Monday, December 13, 2010

Getting Tested Can be Tomorrow's Trend – Refocused Los Angeles County's “Erase Doubt” Campaign Can Change the HIV Testing Norm – Arthika Chandramohan

As of June 30, 2009, a cumulative total of 74, 886 persons with positive diagnoses of HIV had been reported in the Los Angeles County area.[i] As the largest local jurisdiction in the United States, Los Angeles County (LAC) serves an extremely diverse and unique demographic, ethnically and socioeconomically. The distribution of HIV and AIDS cases is similarly unlike any other in the country, with Latinos comprising the largest number of HIV/AIDS cases while nationally Blacks are the racial/ethnic group most affected. Additionally, in the U.S., heterosexual transmission accounts for over 30% of new cases, whereas in LAC, heterosexual risk does not account for more than 10% of HIV cases. While at-risk populations are similarly defined within the LAC as they are around the country, the distribution of these populations combined with the size of citizenry in need of county services make addressing LAC's HIV concerns both a complex and critical process, necessary to improve overall community health.

In a joint effort to aid LAC's battle against HIV transmission, the U.S. Centers for Disease Control and Prevention and the California State Office of AIDS funded the Erase Doubt campaign. An initiative “intended to increase HIV testing in LA County, drive awareness of HIV prevention, and provide information about HIV/AIDS treatment and care,”[ii] the Erase Doubt campaign utilizes strategic advertising and multimedia communications to move citizens, especially those in high-risk communities, to get tested regularly for HIV and AIDS. In celebration of World's Aids Day, the Office of AIDS Programs and Policy announced the Erase Doubt sponsored, county-wide casting call for faces of the new March 2011 campaign created to expand outreach via multimedia advertising.[iii] The campaign's newest endeavor marks a continued effort to become increasingly relevant to the highest risk populations served, specifically women of childbearing age, MSM (men who have sex with men) of color, multiply-diagnosed individuals (mental illness and substance abuse), and transgendered persons.i Yet in the midst of these efforts little has been done to assess the accomplishments of past projects and aspects of the campaign. The message propagated by authorities at the Department of Public Health is one that few high risk populations can actually relate to. By considering the social and behavioral theories that often define personal decision making and choice, it quickly becomes clear that while diversifying venues of communication appear to be progressive, these efforts may actually be significantly misguided. A deeper examination of the actual content and message being broadcast reveals that even if new avenues to disseminate the campaign's information are discovered, these measures may not significantly affect patterns of behavior change. However, with a few modifications, this intervention has the potential, and the resources, to significantly impact the landscape of LAC's accepted sexual health practices.

Image is Everything, Especially when Effecting Behavior Change

The Erase Doubt campaign utilizes a central websiteii as the foundation of its efforts. While the campaign's logo is a creatively merged question mark and red ribbon (associated with AIDS awareness), the rest of the message is a little less endearing and little more intimidating. The message conveyed is serious no doubt, but the phrasing and imagery is nothing short of threatening. “Get an HIV Test; The virus could be in you” is the banner's direct message. The accompanying image displays representatives of a few of the program's target demographics, with expressions as somber as the written words. The seriousness mirrored throughout the multiple tabbed resources attempts to capitalize on negativity as a root for social and individual change. Unfortunately, dramatized negativity with the intent to scare people into action often incites the opposite response from target audiences.[iv] This is especially the case in younger populations in the face of threats to their freedom of choice and independence.[v] In fact, studies have found that the more severe someone perceives the results of a decision to be, the more likely they are to continue without changing their decision. Within the context of the Erase Doubt campaign, this behavior, influenced by what is known as the Psychological Reactance Theory,[vi] has serious implications.

When audiences are directed to a website that illustrates an HIV test is necessary to respond to a possible attack against ones body, two potential responses are incited. Firstly fear, which can then quickly proceed to a secondary reaction of rejecting the possibility, and thus the necessity, to get tested. Similar ad campaign's featuring dark, discouraging images have met with little success.[vii],[viii] Psychological Reactance Theory dictates that in the face of a threat, people have a tendency to behave in the opposite manner than that which they are told they should. The Erase Doubt campaign does more than suggest one should get tested; rather, it actually posits a physical threat to the reader – that the virus could actively be “in you.”ii In the face of such a bold claim, many may rebel after internally rejecting the claim, and others may become too overwhelmed to confront the problem, or take the steps that the program suggests. In both cases, the ads accomplish the opposite effect of their intent.

