Crossing T’s And DOTing I’s: Is DOTS Enough To Improve Treatment Adherence?-Molly McCoy

Public Health Problem: Long-Term Medication Adherence in Tuberculosis

Tuberculosis (TB) infection and disease is an ongoing, long-existent global public health problem. TB is the leading infectious cause of adult death and disability in the world and is estimated to infect up to one third of the world's population and result in between two and three million deaths annually.(1) Although TB is treatable with antibiotics with a high cure-rate for those who are immune-competent, multi-drug resistant tuberculosis (MDR-TB) has emerged as a major obstacle for the control of TB worldwide.(2) MDR-TB is a result of incomplete or ineffective TB treatment. MDR-TB cases range up to 27% of cases as reported by the World Health Organization (WHO) and occur in areas with already established TB control programs, such as the WHO DOTS (directly observed treatment, short course) program.(3)
In 2009, the estimates for global burden of Tuberculosis were: 9.4 million incident cases, 14 million prevalent cases, and 1.3 million deaths among HIV-negative people.(4) These rates persist despite effective tuberculosis antibiotics having been available since the 1940’s.(5) Prevention, diagnosis, and treatment of tuberculosis latent infection and disease are becoming increasingly complex due to the development of drug-resistance and co-infection with Human Immunodeficiency Virus (HIV).
One of the biggest challenges faced in treatment of both active disease and latent infection is adherence to the treatment regimen.(6) The problem of low retention rates in treatment can be attributed to 1) the regimen’s length, which is nine months in the short-course regimen, 2) the number of pills in the regimen and side-effects, 3) low access to medical care, and 4) the effect of feeling better before treatment is complete, which can occur even months prior to completion.(6) All of these factors can lead to the behavior of stopping treatment. In addition, patients who are HIV-infected have even more complicated treatment regimens, which may lead to poorer adherence in this sub-population despite likelihood of more severe TB symptoms.(6)
The result of treatment default has severe consequences for both the individual and the community in which they live. For the individual, it can result in prolonged disease, relapse, development of drug-resistance, or even death.(5,6) Drug resistances is a problem because second round treatment is difficult, as some drugs may no longer work against that patient’s strain and second-line drugs to which it would be susceptible still are expensive and may be inaccessible. Treatment failure is also a problem for the greater community, because if the patient relapses he/she can infect others. If the strain of M. tuberculosis has developed drug-resistance, any infection transmission to others will be with this already resistant strain. At some DOTS program sites, adherence is reported to be as low as 50%.(5) Therefore, effective public health interventions, or the bolstering of current programs, are desperately needed to increase treatment adherence, particularly for high burden countries.
Intervention: Directly Observed Therapy, Short-course (DOTS)
The goal of TB control is to break the cycle of transmission by treating TB cases as early and efficiently as possible. In this effort, the WHO launched the ‘Directly Observed Therapy, Short-course’ (DOTS) strategy in 1994 in areas where tuberculosis disease burden was high.(7) The broader program strategy includes five key elements: political commitment, accessible laboratory services, strict supervision of each dose of treatment (DOT), uninterrupted supply of medications, and effective surveillance and monitoring systems for patient follow-up.(8) This strategy involves patients being directly observed when they take their medication every day over the six or nine months of treatment (short-course for latent infection and active disease respectively).(9) Observers can be “health workers, employers, or any responsible community member”.(9) The objective of DOTS is to ensure that patients complete their treatment course, and this in turn improves cure rates.(9) Cure rates have been reported up to 95% at various DOTS sites, unfortunately these results have not been replicated consistently under everyday conditions as opposed to clinical trials.(8) With such a comprehensive approach, it is hard to see why in some places the DOTS strategy could fail.
According to their 2010 global report, WHO declared that “between 1995 and 2009, a total of 41 million TB patients were successfully treated in DOTS programmes, and up to 6 million lives were saved including 2 million among women and children”.(4) This is evidence of great strides in the fight against TB. It is also important to note that as their target for treatment completion is 85%, and that for 2009 13/22 (59%) high burden countries met the target.(4) DOTS is considered to be the gold standard in treatment of TB.(7) However, some studies have found no significant differences in cure rates for patients in DOT compared with the control group who had self-administered treatment.(10) It is important to determine the effectiveness of the DOTS intervention, and where it falls short of the mark.
Despite DOTS program implementation across the world, there are still close to 9.5 million new cases per year worldwide.(4) Some countries still cannot achieve the WHO target of at least 85% treatment compliance.(4) Some reviews of the strategy find no difference in cure rates or rates of treatment completion between DOTS and the previously used self-administered treatment (SAT) model.(5,8)
Daunting questions remain: With treatment made readily available, why are some DOTS programs failing where others succeed? Why would people make the irrational health decision to discontinue treatment? What can public health do to rectify the flaws of DOTS interventions, as they currently exist?
To begin to answer these questions, we must first identify key elements of the DOTS program that are flawed. This critique will use theories of health behavior to explain where DOTS went wrong, and to formulate innovative strategies to increase TB treatment adherence in future interventions. First, although the overall program approach is composed of five key elements that take into consideration factors outside clinic treatment, the intervention itself is still rooted in individual-centered health behaviors models. Second, the DOTS approach fails to account for environmental and social factors influencing patient treatment adherence behavior. Finally, there is even potential for negative labeling and stigma under the current DOTS intervention.
