18). This behavioral intention is based on one's perceived behavioral control, which is made up of a person's self efficacy, or a belief in the ability to actually perform a behavior and a belief in the amount of power they have in actually performing the behavior (18).

            The assumption behind Social Cognitive Theory and the Theory of Planned Behavior is that people are rational decision-makers. However, these theories are flawed in that they overlook emotional variables, particularly those associated with sex, which tend to make individuals' behavior especially irrational. In Dan Ariely's book Predictably Irrational: The Hidden Forces That Shape Our Decisions, he discusses an experiment he conducted to demonstrate the influence of arousal. Male heterosexual participants in his study were asked to respond to questions while imagining how they would respond while sexually aroused. The first set of questions revolved around sexual preferences, the second revolved around the likelihood of engaging in sexually immoral behaviors, and the third set revolved around the likelihood of engaging in unprotected sex. Later on in the experiment, the participants were instructed to view arousing pictures and to masturbate while answering the same sets of questions as were originally asked. One of the findings of the study was that individuals were 25% more likely to predict that they would not use a condom in the aroused state than in the unaroused state (19).

            The theoretical basis of Safe in the City assumes that knowledge influences attitudes and that attitudes then influence behavior, yet this is not how actual behavior change seems to work. After watching Safe in the City, individuals may be of the mindset that they will always use a condom, but passion in the heat of the moment has been shown to say otherwise, particularly if one does not have the communication skills necessary for negotiation. While the IMB Model, Social Cognitive Theory, and the Theory of Planned Behavior may work well as a foundation for public health interventions that train in these types of skills, they do not sufficiently address how one can be expected to negotiate behavior, such as condom use, in an irrational or emotional state without training in a specific set of skills.

Critique #3 – Optimism Bias, Illusion of Control, and Stigma Theory Left Unaddressed            Because of the stigmatized nature of an STD/ HIV diagnosis, all public health interventions that aim to reduce new infections will have some of the same fundamental barriers. These barriers stem from Optimism Bias, the Illusion of Control, and the Stigma Theories.

            Optimism Bias is a bias that causes a person to believe that they are less likely to experience a negative event compared to others, yet more likely to experience a positive event (20). In fact, people who regard a disease as extremely serious are most likely to think that their likelihood of contracting that disease is less than average (21). Optimism Bias is the belief that contracting an STD/HIV could “never happen to me”, which leads people to engage in risky behaviors like having unprotected sex. Safe in the City does not address Optimism Bias, so even if an individual views the video, they may not think that the information pertains to them.

            The Illusion of Control is the tendency for people to overestimate their ability to control events, for instance to feel that they control outcomes that they actually have no influence over (22). Realistic control would be the use of condoms, because using a condom does provide actual protection, whereas illusory control would be asking about a partner's sexual history, where this does not provide actual protection, particularly if one's partner has never actually been tested (23). The Illusion of Control can be reinforced every time an individual has unprotected sex but does not get an STD, leading that individual to continue with that risky behavior (23). While realistic control is addressed in Safe in the City through the promotion of consistent condom use, all partners getting tested, and the omission of illusionary control, this may not transfer to the viewer in the clinic who has avoided STDs despite inconsistent protection. In addition, while the video does stress the importance of using a condom every time, Safe in the City does not stress the need to get tested after each unprotected sexual encounter and after each change in partner, particularly if there is not an understanding of mutual monogamy. Instead, the video assumes the viewer will never make a mistake and does not include this possibility in the scenarios.

            Stigma Theory is when an individual has an attribute and society discredits and rejects the individual because of that attribute (24). STDs, particularly HIV, are attributes affected by Stigma Theory and result in an individual being ostracized, rejected, avoided, and discriminated against by families, healthcare professionals, communities, and governments; violence against one who is perceived to have AIDS/HIV or who belongs to a high-risk group also occurs (25). Because Safe in the City is currently only implemented in public STD clinic waiting rooms, it does not address Stigma Theory adequately. The venue should not be exclusive and instead should reach those who are afraid of getting tested for fear of getting a positive result. In addition to Stigma Theory related to testing, some people may fear that using condoms, whether or not one is infected or not, may bring partner rejection (25). Safe in the City does not address how to proceed in a scenario in which one person attempts to negotiate condom use but has a partner that is resistant.