The effects of negative propaganda are exacerbated in targeted groups by additional statements that paint a much more dire picture in numbers and words rather than pictures and stories. In all press releases and published references to the Erase Doubt campaign, the following statistics are consistently displayed:

· 70% of women living with AIDS in Los Angeles County got HIV through heterosexual contact.

· Just over half of all new sexually transmitted HIV infections are spread by people who have it and don’t know it.

· 7 out of 10 people living with HIV/AIDS in Los Angeles County are gay or bisexual men.

· African-Americans make up 9.8% of Los Angeles County’s population, but account for 22% of living HIV/AIDS cases.

· Latinos make up the largest number of people living with AIDS of any racial and ethnic group in Los Angeles County.

· You are up to 5 times more likely to get HIV if you already have an STD.ii

Rather than highlight positively the need for specific groups – heterosexual women, gay/bisexual men, African-Americans, Latinos, and STD-infected populations – to get tested, the glaring statistics do more to stigmatize these populations rather than empower them to get tested. As a result, these vulnerable and at-risk populations are more likely to react by opposing the suggested Whether out of embarrassment, fear of self-identifying, or rebellion to being singled out,[ix],[x] the grave facts polarize individuals more than they convince them to follow through with the desired behavior. The presented statistics share a lot of scientific information about high-risk populations, but the presentation of statistics do little to further the proposed behavioral change. Instead, the “Law of Small Numbers”[xi] suggests that people are more receptive to single, specific stories of individuals who can depict the true outcomes of not getting tested. Inherently irrational, the theory supposes that ads designed to alter people's perception of risk would use personalized stories rather than numbers and probability to convey the necessity of a behavior change. The Erase Doubt campaign does quite the opposite, highlighting facts and figures in an effort to spur especially vulnerable populations to act.

Complicating the question of how to appropriately identify and acknowledge the unique risks associated with the practices preferred by those of differing sexual orientations, is the stigma associated with different diasporas of sexual identity. A study found that of men who self-identified as heterosexual, 31% of those infected, and 16% of those uninfected (with HIV), reported having had anal sex with men—of these subjects, 100% of the infected and 67% of the uninfected men reported inconsistent condom use during anal sex with men.[xii] The tendency to favor reporting sexual identity as “heterosexual” while practicing behaviors that are normally targeted from a public health perspective, as behaviors that gay/bisexual populations engage in, poses quite a hurdle for creating targeted messages. Instead of distinguishing groups based on how they self-identify it appears to be more important to address specific behaviors as being high-risk. The attachment and stigma associated with behavior appears to be less deterring than using identifying language (i.e. homosexual/ heterosexual), as subjects were willing to report these.[xiii] Thus, the Erase Doubt campaign's endeavors to enable high-risk groups to change their behavior by acknowledging intimidating statistics may actually be largely ineffectual.

Reducing Barriers: a Part of the Equation, But not the Answer

Another element of the Erase Doubt program, is to disseminate valuable resources about where in the Los Angeles County area people can locate and utilize HIV testing services. By making information available to people—by reducing the hurdles preventing access to such care—Erase Doubt assumes that populations will resort straight to action. Unfortunately, additional factors often prevent or complicate an individual's decision to get tested after being informed, from translating into the actual behavior change of getting tested for HIV. This seemingly straightforward assumption, that people will weigh the perceived benefits and barriers to making a behavior change and then act to change that behavior once those barriers are minimized and benefits maximized, is the foundation of the Health Belief Model.[xiv] The model posits that educating people about the consequences of their behaviors and then minimizing the barriers to changing it are enough to make them change. Within the Erase Doubt campaign, developers appear to have created a resource that grants people the opportunity to change, but does nothing to instill the capacity to change that would drive an actual behavior change. Simply knowing where to get tested would ultimately not be enough of a motivation to actually get tested.[xv]