Critique One: Use of Health Belief Model
The DOTS approach is inherently based on the patient making the rational decision to seek treatment, once diagnosed, and finish that treatment course until they are cured, based on weighing the pros and cons of that decision. If the patient were to make an irrational decision, as in not to accept or to discontinue treatment, the program fails. The only barriers to making the irrational decision that the program employs is the rigid approach at strict adherence through DOT, which makes patients accountable to the care-giver, and thus keeping them in treatment. Basically, this approach assumes that people will want to be cured of tuberculosis so they will go through the treatment plan as advised by the clinician. This foundation philosophy is similar to the health belief model.
The health belief model views health behavior change as based on a rational appraisal of the balance between the barriers to and benefits of action.(11) According to this model, the perceived seriousness of, and susceptibility to, a disease influence individual's perceived threat of disease.(11) So if tuberculosis is perceived to be a serious condition by the individual, and they are susceptible to death due to TB if they do not seek treatment, and the perceived threat of death is great, then they will seek treatment. Also, if they are in treatment, and they perceive the seriousness of their symptoms to be great, and believe they are susceptible to relapse if they quit treatment, then they will perceive that the treat of re-infection is great and will stay in treatment.
Similarly, perceived benefits and perceived barriers influence perceptions of the effectiveness of health behavior, which is this case in submitting to DOT.(11) Perceived benefits would be disease cure, assuming the patients believe the drugs will lead to a cure. Perceived barriers considered by the DOTS approach include drug supply and funding, which they impart as key elements of the program. The patient may or may not be aware of these measures, and may believe he/she does not have the money to pay for treatment, which would make going to the clinic at all an ineffective behavior if they believe they cannot access the treatment even if they do believe it works. There are other potential perceived barriers to treatment effectiveness, which the approach does not account for, some of which will be discussed later in this analysis.
This theory focuses on cognitive variables as part of behavior change, and assumes that attitudes and beliefs, as well as expectations of future events and outcomes, are major determinants of health related behaviors.(11) In the face of certain alternatives, this theory proposes that individuals will choose the action that will most likely lead to positive outcomes.(11) The program makes the assumption that patients will believe that the medications work, and therefore want the treatment. Depending on the region, there may be distrust of western medicine, alternative/traditional beliefs about cause and cure of tuberculosis, and numbers of patients stopping treatment early who then get sick again. All of these factors could affect the individual’s attitudes about the behavior of accepting treatment for nine months, and are not considered in individual-level models.
High-perceived threat, low barriers and high-perceived benefits to action increase the likelihood of engaging in the recommended behavior.(11) It has been suggested that the health belief model focuses on a single threat and prevention behavior and do not include possible additional threats competing for the individual's attention.(11) The DOTS approach functions mainly in the developing world, where these programs are most needed, so there are numerous competing threats the patient may weigh in when considering taking medication according to the regimen or not, as well as perceived barriers.
The patient may lose time and wages by making the required trip to the clinic every day, which may be substantial barriers for the patient in accessing treatment. The competing threat of job loss may be perceived as a greater threat than that of infection relapse or even infecting others. The occurrence of other illnesses may deter a patient from traveling as that may pose a greater thereat than the chronic TB. In addition, the side effects of taking medication may be severe enough to compete with severity of symptoms, or may hinder work performance, again posing the threat of job loss or forced time away from work. These outside threats may become a greater weight on the decision scale especially in the last months of treatment, when the patient will feel much better, even though there are still low levels of bacilli circulating that could multiply and cause a complete relapse. One study found that the largest contributing factor in patient non-adherence was due to patients “beginning to feel better” and that this accounted for 45.1% of treatment dropout among those who left treatment.(12)
While the health belief model may predict adherence in some situations, it has not been found to do so for "risk reduction behaviors that are more linked to socially determined or unconscious motivations".(11) When applying this theory to long-term medication adherence, it is also important for the influence of socio- psychological factors to be considered. For example, cultural beliefs about TB – such as its relationship with witchcraft or belief in traditional versus western medicine, could reduce an adherence intervention's effectiveness.(11) The theory is limiting in its dependence largely on rational processes and does not allow explicitly for the impacts of emotions or self-esteem on behavior, which may be related to a stigmatized disease such as tuberculosis.(11)
In the broader scope, the DOTS approach intends to control the spread of TB by one prevention method, which is treatment of all active cases. It is as if the DOTS plan has blinders on to all the outside factors that could cause it to fail.
Critique Two: DOTS Approach Does Not Account for Behavior-Influencing Social and Environmental Factors