            Safe in the City, along with many other STD/HIV prevention interventions, does not provide ways to combat Optimism Bias, Illusion of Control, and Stigma Theory. A video may not be the best way to address these barriers since interaction with the individual is needed in order to determine their exact level of risk. The intervention’s venue is also problematic since those who are most at-risk for infection may not be successfully reached.

Proposed Intervention

            Safe in the City is not an entirely failed intervention. In fact, it is listed in the CDC's Compendium of Evidence-Based HIV Behavioral Interventions and is classified as a best-practice intervention due to positive evaluation findings (26). As a brief, video-based, individual-level intervention, Safe in the City is effective among males. As an intervention that is easy and inexpensive to implement and that can reach large numbers of STD clinic patients of different races/ethnicities and of different sexual orientations, it can be considered a success. For clinics that want to provide a STD/HIV prevention component but do not have the resources or funding for individual counseling or a group-level program, Safe in the City might even be the best option to make a meaningful impact. Moreover, research does show that implementing a lone video in a clinic is better than solely implementing standard clinic procedures (13, 14).

            A number of aspects of the intervention are good and should be incorporated into the modified intervention. Psychological reactance is the theory that when an individual is told that they cannot have something, there is more of a desire to get that particular something (27). While oftentimes public health interventions tell people what to do or not to do, Safe in the City instead empowers people by giving them choices while still insisting on condom use. There is an entire section of the video devoted to different styles of condoms that one can choose from, even ultra-sensitive ones for those who complain that they do not like the feeling of condoms. Communications theory and modeling call for a likeable, familiar, and similar person to deliver the message. Safe in the City successfully accomplishes this by using a young and racially/ethnically and sexually diverse cast of characters. Reciprocity is the idea that if someone does something for you, you feel like you want to do something for them (28). In the case of Safe in the City, the video drills into one's head that STD clinics have free condoms for the taking. Research has shown that when free condoms are visibly provided, about 80% of people take them, and of those that take them, almost 75% of people report using them (29). Finally, the video shows different reasons for using condoms including STD/HIV prevention, pregnancy prevention, and avoidance of long-term effects of STDs such as infertility, and the importance of using a condom for an entire sexual encounter from start to finish, waiting to know your status and your partner's status before having sex, standing your ground on using a condom even in the heat of the moment, and getting yourself and your partners tested (7, 9, 11).

            The proposed intervention will still involve the Safe in the City video in its full format, but it will also contain a group-level component led by a trained facilitator. This new component will involve group discussion, a skills-building session, STD/HIV and condom use information, and the distribution of free condoms. The following proposed modifications to the intervention will address the critiques detailed in the previous section in the hopes that with the new group-level component, Safe in the City could be an even more effective intervention in reducing rates of new STD/HIV infections.

Modification #1 – Addition of a Small Group Component

            The largest proposed modification to the Safe in the City intervention entails structural change. Instead of an entirely individually-based intervention, the proposed intervention would be a single session, small group-level intervention. This modification directly addresses the issue regarding the lack of opportunity for developing and practicing skill building. Specific aspects are pulled in part from a variety of similar video-based interventions that have an added counseling or group-level component, including RESPECT, Sisters Informing Sisters on Topics about AIDS (SISTA), and Video Opportunities for Innovative Condom Education & Safer Sex (VOICES/VOCES) (30, 31, 32, 33). To begin, small groups of about 4 to 8 individuals would be convened by gender and race/ethnicity, led by a trained facilitator of the same gender and race/ethnicity as the makeup of the group. The session would start with a viewing of the Safe in the City video in its entirety. Once the video was complete, the facilitator would begin the discussion by asking questions about the situations and characters in the video and encouraging participants to relate them to their own lives. The goal of this portion of the session is to increase the perception of personal risk of STD/HIV infection among the participants. Rather than providing general knowledge about STD/HIV, the discussion would focus on the behaviors that put people at risk for infection. The facilitator would also correct any misinformation about STD/HIV and condom use that is discussed.