The Health Belief Model is generally efficacious when attempting to inspire simple, one-time decisions, but when it comes to complex behavior changes, the model tends to be a weaker predictor of effectiveness.[xvi] In this case, while on face value the decision to get tested for HIV may appear menial and a relatively singular event, the results can carry significant life complications. Deciding to get tested also implies that an individual has come to terms with receiving the results of that test, regardless of its implications. This is where the decision becomes complicated. Almost anyone can be sufficiently prepared to deal with the a negative result, but receiving positive results could have an even more deleterious effect on a person's life than not knowing, if they are not prepared to deal with that information. Thus, convincing an individual to commit to this behavior change requires more than preparing them to go to a testing center; preparing them to deal with the results of that test is a vital part of convincing and committing them to act. Unfortunately, the Erase Doubt campaign does little to actually assure people that they are prepared to deal with the consequences of their test.

The program spends the majority of its efforts (on its website and assorted media productions) convincing individuals to get tested, but the extent of its resources about treatment include a paragraph of hopeful language and a hyperlink to a generic Los Angeles HIV/AIDS resource network. While the link may provide useful information to an individual, the scarcity of integrated resources to deal with a positive result is unnerving. It creates an additional decision element – if positive, will the individual be able to navigate through available resources to get appropriate treatment? In some cases, the minimal attention paid to treatment may misinform people about the extent of resources available, or worse, may depict a “positive” diagnosis as something not worth discussing. In a way, highlighting the need to get tested without thoroughly addressing what can be done if they do test positive, diminishes the perceived possibility of receiving such a diagnosis. For those who do, this can compound feelings of isolation and stigmatization. Prior to getting tested, all of these factors would influence an individual's decision to do so in the first place, making it a complex and confusing decision not easily governed by the provisions of the Health Belief Model.

Immediacy can Prevent Indifference

Another shortcoming of the Erase Doubt campaign is its inability to correlate getting tested with any immediate benefits. The threat of testing positive has been explored above, and can be considered a definite negative from the perspective of the “unknowing”. Testing negative may be a relief, or a reassurance, but few if any distinct benefits are emphasized by Erase Doubt's message. Many public health programs fail to instigate definite behavioral changes because they do not address an individual's investment in short-term gratification. People tend to be less invested in actions that will result in positive results weeks, months, or years later, and are far more interested in the benefits within their immediate future.[xvii] Neither the Erase Doubt website nor its publications feature any such immediate benefit to getting tested, and the action itself is framed in a threatening and ominous light.

Taking the time to discover whether or not one has HIV is not depicted as an inherently valuable decision. Knowing one's HIV status does not actively prevent acquiring HIV, thus the aforementioned fears and apprehensions about getting tested can easily dominate the guilt or anxiety associated with any need to get tested. Erase Doubt's materials make doubt about whether or not one has HIV a negative and precarious situation instead of stressing that knowing your status puts one in a positive and beneficial position. The theory of reasoned action[xviii] suggests that because the general population believes that not getting tested is negative, individuals will self-motivate into action, and get tested. Socially, testing rates have been on the decline,[xix] while media campaigns like Erase Doubt have been emphasizing knowing ones HIV status (or at least that not knowing is an unfavorable option). While it would appear that the cultural norms are shifting towards a standard of getting tested, unstated in the model, actually getting tested and simply intending to are very different.

Public health programs tend to be ineffectual if they are unsuccessful at equipping people with the means to turn intention into action. Because not acknowledging this link is tantamount to assuming making the decision to get tested is relatively straightforward and simple, there are very real shortcomings to a program that fails to provide resources and appropriate motivation. Thus, greater measures ought be taken to make Erase Doubt's message more consequential, by levying some form of personal benefit that can be imminently realized.

Erase Doubt is a well funded multi-organizational endeavor that has the ability to commission solid changes to the landscape of HIV testing in the Los Angeles area. The undertaking is admirable and necessary, in a county that hosts 30% of the state's cumulative AIDS cases.[xx],[xxi] However there are a few fundamental problems with the campaign's approach that must be addressed before significant strides in HIV testing will actualize. The current model that frames “not knowing” in a dark and dramatically negative light, that presumes the decision to get tested is simple and straightforward and can be made irrespective of resources for post-decision support, and that fails to address the immediate needs and wants of its target population, will be handicapped by these facets and will not realize the full potential that such a combined effort should.