The DOTS overall approach tries to incorporate “political commitment, accessible laboratory services, strict uninterrupted supply of medications, and effective surveillance and monitoring systems for patient follow-up”(4,8) in addition to supervision of each dose of treatment (DOT). Despite consideration of many practical issues that could arise in facilitation of DOTS strategy, it fails to consider social or environmental factors of the area in which it will be introduced.
The advantages of DOT are that people can be closely monitored and that there is a social process with peer pressure that may improve adherence.(5) In this way, one aspect of social influence is considered, but this is the only allowance for it. The disadvantages associated with DOT are that it moves away from adherence models of communication with cooperation between patient and provider back to a traditional medical approach with the patient as the passive recipient of advice and treatment.(5)
Patients may not like feeling as though they have no power in their treatment plan, as in the DOTS program, which is entirely clinician-managed. The paternalistic enforcement of observed drug swallowing may cue the natural human tendency to rebel, especially after months of forced directives. This method could actually make it less likely that the patient will return for subsequent treatments, if they feel they have no control, as the doctor has all of the power. Finally, it may make adherence worse if it is rigidly applied in an authoritarian setting or where people are expected to travel considerable distances to have their treatment supervised. The alternative of course, is to simply not return to the clinic for treatment. After months of medication, and finally feeling better, the odds that the patient will return under such conditions may be unlikely, considering the reduction in perceived severity of disease and risk of relapse with mitigation of symptoms. Not returning to the clinic may be perceived by the patient as a way to take back that control.
Another social factor that should be taken into consideration are role of the family in decision-making, which may be very different depending on the age and sex of the patient. If the patient is female or a child, in some cultures the decision to attend or not attend treatment may not be up to the patient.
Resource implications for a DOTS policy are substantial, particularly in low and middle-income countries where the caseload is high. Therefore, the strategy should be proven effective in the area before wasting countries already limited resources. DOTS strives for an uninterrupted supply chain of medication, yet one study found that “running out of drugs at home” was the patient-reported cause of treatment default in 25.4% of those who dropped out of treatment, which could occur in programs implemented with the pill-count method of observation.(12)
DOTS also does not directly account for staff time to manage DOT, which can put a great strain on the overall system. A chaotic clinic environment may influence the patient’s perception that his/her attendance causes problems for the rest of the clinic, and that doctors do not have time for them. Doctors may even lose credibility if the patient sees they are struggling and begin to question whether the treatment will really work.
In a study of risk factors for treatment discontinuation in DOTS programs in India, it was reported that alcoholism, illiteracy, having other commitments during treatment, inadequate knowledge of TB, poor patient provider interaction, lack of support from health staff, and dissatisfaction with services provided were all factors independently associated with treatment default.(13) Another environmental factor that could affect medication adherence is when care providers do not provide adequate explanation of treatment course and the importance of adherence. One study cited that 25.7% of dropout rate was due to “lack of knowledge on the benefits of completing the course” of treatment.(12) A study conducted in Nepal found that non-adherence was significantly associated with unemployment, low-status occupation, low annual income, and cost of travel to TB treatment facility.(14) This shows that socio-economic status is yet another factor for treatment default which should be considered when developing interventions.
There is strong evidence that there are many social and environmental factors that should be considered when running a DOTS program. Currently, social and environmental factors as not considered in DOTS implementation.
Critique Three: Potential for Negative Labeling and Stigmatization Associated with Tuberculosis Treatment
There is an ongoing presence of stigmatization associated with TB disease particularly in developing nations that has been well documented.(15) Understanding the origins of TB stigma is integral to reducing its impact on health.(15) As beliefs about the origins and transmission of TB may vary by culture, often resulting in stigmatism, seeking treatment can be a very delicate matter.(11) Although there is geographic and cultural variation in the explanations for why TB is stigmatized, most authors identify the perceived contagiousness of TB as a leading cause of stigmatization.(15) Lack of knowledge regarding routes of TB transmission may also contribute to TB stigma.(15)
In areas with high HIV prevalence, where HIV and TB co-infection is common, the association between the two diseases has contributed to the stigmatization of TB.(15) TB is perceived as a marker for HIV positivity; therefore, HIV-associated stigma is transferred to TB-infected individuals, regardless of their HIV-status.
Other causes of TB stigma include the perceived associations of TB with malnutrition, poverty, being foreign-born (U.S.), and of low social class.(15) Finally, TB stigma may occur because an affected individual’s community believes he or she must have done something to deserve to be infected.(15) This judgment may reflect the belief that TB is divine punishment for a moral or personal failing, which then justifies the stigmatization.
Social stigmatization can also lead to negative labeling of TB patients. Internalization of negative labels brought on by stigma associated with transmission of TB can have great psychological effects and could affect treatment adherence. TB-infected individuals perceive themselves to be at risk for a number of stigma-related social and economic consequences. Because the most common result of TB stigma is isolation from other members of the community, TB infection can substantially impact economic opportunities.(15) For those who do seek treatment, studies suggest an increasingly negative and demoralizing effect of DOT on patients.(5)
Several studies suggest that health-care providers and at-risk community members perceive TB stigma to have a more substantial impact on women’s health-care-seeking behavior than on men’s.(7,12,15) This could in part account for the lower disease rates in women, if women fear TB as a diagnosis and decide not to seek care.
Fear of stigmatization can delay diagnosis, and deter acceptance of treatment, and even continuing treatment once it has begun. Developing a reputation as a dirty or diseased individual could be a great deterrent in continuation of treatment. Unfortunately, the DOTS program as of now does nothing to ensure confidentiality of treatment. If treatment were self-administered at home, it would be unlikely that the community would know what pills the person was taking, whereas attendance to a TB clinic or to a general facility on a daily basis may not be conspicuous enough to hide the truth.
Revamping the DOTS Strategy
Tuberculosis is an extremely complicated disease, with a long and complex treatment regimen that must be followed consistently to achieve a good outcome. There is no easy answer to why the DOTS program fails in some places. It is a challenge to design, create, implement, and evaluate an intervention to increase treatment adherence. The DOTS approach has made a great impact in most places. It is not easy to create dynamic, sound interventions that account for the multitude of factors that contribute to the complexity of this disease and the human behaviors that affect its treatment. However, improvements can be made to address the shortcomings of the program using social and behavioral health principles.