            Following this discussion would be a skills-building session to work on developing and practicing skills needed for overcoming barriers to condom use. After the skills-building session, the facilitator would educate participants about the different types of condoms available for use. Before the group disbands, the facilitator would actively distribute, rather than passively provide, different types of condoms to participants based on what the participant identifies as needing. Throughout the intervention the facilitator would be available for questions and at the end would let participants know how to contact them if questions or concerns should arise after the session. It should be noted that depending on the needs of a particular group due to gender or culture, aspects of the session could be altered.

             An added group-level component allows participants to learn something through group interaction that they cannot learn from a video alone. Groups accomplish this by sharing common experiences, exposing one another to positive peer influence, increasing motivation to change, and providing support (34). The CenteringPregnancy program exemplifies this in another area of public health, prenatal care. While prenatal care is traditionally delivered individually, the CenteringPregnancy model is based on the theory that groups are effective in providing support and helping people reach goals and so is instead delivered in a group format by a healthcare provider to women in similar stages of pregnancy (34, 35). Evaluations of Centering Pregnancy show that compared to a one-on-one interaction, the group-level program increases social support, perceived empowerment, and exposure to useful skills and information (35). Adding this type of group-level component to Safe in the City will allow participants to learn from one another through discussion, social modeling and the aspects needed for modeling to be successful, behavioral capability and self efficacy, and will thus strengthen the existing intervention.

Modification #2 – Skills Building with Motivational Enhancement and Theory of Gender and Power

            The second modification addresses the flaw in basing a risk reduction intervention on theories that assume behaviors are rational, like Social Cognitive Theory and the Theory of Planned Behavior, while the original intervention is not built to give people the tools to make positive decisions in irrational states. The incorporation of a skills-building session however, complete with group practice and facilitator and group feedback on performance, allows a participant of the new intervention the ability and confidence to negotiate condom use even in an emotional state.

Under the guidance of the facilitator, participants of the new intervention would role-play, practice, and discuss communication skills like sexual assertiveness, which includes refusal skills, or the ability to refuse unwanted sexual contact, and condom negotiation. Training in these types of skills is effective in increasing the frequency of condom-protected sexual activity (36, 37). The skills would first be modeled by the facilitator and then practiced and discussed. The group would discuss problems they have encountered in trying to adopt safer-sex behaviors and develop and practice strategies for overcoming these problems. The IMB Model would now be used in full as a theoretical basis. This skills-building component is also founded in Motivational Enhancement, which promotes positive outcomes by actively involving participants in the behavior change process and in developing risk-reduction strategies that are suited to their own situations (38).

            While this sexual assertiveness skills-building aspect of the modified intervention would ideally address the fact that the original intervention is ineffective in increasing condom use among females, the group sessions would also have a component based on the Theory of Gender and Power. The Theory of Gender and Power is a social structure theory that posits that there is a sexual division of power that characterizes the gendered relationship of males and females, and that this division of power may explain non-condom use among women (39, 40). The modified intervention would address this power imbalance by correcting the misconception that a female asking her partner to use a condom use may imply infidelity or may compromise the relationship. SISTA, a peer-led HIV prevention program for African American women founded in the Theory of Gender and Power, has been shown effective in increasing consistent condom use, sexual behavior, self-control, sexual communication, and sexual assertiveness skills and in increasing partner adoption and support of consistent condom use (31). Borrowing from SISTA, facilitators of the new intervention for women would also use cultural- and gender-appropriate materials to encourage pride and enhance self-worth and teach verbal and nonverbal communication skills intended to reach partners hesitant to use condoms consistently or at all (31).