Plugging the Loopholes – First make it a Positive

Public health programs are often better served by embracing social and behavioral theories that offer a different perspective to the average intervention. More specifically, marketing theory and branding theory suggest that by adopting a more “public selling” and less “public service” approach to behavior changes, public health initiatives have the potential to be far more fruitful.

Branding theory offers that people are naturally attracted to feeling like a part of a group that has defined itself in specific ways.[xxii] By creating a set of associations for those who can be “branded” by the suggested behavior change, any public health mission can more successfully recruit and retain people to engage in that change. “The 8ighty 4our” campaign[xxiii] and the “Crush” smoke-free campaign[xxiv] are two examples of effective branding that have associated public health behavior changes with a set of images and qualities that define the population who engage in them. If the Department of Public Health redefined the message and image associated with its “Erase Doubt” campaign, then it has the potential to experience similar success. More precisely, if the message was re-framed as the “I Know” campaign, that fostered a sense of unity and group identity for those who had gotten tested and knew their HIV status, then a more positive brand could be associated with the behavior. Creating a community around the fact that their HIV status is known is the first step to selling the public the “I Know” brand which intrinsically attracts people to its cause not by promoting the fears associated with not knowing, but rather by embracing the community and camaraderie that can be achieved by knowing.

Similarly, marketing theory would argue that the behavior of getting tested will more successfully be sold to the public by defining and packaging it to meet the want, needs, and core values of the population. Rather than using one's “health” as the primary core value or motivation for the behavior change, understanding what is most important to the target demographics is the first step to effectively employing marketing theory. Within the minority communities of interest, a major proportion are teens to young adults, with average age at contraction decreasing.xix At this age, individuals tend to highly value their freedom and independence, and are attracted to opportunities that allow them to make choices. By creating marketing materials that put that decision making power in the hands of the individual, campaign officials are more likely to see a favorable community response. Slogans like, “I Know. Do you?” take a step back from dictating what an individual should or should not do, and instead project the image of an organization that embraces its decision and is offering the opportunity to join, if one adopts the behavior change. The lack of force or intimidation brought upon by messages this slogan plays more to the highest values of a younger population by putting the power to decide in their hands.

Lastly, this altered image may usher greater success because of the positive connotations offered by its slogan and theme, compared to the negative one it currently projects. Framing theory states that people are highly affected by the way an issue is framed or presented.[xxv] The setting through which they receive a message can incite irrational decision making because the topic is viewed through an especially negative or antagonistic lens. In its current form, the Erase Doubt campaign does just that—it displays images and graphics that attest to the seriousness and possible harmfulness of not knowing. Conversely, a program that framed the decision to get tested in an empowered and excited way could abate the issues caused by negative framing. By portraying self-assured and excited individuals on the website, and associating these favorable images with an affirmative and confident “I Know, Do You?” slogan, the issue of getting tested is received in a completely different light. This non-threatening approach has a greater chance to resonate with higher risk populations, and can dramatically shift the social norm toward wanting to get tested, and being able to say “I know.”

Give People Resources and Role Models on Both Sides

Understanding the delicate decision making process that is required to get tested is the first step to destroying the fallacy that the Health Belief Model proposes. To address this, the Erase Doubt program must integrate a network of possible resources that can aid in addressing issues other than merely access to getting tested. In making the decision to get tested, an individual must be well informed enough to feel positive about the decision, no matter the consequence. The program's holistic aim must involve portraying knowing your situation as always better than not knowing.