As shown in the critique of the DOTS approach, there are several flaws that require development or expansion. The first critique addressed the use of the health belief model as the underlying foundation of the DOTS strategy. As an alternative, incorporation of other more comprehensive models could be used to account for more influences of human behavior in making new interventions. For example, learning theories presume that adherence to medical regimens requires social support and freedom from physical and social barriers.(16) One study’s results support the use of these theories in that adherence counseling had a positive effect on adherence, while engaging in other risk behaviors had a negative effect on adherence.(16) These models allow for irrational behavior, which the health belief model does not. This would be an improvement because it will allow for expansion to factors other than perceived severity and susceptibility and perceived barriers and benefits. By allowing for the possibility that humans may make irrational decisions, the influences that lead to irrationality could more clearly be seen. Considering internal impacts of emotions and self-esteem and external impacts such as social and environmental factors can help to accomplish this.
The second criticism of the DOTS strategy was that it failed to account for social and environmental factors. Leaving these factors out of consideration came at great losses of patients not returning to clinic for treatment.(17) In order for the DOTS intervention to work, it must be bolstered with consideration of social and environmental factors that are site specific where feasible. In many studies it has been reported that while patients found the overall TB care approach efficient and economical in general, they faced numerous barriers to regular attendance for the direct observation of drug-taking (most especially, time, travel costs, ill health and need to pursue their occupation).(3,9,10) This suggests that there are significant environmental barriers that must be taken into consideration in updating the DOTS strategy. If used, DOT should be flexible and convenient regardless if conducted at a health facility or in patients home with a nurse. The emphasis should shift in practice from pill counting towards patient-centered treatment support, together with education on what to expect from disease and medication.
One study reported that provider attitudes were poor: health facility workers expressed cynical and uncaring views; community health workers were more positive, but still arranged direct observation to suit their schedules, rather than their patients’.(12) This is clearly not an example of a supportive environment. Interventions are needed to improve clinician-patient communications and staff attitudes so that patients do not encounter a clinic environment in which they feel demeaned.
A social factor not previously incorporated in the DOTS strategy is family involvement. As noted, the head of the household may make decisions on whether or not other members of the family will be permitted to go to treatment everyday. Factors that could affect this decision include economic feasibility, social stigma, or mode of transport to TB treatment site. By involving the family from the beginning of treatment, there is a higher likelihood of treatment adherence, resulting from receiving the same education the patient receives. Incorporation of the family in treatment could work in TB control by screening family members for the disease while they’re at the clinic. If a patient feels supported by his/her family, they may be more likely to feel acceptance of their disease and receive the treatment without default. Family support could also work to increase self-efficacy and self-esteem, even in the face of stigmatism from others in community. In a similar intervention, improvement of patient education messages and adherence counseling should also me implemented.
Another social intervention that proved to be successful in practice was a ‘cultural intervention’ which involved five elements: 1) the same interventionist nurse was used for the same patient at each clinic visit in order to establish a relationship, 2) family members names were noted in medical chart in order for the nurse to inquire about the patients family at subsequent visits, 3) A common Latino proverb was stated by the nurse at each visit, which subsequently became the logo for the study and was put onto stickers and small gifts for nurses to distribute to participants at random visits, 4) Educational materials were culturally adapted and written at sixth-grade reading level, 5) All nurses were fluent in Spanish.(18) These elements were all based around core Latino values and culture, which made the intervention tailored to the population they were serving. This intervention uses the principle of liking in order to help the patients relate to the nurse and in turn, improves their adherence to treatment.
The final flaw in this critique was failure of the DOTS program to address stigmatism in its strategy, and the potential for negative labeling that this could incur. One possible intervention would be widespread education campaigns. One reason stigmatism is so prevalent is a lack of knowledge on routes of transmission, as well as association with many negative characteristics, such as poverty, poor hygiene, malnutrition etc. Collective cognitive change is slow, so an education campaign certainly will not change social norms on its own to eliminate stigmatism towards TB, but it could reduce it with time. While some studies report lack of knowledge as a main factor in stigma development, others have noted that education campaigns are ineffective.(15) Therefore, tailoring education campaigns to a specific audience and using effective social theories and principles is imperative in their development.
Although community and institutional norms ultimately mediate stigmatization, wide-scale interventions to change these norms can be difficult. A smaller-scale intervention that could be utilized is support groups for people who are in treatment. The groups extend a social support and sense of belonging that could help to limit the internalization of negative associations with TB as labels. These have been effective in reducing HIV/AIDS stigmatization in Voluntary Counseling and Testing (VCT) centers that hold support groups. This seems to be a promising approach in helping TB-infected individuals resist TB stigma, particularly through TB clubs, says one assessment.(15)
Finally, it is essential to continue to develop other interventions—for example, counseling TB-infected patients or introducing default-screening policies in high TB prevalence areas—to reduce TB stigma. It is also important to supplement this bottom-up approach to reducing TB stigma with an assessment of interventions designed to directly address stigmatizing community norms about TB.
Since its implementation in 1994, DOTS has accomplished great things in TB treatment. However, treatment adherence continues to be a serious problem in TB control. The DOTS strategy is built on traditional health belief models that fail to consider environmental and social factors contributing to alternative behaviors. Overall, the DOTS approach’s biggest downfall is in its failure to customize each implementation program site. By not tailoring the program to account for the social and environmental factors that will potentially influence behavior in that region, and making the assumption that patients behave rationally and stay in treatment without additional interventions, significant numbers of patients quit treatment. With several modifications, including integration of more comprehensive theories such as learning theories, increasing flexibility of treatment plans, opening communication lines between patients and providers, moving towards patient-centered care, improving patient education, instituting adherence counseling, developing evidence-based education campaigns, forming support groups and involving families in treatment, and utilizing core values of the culture to improve clinic and treatment experience.