            Finally, by actively distributing condoms to the program participants and making sure they are aware that condoms are always available for free at the clinic, the message sent is that there is no reason to ever be without one. Because people have a tendency to forgo condoms in the heat of the moment if they are not readily available, making sure that condoms are indeed always available is a good step towards combating people's would-be irrational behavior.

Modification #3 – Personal Risk Assessments, Teachable Moments, Alternate Venues

            The modified intervention would address Optimism Bias through the personal risk assessments that occur after the viewing of the Safe in the City video. Relating the scenarios displayed in the video to ones in the participants' own lives, will make it clear that anyone can get an STD/HIV from unprotected sex, not just those who are stereotyped as “dirty”. This message will increase perception of risk of unprotected sex and reinforce the need for all individuals to use condoms (41). For participants who appear to underestimate their personal health risks, individual intensive counseling may be necessary to overcome Optimism Bias.

            The group-level component would also be able to address participants experiencing illusory control through teachable moments brought about by the personal risk assessment discussion. Teachable moments are situations that create an opportunity to influence behavior change (30). One way of accomplishing this is following the format used in a research study that used failure experiences as a way to undermine perceived invulnerability to HIV and reduce Optimism Bias, resulting in increased perceptions of personal risk for HIV and intentions to use condoms (42). In the study, the facilitator asked participants to write about a time when they had sex without a condom followed by a group discussion about why condoms are a necessity, an exercise which forced participants to remind themselves of a past failure while also simultaneously reminding themselves that condoms are essential in protecting oneself (42). Participants then individually judged whether individuals were HIV-positive or negative based on pictures and brief biographical and sexual experience information. The majority of participants performed at or below chance levels (42), also demonstrating failure.

            The sexual assertiveness skills-building portion of the group session and the component where the facilitator corrects misconceptions about what it means when one partner asks their partner to use a condom is intended to address the Stigma Theory critique. An additional way of addressing Stigma Theory is to hold the intervention in venues other than public STD clinics where other at-risk individuals can be found. These could include venues such as family planning centers, community health centers, schools, businesses, churches, drug rehabilitation clinics, and correctional facilities.

Conclusion

            Safe in the City is an individual-level, brief, single-session, video-based intervention designed to prevent new STD/HIV infections by encouraging increased condom use among clients in STD clinic waiting rooms. Because clients simply view the video, there is no development of skills necessary to successfully negotiate condom use with sexual partners and no discussion of common barriers to condom use or strategies to overcome these barriers. By encompassing the video within a small group component, the modified intervention would include gender- and culturally- appropriate segments on personal risk assessment, sexual assertiveness skills-building, overcoming barriers to condom use, accurate condom information, and condom distribution. These added segments aim to address issues related to the theoretical foundation of the original intervention, behavioral irrationality, Optimism Bias, the Illusion of Control, and Stigma Theory in the hopes that such modifications would transform the original intervention into a more effective intervention for increasing condom use and reducing rates of new STD/HIV infections.

References

1. Centers for Disease Control and Prevention (2011). Sexually Transmitted Disease Surveillance, 2010. Atlanta: U.S. Department of Health and Human Services. Retrieved November 20, 2012 from http://www.cdc.gov/std/stats10/surv2010.pdF

2. Centers for Disease Control and Prevention (2012). HIV in the United States: At a Glance. Retrieved November 20, 2012 from http://www.cdc.gov/hiv/resources/factsheets/PDF/HIV_at_a_glance.pdf

3. Marks, G., Crepaz, N., Senterfitt, J. W., and Janssen, R. S. (2005). Meta‐analysis of high‐risk sexual behavior in persons aware and unaware they are infected with HIV in the United States: Implications for HIV prevention programs. Journal of Acquired Immune Deficiency Syndrome, 39, 446‐453.