To do this is no easy task, as the imputation and derision that can accompany a positive HIV test are still vastly prevalent in society. A significant proportion of resources would do well to be invested in developing comprehensive resource maps of the LAC HIV treatment setting. Assimilating media campaigns that paint the current treatment possibilities and quality of living with a positive diagnosis would be essential to surmounting the barriers that prevent intent from turning into action. Another pertinent variable is the social context within which an individual makes a decision. When regular HIV testing is not dictated as a societal norm, a substantial hindrance to act will continue to domineer individual decision making. To address this obstacle, campaigners can capitalize on local and larger role models who are relevant to intended populations. These role models should be both HIV positive and negative, but all with the knowledge of their individual status—Magic Johnson, Greg Louganis, and Roy Simmons are all exemplary public figures, thriving with a positive diagnosis. On the local level, the program should aim to create networks that are centralized on people who can embody and associate positivity and confidence with knowing one's HIV diagnosis. The Crush campaignxxiv does an effective job of recruiting and capitalizing on the resource that these individuals can be. According to the diffusion of innovations theory,[xxvi] by locating and recruiting key public and local figures to initially accept and embrace the proposed behavior change, known as “early adopters,” a critical mass of behavioral conformists will be spurred to adopt the behavior change, followed by a catalyzed, significant change in accepted HIV testing behavior practices.

The remaining significant weakness of the existing Erase Doubt campaign, is its blind eye to providing any immediate benefits to getting tested for HIV. If community and brand is associated with the campaign, then the opportunity to identify with those positive characteristics, as well as to belong to a group in an effort to be a part of a bigger movement, will be noticeable benefits to making the decision to get tested. Additionally, in cohort with readjustments of the “Erase Doubt” to the “I Know” campaign, developing that accessible and extensive resource database offers an opportunity to create another, at least image, of a benefit. Having a well developed set of available services can justify making the claim, “Knowing Can Save Your Life.” Instead of highlighting that not know could lead to personal demise, it is important to focus on the benefits of knowing one's situation earlier rather than later in life. Again, by framing the issue positively,xxv developers can create a prior under emphasized immediate benefit. These techniques will fundamentally aid efforts to combat the presumptions and influences of the Health Belief Model on this public health program.

Looking Forward

While the landscape of HIV risk factors in the LAC is unique, the psycho-social demands of its population are similarly bound by certain patterns of behavior. Only by employing social and behavioral theories as the foundations of programs and policies will they stand a chance of being sustainable and successful. Such campaigns are necessarily complex and must be dynamic to address the multitude of factors that can affect an individual's, especially a high-risk individual's, behavior. In this case, the Erase Doubt initiative has neglected to account for psychological impact, and thus behavioral responses, incited by their methodology of choice. Negative imagery and messages combined with an assumed and oversimplified path to behavior change create an encumbered and ineffectual mission. However, by understanding and assimilating social and behavioral principles, officials do have the opportunity to transform this campaign and achieve sustained behavior changes. Creating immediately attributable benefits to getting tested, developing resources and promoting productive lifestyles of those living with HIV, and re-framing the campaign's theme into a positive, empowered organization that deciders would want to join, are all immediate changes that can radically affect public reception. The resources available to the Erase Doubt campaign are formidable, and with some refocusing and assessment with behavioral theories in mind, it can progress to have a substantial impact on HIV awareness, prevalence, and transmission in the Los Angeles County community.

[i] HIV Epidemiology Program, Los Angeles County Department of Public Health, An Epidemiologic Profile of HIV and AIDS in Los Angeles County, 2009: 1-151.

[ii] "Erase Doubt." County of Los Angeles. Web. 1 Dec. 2010. .

[iii] "Erase Doubt Kicks Off World AIDS Day with LA County-Wide Casting Call." PR Newswire: Press Release Distribution, Targeting, Monitoring and Marketing. PRNewswire, 1 Dec. 2010. Web. 08 Dec. 2010. .

[iv] Block, Lauren G., and Punam A. Keller. "When to Accentuate the Negative: The Effects of Perceived Efficacy and Message Framing on Intentions to Perform a Health-Related Behavior." Journal of Marketing Research 32.2 (1995): 192-203. Print.

[v] Kelly, K. J., Comello, M. L. G., & Slater, M. D. (2006). Development of an aspirational campaign to prevent youth substance use: 'Be under your own influence.' Social Marketing Quarterly, 12, 14-27.