References


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Putting Testing to the Test: A Critical Evaluation of Voluntary Counseling and Testing in Sub-Saharan Africa – Jennifer Foth

Putting Testing to the Test: A Critical Evaluation of Voluntary Counseling and Testing in Sub-Saharan Africa – Jennifer Foth
Introduction
In the fight against HIV/AIDS in sub-Saharan Africa, HIV voluntary counseling and testing (VCT) has been touted as an effective individual-level intervention. The primary benefit of VCT (which consists of pre-counseling, testing, and post-counseling) lies in the information that is provided before and after testing, which is believed to enhance individual HIV risk reduction knowledge, attitudes, and behaviors (1). For those receiving positive test results, VCT can serve as a gateway to clinical care and support services to reduce the probability of transmitting HIV to others (2). For those who test negative, VCT provides information on safer sex behavior and how to prevent future infection. However, despite the benefits offered by VCT, its utilization among high-risk populations in sub-Saharan Africa remains discouragingly low. Recent estimates based on surveys in 12 high-burden countries in sub-Saharan Africa indicate that only 12% of men and 10% of women have been tested for HIV and received the results (3). Demographic and health surveys in several African countries have also shown that, among those who do not know their HIV status, over two-thirds would like to get tested. Yet, the proportion of those who report actually having been tested remains below 15% in some areas (4).
This discrepancy between intention and actual behavior highlights the fundamental weakness of the theoretical underpinnings of VCT. The support for VCT as an important entry point for HIV risk communication, treatment, and care has overshadowed the need to assess its true impact as a behavioral risk reduction strategy (1). In determining whether testing opens the gate to treatment and promotes behavior change, the extent to which fears of VCT and the barriers to access are overcome must be evaluated. In this paper, I will provide a critique of the theoretical foundation of VCT using alternative theories of social and behavioral change to highlight the specific social and structural factors that discourage VCT uptake in sub-Saharan Africa. I will then incorporate these factors and alternative theories into my proposal for a new, more comprehensive framework for VCT provision in sub-Saharan Africa.
The Theoretical Foundation of VCT
Voluntary Counseling and Testing (VCT) is an HIV intervention that includes both voluntary pre- and post-test counseling and voluntary HIV testing. VCT provides individuals with the opportunity to confidentially explore and understand their HIV risks, learn their HIV status and link to care and support services. The expected effect of VCT is to lower HIV transmission through reduction in high-risk sexual behaviour, improved medical care, and improved access to care and support services for both HIV-positive and HIV-negative persons (5).
VCT is offered in a variety of settings and by many institutions, including non-governmental organizations (NGOs), community-based organizations, mission and government hospitals, and health centers. Integrated VCT is usually incorporated into existing healthcare settings, such as sexually transmitted infection (STI) and tuberculosis clinics, family planning and maternal health services. Stand-alone programs, typically operated by non-governmental organizations, offer VCT away from health services but with frequent referrals to care and support services (6). Mobile VCT entails the provision of testing services by mobile teams from a van equipped with HIV-testing facilities. Mobile teams will often set up temporary sites where they offer services to the general population, defined groups such as a church congregation, or to hard-to-reach groups such as injection drug users and sex workers. Under the home-based VCT approach, counseling and testing services are provided door-to-door in client homes, often by community health workers. This approach enables counselors to both test and discuss HIV risk and prevention on a larger scale, one family at a time (6).
All of the aforementioned VCT provision methods fall under the category of client-initiated VCT, indicating that those who wish to get tested must take the initiative and seek out the services themselves. Each method therefore requires individual recognition of the risk and severity of HIV, followed by the decision to get tested. Client-initiated VCT is thus founded firmly upon the Health Belief Model (HBM), a model of health behavior change originally developed to explain the uptake of health services (7). The HBM stipulates that health-related behavior depends on four key beliefs about perceptions regarding the condition: susceptibility to the condition, its severity, the benefits of adopting a new behavior and the barriers to implementing that behavior (8). In deciding whether to utilize VCT, individuals must believe 1) that they are susceptible to contracting HIV and 2) that the consequences will be severe if they do contract the disease. The benefits of getting tested and knowing one’s HIV status are then weighed against any barriers to VCT utilization that might exist. Assuming the benefits outweigh the costs, the HBM predicts that individuals will decide to – and eventually will – get tested.
Studies have shown, however, that intent seldom leads to behavior when it comes to the uptake of VCT within sub-Saharan African populations. The architects of VCT programs have failed to consider “the role of demographic, socio-psychological and structural variables… [that serve] to condition both individual perceptions and the perceived benefits of preventive actions” (7). Disparities in risk perception, fear of social stigma, concerns regarding the confidentiality of one’s status, and issues of accessibility all directly challenge the rationale for the HBM as the theoretical basis for VCT service provision (9).
Disparities in Risk Perception
One of the primary underlying assumptions of the HBM as it relates to VCT is that populations in sub-Saharan Africa are aware of the risks posed by HIV/AIDS, and that this awareness is sufficient to increase individual perceptions of susceptibility and disease severity. Education and awareness campaigns, detailing the high rates of HIV infection and encouraging the adoption of risk reduction strategies (i.e. abstinence, condoms), abound in sub-Saharan Africa. VCT providers have even developed their own media campaigns to increase awareness of HIV risk and promote testing services. Unfortunately, as the statistics on VCT utilization indicate (see Introduction), these educational campaigns do not appear to be achieving the desired results. In reality, the content of these campaigns often works to their own disadvantage. VCT campaigns frequently employ images of middle-class couples and individuals to convey their message. Unfortunately, these images do not always resonate with all segments of the population. As one woman notes, ‘‘In rural areas the billboards should not show pictures of rich people from town. Where is the tomato seller in the market who says to her neighbor, ‘Please mind my stall. I want to fetch my husband and we go for VCT?’’’Others have expressed their frustration with ‘‘mass media depicting couples counseling as only for the few who have big dreams, laptops and MAs... How many of our women have that?” (10).
The disconnect between the individuals featured in, and the individuals exposed to, VCT campaigns may therefore be compromising their effectiveness. In his article entitled “Deflecting Reactance: The Role of Similarity in Increasing Compliance and Reducing Resistance”, Paul J. Silvia argues that social influences, including education and awareness campaigns, “can threaten people’s freedom to decide autonomously, to form their own opinions, to hold various attitudes (or none at all), and to do what they feel free to do” (11). Campaigns extolling the dangers of HIV, and compelling individuals to use VCT and other risk-reduction methods, pose an inherent threat to individual autonomy, particularly as it relates to sexual decision-making. While such campaigns may create an initial positive force to comply, they ultimately create a stronger negative impulse to react (11). However, reactance can be minimized when messages that threaten autonomy are presented by people with a high degree of similarity to the target audience. As Silvia notes:
An individual is likely to feel that persons with status, values, interests, and needs similar to his own see things as he does and judge them from the same point of view. Because of this, their assertions about matters of which the individual is ignorant…will tend to carry special credibility. (11)

The lack of similarity between at-risk populations and the individuals featured in VCT campaigns may thus be inducing psychological reactance and compromising their goal of increasing perceptions of HIV susceptibility and disease severity.
In many sub-Saharan African countries, a gender gap in HIV/AIDS risk perception serves to further undermine the objectives of VCT. A number of studies have shown that, overall, men are less likely than women to perceive themselves as at risk of contracting HIV/AIDS (10), an important finding given the asymmetrical power dynamics that typically characterize male-female relationships in sub-Saharan Africa. As described in the Theory of Gender and Power, relationships between men and women are characterized by three major structures: the sexual division of labor, the sexual division of power, and the structure of affective and social exposures (12). Power in this context is conceptualized as having the power to act or change, or having power over others. The inequities resulting from the sexual division of power are often manifested in behavioral risk factors for HIV. As the power inequity increases in favor of men, women’s sexual choices and behavior may be constrained (12). Women may thus feel they do not have the self-efficacy (or confidence in their ability to effect change) necessary to negotiate VCT utilization. As one Kenyan woman explained: ‘‘The woman usually brings the message of VCT home. Like in my case. Then I’ll keep asking let’s go for a test but we will never go unless he thinks we need to. Once he makes up his mind we go…’’(10). In fact, most married females in the same Kenyan study reported that they would have to obtain permission from their spouses before making any type of sexual decisions such as when to have sex, use a condom or get tested for HIV, choices which are generally perceived to be within the realm of male decision-making (10). The same study also showed that, while taking condoms home from a VCT session was viewed as acceptable for male clients, for women it was quite different, as ‘‘most women would risk having unprotected sex rather than offend their partners by taking home condoms–especially the married ones since it could seem as though they do not trust them [their husbands]’’ (10). Failure to recognize and address these gendered power dynamics will inevitably limit the reach and impact of VCT services on female populations within sub-Saharan Africa.
HIV/AIDS Stigma
VCT uptake in sub-Saharan Africa is also heavily influenced by social norms and attitudes, most notably the stigmatization of persons living with HIV/AIDS (PLHAs). In ancient Greece, the term ‘stigma’ referred to a sign, mark, cut or burned into the body that designated the bearer as a person who was morally defective and to be avoided (13). Today, according to Erving Goffman’s theory of social stigma, a stigmatized individual is:
[One] whose social identity, or membership in some social category, calls into question his or her full humanity; the person is devalued, spoiled or flawed in the eyes of others. Generally, there is nothing objectively wrong with the person, it is those others who supply the label and attach a negative meaning to whatever characteristic the individual possesses. (13)