4. Centers for Disease Control and Prevention (2012). How You Can Prevent Sexually Transmitted Diseases. Retrieved November 24, 2012 from http://www.cdc.gov/std/prevention/default.htm

5. Centers for Disease Control and Prevention (2012). Condom Fact Sheet in Brief. Retrieved November 24, 2012 from http://www.cdc.gov/condomeffectiveness/docs/CondomFactsheetInBrief.pdf

6. Centers for Disease Control and Prevention (2008). Safe in the City: A Video-Based Waiting-Room Intervention for STD Clinic Patients. Retrieved November 24, 2012 from http://www.effectiveinterventions.org/Libraries/SITC/Safe_in_the_City_Fact_Sheet.sflb.aspx

7. SafeintheCityVideo (June 3, 2008). Jasmine and Paul (Safe in the City). Retrieved November 18, 2012 from http://youtu.be/nPkV_A_uXkc

8. SafeintheCityVideo (June 3, 2008). How to Use a Condom. Retrieved November 18, 2012 from http://youtu.be/tcpfZKvOFZ4

9. SafeintheCityVideo (June 3, 2008). Theresa and Luis (Safe in the City). Retrieved November 18, 2012 from http://youtu.be/tTMws-1MniA

10. SafeintheCityVideo (June 3, 2008). A Condom for Everyone. Retrieved November 18, 2012 from http://youtu.be/7d6oqRB79ws

11. SafeintheCityVideo (June 3, 2008). Christina and Ruben (Safe in the City). Retrieved November 18, 2012 from http://youtu.be/H0Mqp1b-37k

12. Warner, L., Klausner, J.D., Rietmeijer, C.A., Malotte, C.K., O'Donnell, L., Margolis, A.D., Greenwood, G.L., Richardson, D., Vrungos, S., O'Donnell, C.R., and Borkowf, C.B., for the Safe in the City Study Group (2008). Effect of a Brief Video Intervention on Incident Infection among Patients Attending Sexually Transmitted Disease Clinics. PLoS Medicine, 5(6): e135.

13. O’Donnell, L., San Doval, A., Duran, R., and O’Donnell, C.R. (1995) The effectiveness of video-based interventions in promoting condom acquisition among STD clinic patients. Sexually Transmitted Diseases, 22, 97–103.

14. O'Donnell, L., San Doval, A., Duran, R., and O’Donnell, C.R. (1995). Video-Based Sexually Transmitted Disease Patient Education: Its Impact on Condom Acquisition. American Journal of Public Health, 85(6), 817-822

15. National Cancer Institute. Theory at a Glance: A Guide for Health Promotion Practice. Part 2. Bethesda, MD: National Cancer Institute, 2005, pp. 9-21 (NIH Publication No. 05-3896).

16. Bandura, A. (2001). Social Cognitive Theory of Mass Communication. MediaPsychology, 3, 265-299.

17. Fisher, J.D. and Fisher, W.A. (1992). Changing AIDS-risk behavior. Psychological Bulletin, 111(3), 455-474.

18. Individual health behavior theories (chapter 4). In: Edberg M. Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Sudbury, MA: Jones and Bartless Publishers, 2007, pp. 35-49.

19. Ariely, D. Predictably Irrational: The Hidden Forces that Shape our Decisions. New York: Harper Collins Publishers, 2008.

20. Weinstein, N.D. (1980). Unrealistic Optimism About Future Life Events. Journal of Personality and Social Psychology, 39, 806-820.

21. Kirscht, J.P., Haefner, D.P., Kegeles, S.S., and Rosenstock, I.M. (1966). A National Study of Health Beliefs. Journal of Health and Human Behavior, 7(4), 248-254.

22. Langer, E.J. (1975). The illusion of control. Journal of Personality and Social Psychology, 32, 311-328.

23. Thompson, S.C., Kent, D.R., Thomas, C., and Vrungos, S. (1999). Real and Illusory Control Over Exposure to HIV in College Students and Gay Men. Journal of Applied Social Psychology, 29(6), 1128-1150.