1. [vi] DeFleur ML, Ball-Rokeach SJ. Theories of Mass Communication (5th edition), Chapter 8 (Socialization and Theories of Indirect Influence), pp. 202-227. White Plains, NY: Longman Inc., 1989.

[vii] Szwarc, Sandy. "Remember the BMI Report Card Debate?" Web log post. Junkfood Science., 27 Sept. 2008. Web. 2 Dec. 2010. .

[viii] Broeke ten, A. (2006) The effect of role sets and indirectness on the perceived face threat and perceived persuasiveness of anti-obesity messages.

[ix] Brehm, Jack W. "A Theory of Psychological Reactance." Organization Change: a Comprehensive Reader. San Francisco, CA: Jossey-Bass, 2009. 377-90. Print.

[x] Clee, Mona A., and Robert A. Wicklund. "Consumer Behavior and Psychological Reactance." Journal of Consumer Research 6.4 (1980): 389-405. Print.

[xi] Tversky A, Kahneman D. Belief in the law of small numbers. Psychological Bulletin 1971; 76:105-110.

[xii] Wohl, Amy R., Denise F. Johnson, Sharon Lu, Wilbert Jordan, Gildon Beall, Judith Currier, and Paul A. Simon. "HIV Risk Behaviors Among African American Men in Los Angeles County Who Self-Identify as Heterosexual." Journal of Acquired Immune Deficiency Syndromes 31.3 (2002): 354-60. Print.

[xiii] Doll, Lynda S., Lyle R. Petersen, Carol R. White, John W. Ward, and The Blood Donor Study Group. "Homosexually and Nonhomosexually Identified Men Who Have Sex with Men: A Behavioral Comparison." The Journal of Sex Research 29.1 (1992): 1-14. Print.

[xiv] Rosenstock IM (1966), "Why people use health services", Milbank Memorial Fund Quarterly 44 (3): 94–127

[xv] Ogden J. Some problems with social cognition models: a pragmatic and conceptual analysis. Health Psychology 2003; 22:424-428.

[xvi] Thomas LW. A critical feminist perspective of the health belief model: implications for nursing theory, research, practice, and education. Journal of Professional Nursing 1995; 11:246-252.

[xvii] Bickel, Warren K., and Rudy E. Vuchinich. "Part 4 Health Behavior as Intemporal Choice." Reframing Health Behavior Change with Behavioral Economics. New York: Routledge, 2009. 165-218. Print.

[xviii] Fishbein, M., & Ajzen, I. (1975). Belief, Attitude, Intention, and Behavior: An Introduction to Theory and Research. Reading, MA: Addison-Wesley.

[xix] United States of America. County of Los Angeles Department of Public Health. Office of AIDS Programs & Policy. HIV Testing Annual Report. Ed. Rangell Oruga, Pamela Ogata, and Jacquiline Rurangirwa. Los Angeles County, 2009. Web. 2 Dec. 2010. .

[xx] HIV Epidemiology Program, Los Angeles County Department of Public Health. HIV/AIDS Surveillance Summary, July 2008: 1-30.

[xxi] California Department of Public Health, Office of AIDS, HIV/AIDS Case Registry Section, data as of June 30, 2008.

[xxii] Blitstein JL, Evans WD, Driscoll DL. What is a public health brand? (Chapter 2). In: Evans WD, Hastings G, eds. Public Health Branding: Applying Marketing for Social Change. Oxford: Oxford University Press, 2008, pp. 25-41.

[xxiii] The Eighty-Four | A Youth-led Movement Fighting for a Tobacco-free Generation in Massachusetts. Web. 08 Dec. 2010. .

[xxiv] "About Crush." CRUSH. Web. 08 Dec. 2010. .

[xxv] Crosby RA. Kegler MC, DiClemente RJ. Understanding and applying theory in health promotion practice and research (Chapter 1). In: DiClemente RJ, Crosby RA, Kegler MC, eds. Emerging Theories in Health Promotion Practice and Research: Strategies for Improving Public Health. San Francisco, CA: John Wiley & Sons, Inc., 2002, pp. 1-15.

[xxvi] Pemberton, H. E. (1936) 'The Curve of Culture Diffusion Rate', American Sociological Review, 1 (4): 547-556.

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