Stigma is most frequently attached to a disease whose cause is perceived to be the bearer’s responsibility. Consequently, because the primary routes of HIV/AIDS transmission are behaviors that are widely considered to be voluntary and immoral (homosexuality, promiscuity, sex prostitutes, intravenous drug use, etc.), PLHAs are seen as responsible for their condition (14). In many sub-Saharan African countries, fear of HIV stigma is cited as a main cause of reluctance to utilize VCT, since those who test positive may face rejection from their family and community.
In our society, people are rejected when they are infected with HIV. . . When someone is rejected by his entourage because he is ill, he will find himself confronted with two illnesses instead of one – because exclusion is also an illness. [Bamako, man, 28 yrs old] (15)

Regardless of one’s test results, the mere act of entering a VCT site may be enough to incur social stigma. Given the very public face of stand-along VCT centers, an association is often automatically made between visiting testing centers and being HIV positive. Such associations can decrease motivation to seek out VCT among individuals who do not want to “give people the wrong idea” (10). Given the choice, many would rather not know their HIV status than risk being labeled and ostracized if they happen to test positive.
HIV/AIDS related stigmatization manifests itself in numerous contexts, not just within the community (13). In fact, fear of stigmatization from VCT counselors themselves is frequently cited as a significant deterrent to VCT utilization. Counselors often live within the community where the VCT center is located and are embedded in the local social networks. Thus, for those interested in being tested, VCT counselors symbolize the incursion of public, social stigma into what should be a very private experience. As a result, confidentiality and distrust of VCT personnel is often a major concern for those considering VCT. As one man from Malawi explained:
[I]f I can be tested at Mhojo Health Centre, VCT counselors there know me and if that counselor at the VCT [centre] finds me with the virus then he can start spreading the messages to friends of mine, and if I know about that then it becomes very bad to my life...(16)

The location of VCT centers may further spark concerns over stigmatization and confidentiality among those interested in getting tested. As previously noted, VCT is often provided at stand-alone sites or by mobile VCT teams in public venues such as churches or community centers. These means of provision make it very difficult for individuals to access VCT without being seen, and potentially stigmatized, by other community members. Even integrated VCT services offered in clinical settings may not alleviate confidentiality concerns, as they are often located in separate wings of the building. The separation of VCT from other medical services can quickly reveal the true purpose of an individual’s visit to outside observers who are aware that “there is a separate room for HIV testing and…see you coming into the room with a smiling face, but when you are coming out they find you with a disappointed face, then they just conclude that you have been found HIV positive,” (4).
The effect of HIV/AIDS stigmatization on VCT uptake can be explained in terms of Social Identity Theory, first developed by Henri Tajfel in the 1980s. Social Identity Theory suggests that group memberships form a fundamental part of people’s identities and that people are motivated to establish and maintain their positive social identities (13). Fear of HIV/AIDS stigmatization thus arises out of an individual’s need to protect their identity as health and non-deviant members of society. Unfortunately, fear of HIV/AIDS stigma and concerns over testing confidentiality have lead to an impasse regarding VCT. Given the high levels of HIV/AIDS stigma in some communities, VCT counselors feel ethically bound to warn clients that testing positive could expose them to HIV/AIDS stigma. This warning only reinforces the fear of stigmatization within the community, further decreasing VCT utilization (13).
Barriers to VCT Access
Finally, the structural barriers of cost and distance serve as prohibitive factors to accessing VCT services, particularly in rural areas. High-quality VCT services tend to be located in urban areas that enable VCT providers to reach a greater number of at-risk individuals and tap into a larger pool of trained health professionals. As a result, individuals in rural areas where mobile VCT is not provided must travel great distances to access VCT, often at great cost. Moreover, many VCT centers require clients to visit at least twice – once to conduct pre-counseling and get tested, and once to receive their test results and conduct post-test counseling (17).
Implicit in the Health Belief Model, the theoretical foundation of client-initiated VCT, is the assumption that an analysis of the costs and benefits of testing will lead to the intention and behavior of getting tested. In reality, the high monetary and opportunity costs associated with accessing VCT services more often than not outweigh the benefits of testing for rural or low-income populations. The impact of these costs on individual behavior are captured in the Theory of Self-Efficacy, according to which “two types of expectancies exert powerful influences on behavior: outcome expectancy, which is the conviction that certain behaviors will lead to certain outcomes; and self-efficacy expectancy, which is the conviction that one can successfully execute the behavior required to produce the outcomes” (18). For the over 500 million people living in rural sub-Saharan Africa (19), the financial and structural barriers alone are enough to reduce individual self-efficacy and prevent individuals from seeking access to VCT. In the absence of more pressing reasons to travel to urban areas, individuals will not view the benefits of VCT as being worth the monetary cost of transportation and the opportunity cost incurred by hours spent traveling and waiting to be seen by a VCT counselor (4).
MHC-VCT: A New VCT Paradigm
When faced with significant barriers to access, potential stigmatization and uncertainties regarding testing confidentiality, simply weighing costs and benefits is not enough. The Health Belief Model does not account for these important social and structural factors that so profoundly complicate the issue of accessing VCT. To increase the scope and impact of VCT on increasing HIV risk perception and reducing risk behavior, the theoretical foundations of VCT must be expanded to incorporate these social and structural factors into the VCT provision framework.
First, VCT providers must use the Theory of Psychological Reactance to their advantage, at both the community and interpersonal level, to narrow the gap in risk perception between urban and rural populations. In his study on psychological reactance, Silvia showed that people agree more with messages presented by individuals who shared similar values and beliefs. To mitigate the inherent threat to personal and sexual freedom posed by VCT awareness campaigns, individuals with greater similarity to the target population should be featured in mass communication materials such as billboards, pamphlets, TV and radio advertisements. Individual responses to health messages tend to be “influenced by…background characteristics (such as gender or ethnic group), [and] attitudes,” (3). VCT materials should thus be adapted to the social, cultural and regional contexts in which they are being distributed by prominently featuring members of a particular ethnic group, religion or profession.
On a more personal level, VCT service providers should incorporate participatory meet-and-greet sessions with PLHAs into their education and outreach campaigns. Rather than presenting information on HIV/AIDS risk in a one-directional manner, VCT providers should offer “direct and personal contact with those suffering from AIDS and the chance to exchange opinions with them and to ask questions,” (15). Research and theories such as Fuzzy Trace Theory suggest that, for a change in perception to occur, individuals need to translate statistics and abstract notions of risk into more personal, tangible terms (3, 20). Research further suggests that the mere experience of knowing someone with HIV/AIDS can positively predict individual behavior change (15). Engaging PLAHs in the educational component of VCT will provide clients with the opportunity to see the similarities that exist between themselves and PLHAs, and lead to a greater internalization of risk and perceived susceptibility to HIV.
My second recommendation would be for VCT service providers to focus their efforts and resources on the provision of all-in-one mobile, home-based, couples VCT (hereafter referred to as MHC-VCT). MHC-VCT combines the three VCT sub-groups which have repeatedly been shown to be the most effective in promoting behavior change (6). By enabling couples to negotiate changes in sexual behavior together, the “couples” element of MHC-VCT works to reduce the asymmetries in the sexual distribution of power between men and women, which are often deeply ingrained in the social and cultural fabric. By providing MHC-VCT, counselors can foster an open and honest discussion, in a familiar environment, about the sensitive topics of HIV risk behavior and risk mitigation. The “home-based” element will furthermore increase female participation in traditionally male-dominated societies, in which the husband is the primary decision-maker (17). MHC-VCT brings the services to the women themselves, rather than requiring them to obtain permission from their husbands or forgo their domestic responsibilities in order to access VCT services. The result is greater outreach and impact on both sexes, as evidenced by one Ugandan study, which found that home-based VCT “increased acceptance of testing from 10% to 46% and eliminated differences in acceptance between women and men” (3).
Whenever possible, MHC-VCT visits should be conducted by both a male and female counselor. In many traditional societies, it is not considered acceptable for men to discuss issues relating to sexual behavior with women (and vice versa), even in a clinical setting. Thus, it may be necessary in some contexts for counselors and clients to be matched by gender in order to reduce psychological reactance against HIV risk behavior prevention messages. To assuage concerns over confidentiality, MHC-VCT visits should also be conducted, where feasible, by non-resident counselors. As one Ugandan man noted, the benefit of being tested by a non-resident counselor lies in the fact that “[he] can’t reveal the secret because he doesn’t know anyone in the villages and he will not have time to reveal because we expect him after testing to go somewhere else where there is no one who is familiar with me,” (17). When the employment of non-resident counselors is not fiscally or logistically possible, the importance of confidentiality should be reinforced by intensive counselor training and by providing test results verbally, so as not to leave documentation of HIV status accessible to third parties. These measures will increase client trust in counselors and diminish fears of potential stigmatization resulting from leaked test results.
At the same time, MHC-VCT can combat the stigmatization so often associated with VCT utilization. Providing VCT in a private setting eliminates the stigmatization associated with being seen at, or entering, a public VCT site. Stigmatization of those living with HIV/AIDS, and those who get tested, will be further reduced by the interaction between clients and PLHAs incorporated into MHC-VCT. While one could argue that high levels of HIV/AIDS stigmatization in certain areas might place PLHAs participating in MHC-VCT at greater risk of being ostracized or persecuted (6), there are theories that would contradict that argument. One such theory, proposed by Pryor et al., is the “two-factor” theory of stigma, which suggests that:
When confronted with PLHAs, people's initial reaction is characterised by a relatively automatic negative affect [sic]. Then, given time, cognitive resources, and motivation, this initial negative response can be adjusted. The result is that this adjustment will often result in a more moderate or less negative reaction to the stigmatised person. (13)