24. Goffman E. Stigma: note on the management of spoiled identity. Prentice-Hall: Englewood, NJ. 1963.

25. Center for AIDS Prevention Studies (CAPS) and the AIDS Research Institute, University of California, San Francisco. (2006). How does stigma affect HIV prevention and treatment? Retrieved November 24, 2012 from http://caps.ucsf.edu/uploads/pubs/FS/pdf/stigmaFS.pdf

26. Centers for Disease Control and Prevention (2009). Safe in the City. Retrieved on November 24, 2012 from http://www.cdc.gov/hiv/topics/research/prs/resources/factsheets/Safe-in-the-City.htm

27. Brehm, J. W. (1966). A theory of psychological reactance. New York: Academic Press.

28. Regan, D.T. (1971). Effects of a Favor and Liking on Compliance. Journal of Experimental Social Psychology, 7, 627-639.

29. Renaud, T.C., Bocour, A., Irvine, M.K., Bernstein, K.T., Begier, E.M., Sepkowitz, K.A., Kellerman, S.E., and Weglein, D. (2009). The Free Condom Initiative: Promoting Condom Availability and Use in New York City. Public Health Reports, 124, 481-489.

30. Centers for Disease Control and Prevention (2009). RESPECT Procedural Guide. Retrieved on December 1, 2012 from http://www.effectiveinterventions.org/Files/RESPECT_Procedural_Guide_8-09.pdf

31. Centers for Disease Control and Prevention (2009). SISTA Procedural Guide. Retrieved on December 1, 2012 from http://www.effectiveinterventions.org/Files/SISTA_Procedural_Guide_8-09.pdf

32. Centers for Disease Control and Prevention (2009). VOICES/VOCES Procedural Guide. Retrieved on December 1, 2012 from http://www.effectiveinterventions.org/en/HighImpactPrevention/Interventions/VOICES/ResourcesTools.aspx

33. Cohen, D.A., MacKinnon, D.P., Dent, C., Mason, H.R., and Sullivan, E. (1992). Group counseling at STD clinics to promote use of condoms. Public Health Reports, 107, 727–731.

34. Centering Healthcare Institute (2012). Theoretical Basis for Centering Groups. Retrieved December 9, 2012 from https://www.centeringhealthcare.org/pages/centering-model/theory.php

35. Tanner-Smith, E., Steinka-Fry. K., and Lipsey, M. (2012) A Multi-Site Evaluation of the CenteringPregnancy Programs in Tennessee, Final report presented to the Tennessee Department of Health. Peabody Research Institute, Vanderbilt University, Nashville, TN.

36.Weinhardt, L.S., Carey, M.P., Carey, K.B., and Verdecias, R.N. (1998). Increasing Assertiveness Skills to Reduce HIV Risk Among Women Living With a Severe and Persistent Mental Illness. Journal of Consulting and Clinical Psychology, 66(4), 680-684.

37. Sikkema, K.J., Winett, R.A., and Lombard, D.N. (1995). Development and education of an HIV-risk reduction program for female college students. AIDS Education and Prevention, 7(2), 145-159.

38. Kalichman, S.C., Cherry, C., and Browne-Sperling, F. (1999). Effectiveness of a Video-Based Motivational Skills-Building HIV Risk-Reduction Intervention for Inner City African American Men. Journal of Consulting and Clinical Psychology, 67(6), 959-966.

39. Wingood, G.M. And DiClemente, R.J. (2000). Application of Theory of Gender and Power to Examine HIV-related Exposures, Risk Factors, and Effective Interventions for Women. Health Education & Behavior, 27(5), 539-565.

40.Wingood, G.M. And DiClemente, R.J. (1998).Partner Influeces and Gender-Related Factors Associated with Noncondom Use Among Young Adult African American Women. American Journal of Community Psychology, 26(1), 29-51.

41. Sohn, A., Chun, S., and Reid, E.A. (2012). Adolescent Optimistic Bias Toward HIV/AIDS in Seoul, South Korea. Asia-Pacific Journal of Public Health, 24(5), 816-825.

42. Thompson, S.C., Kyle, D., Swan, J., Thomas, C., and Vrungos, S. (2002). Increasing condom use by undermining perceived invulnerability to HIV. AIDS Education and Prevention, 14(6), 505-514.