The improvements proposed above will make those “cognitive resources” more available to a greater portion of the population. Over time, the elements of the MHC-VCT provision framework can combat HIV-related stigmatization, eventually producing a fundamental shift in the social norms surrounding HIV testing, counseling and the disease itself.
Conclusion
It is clear that the practical barriers of distance and cost, combined with social factors related to the perception of risk and fear of stigmatization, impede VCT utilization in sub-Saharan Africa. These barriers can be largely overcome, however, by reevaluating the theoretical basis of VCT provision and incorporating alternative theories of social and behavioral change. In so doing, the components of MHC-VCT proposed above can help to narrow the gender gap in the distribution of sexual power, thereby decreasing barriers to access, increasing outreach, and maximizing the impact on both male and female perceptions of HIV risk. Unfortunately, human and financial resource constraints may preclude many countries in sub-Saharan Africa from adopting all or most of the MHC-VCT recommendations. To realize the full benefits of counseling and testing, governments, NGOs, donors and the public health community must be willing to challenge the traditional thinking behind VCT provision and focus their resources on interventions that attack the underlying social and structural barriers to access.

















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Suicide Risk and Prevention in South Korea – Glory Song

BEHIND THE PRISTINE VENEER

In the past ten years, South Korea has seen major economic and cultural advancements. Not only has its technological and automobile industries become giants in the global economy, even its cultural export, consisting of music, dramas, movies, fashion, and impeccable looking celebrities, have now garnered worldwide followings and have become household names across all of Asia. Historically a deeply traditional society founded on rigid hierarchy and a strong sense of unification, the influx of wealth and Western ideals have transformed the nation into a hub for consumerism and pursuit of higher living. The ritzy avenues of Seoul, with its fashion billboards, endless stores and countless plastic surgery centers attest to the shift in societal ideals to a glorification of what is glamorous, luxurious, and beautiful.

However, behind Korean National Tourism’s best effort to portray the nation as the junction where rich tradition meets modernity, lie deep-seated social problems of increased senses of alienation and pervasively unaddressed psychological anxieties that serve as direct consequences of a nation that has not confronted the mental illness and social vices brought about by their rapidly transforming society that is leaving so many of its people alone and behind.

A UNIQUE PHENOMENON

In 2006, South Korea surpassed Japan in having the highest suicide rate among the 30 Organization for Economic Cooperation and Development (OECD) nations that include the United States and large parts of Europe (1). In 2009, suicide made up 6.2 percent of the total number of deaths in Korea and ranks as the 4^th leading cause of death in the country, behind common pathological conditions of cancer, cerebrovascular diseases and cardiovascular ailments such as stroke (2). The National Statistical Office (NSO) reported 26.1 suicides per 100,000 people in Korea for 2005. The corresponding figure for the United States was 10.2 (3).

Perhaps a phenomenon that has been unique to South Korea is the overwhelming number of heavily publicized suicides by public figures, including those of former president Roh Moo-hyun, millionaire Samsung heiress Lee Yoon-hyung, and a string of entertainers such as singer U;Nee, supermodel Daul Kim, and most recently, Park Yong-ha, who had been a frontrunner in the “Korean Wave” cultural export movement (4). Due to widely available media outlets, a large subscription to entertainment by the public, and the homogeneity of the population, Korean public figures have an unusually close dynamic with the general public, and everything from their outfit to their personal life to their past history is constantly monitored and a potential subject of scrutiny by the people.

Since popular actress Lee Eun-joo’s suicide in 2005, a consistent trend of copycat suicides have followed in the two months after the announcement of a public figure suicide. Statistics report that the number of people who commit suicide within two months after the death of a celebrity was distinctly higher than those in other months in a given year. The numbers were 2,568 for actress Lee Eun-joo in February, 2005; 2,330 for U;Nee in January, 2007; and 2,876 for actor Ahn Jae-hwan in September, 2008 (5).

Such phenomenon in which people mimic the suicide method they observe has come to be known as “The Werther Effect” (6) and has contributed greatly to Korea’s sharply increasing suicide rate. Yet it is only within the last two years that the national government has really made a centralized effort to launch a campaign in response to this growing social tragedy.

TACKLING THE SURFACE

In late 2008, 10 government ministries and offices came together to develop a blueprint for a national anti-suicide campaign (7). The long-term goal focuses on strengthening the social and economic safety net for those in the low-income brackets and the aged, but in the meantime, the government has also established a series of short-term measures. These measures target what are considered the two main perpetrators for enabling suicide among the population: 1) the media responsible for disseminating news of celebrity deaths to the public and 2) the accessibility of suicidal means to the individual.

In an effort to limit the sensationalism surrounding celebrity death, the Ministry of Health and Welfare has requested that media companies 1) refrain from printing celebrity suicides as headlines and 2) refrain from describing the specific means or situation of the death and interviewing family members of the deceased (6). In efforts to close off access to various means of suicide to the common people, the Ministry of Land, Transport and Maritime Affairs have plans to set up more screen doors at subway stations to prevent people from committing suicide by jumping in front of trains and the Ministry of Food, Agriculture, Forestry and Fisheries have plans to regulate purchases of poison pesticides in an attempt to cut off access to the abuse of such supplies (8).

While it remains to be seen whether these preliminary strategies will make any impact in reducing the rate of suicide, there are certain flaws in these rationale that raises concern as to their efficacy. This paper will highlight three critiques of the Korean government’s anti-suicide intervention strategies and provide alternative suggestions that address each of the three shortcomings.

CRITIQUE 1: OVERSIMPLIFICATION OF THE SOCIAL COGNITIVE THEORY

Social cognitive theory posits that individuals learn by watching what others do and that behavior change is affected by environmental influences, personal factors, and attributes of the behavior itself (9). Furthermore, self-efficacy, or the belief a person has in his or her capability to perform the behavior, is central to the individual performing the behavior. However, within a societal set-up like South Korea, environmental influence and social pressure play a formidable role in the coercion of individual behavior.

While the social cognitive theory as it stands may be valid in a Western society where individualism and self-reliance are upheld, its component make-up become less balanced in traditional Asian societies that strongly value homogeneity and conformity to a set of social expectations. In South Korea, environmental influence is so extensive that it spills over to influence personal belief and even the ideation of self-efficacy.

The fundamental assumption underlying the effort to restrict public exposure to celebrity deaths is that individuals imitate what they see and thus conversely, if individuals are shielded from such exposure, they will be less likely to imitate. While it seems the Ministry of Health grasps, to a certain extent, how powerful the entertainment industry is in influencing public opinion, it does not understand just how deeply its citizens are drawn into the lives of these glorified entertainers.

Efforts to limit public exposure are impractical in two ways: 1) it is simply not feasible to control all channels of information that reach citizens on a daily basis and 2) the level of response to a celebrity suicide is not so much determined by the choiceness of words in its reporting or whether it makes it to the front page, but by how well-known and well-loved that individual was prior to his or her death.

Indeed, according to monitoring by the Korean Association for Suicide Prevention , among 343 articles in 10 major newspapers and 113 reports by four major broadcasters, 60.1 percent failed to follow the guidelines (6). Furthermore, even if all media outlets did refrain from overt reporting, the news of their death can still travel via blogs, forums, chatrooms, unofficial news sites, word of mouth, etc. Ultimately, it’s the shock and perceived gravity of the loss, and not the degree of its exposure, that triggers individuals to follow suit.

CRITIQUE 2: MISUNDERSTANDING OF “SELF-EFFICACY”

The rationale behind the government’s effort to censor the ways in which individuals can achieve suicide is understandable – after all, with fewer viable means of committing suicide, it would seem that less people would choose to do so. In this way, the government may believe they are undermining the perceived self-efficacy of individuals and deterring them from committing such an act. However, what they may not realize is that for an individual to witness the death of a well-known public figure may provide the strongest support that he or she can take action and ownership of their life and end it. While the government believes that the availability of resources is what limits or enables the perceived ability of someone to make a choice, the very reality of someone well-known actually committing suicide is infinitely more powerful of an instigator. Thus, expending resources to limit certain means out of an almost infinite number of possibilities may prove futile as a buttress against the impact of real death.

In another way, limiting access also may prove too late of an intervention in preventing suicide. In one study performed in Korea looking at clinical characteristics of depressed patients, researchers found that of 1183 participants they recruited, 21.4% had a history of suicide attempts (10). This means that individuals who are attempting suicide may have a long history of suicide ideation and even unsuccessfully acting on it. When one contrasts a few mere subway screens to the years of ideation and depression that may have taken root in an individual, it is easy to see why such prevention efforts may be limited in their efficacy.

CRITIQUE #3: NOT IDENTIFYING THE ROOT OF THE PROBLEM

Finally, one can argue that asking the media to refrain from reporting may actually aggrevate the problem by conveying the message that suicide is not a serious issue that needs to be addressed. At the root of the phenomenon is not simply that individuals simply mimic what they see celebrities do, but rather, that long withstanding pressures and anxieties pressing in from all sides has driven them to a point where seeing someone else acting out the thought that had been plaguing their own minds for so long only serves as the trigger that catapults them from contemplation to action.

Studies have found that since the 1997-1998 East Asian Financial Crisis that yielded 19.9 suicides per 100,000 people, numbers have consistently been high and on the rise (11). One study found that suicide rate was clearly related to the unemployment rate and also a result of the widening rich-poor gap and social polarization that also resulted from the financial crisis (12). Additionally, studies found that while the absolute increase in suicide rates are attributed to older individuals over 45, the proportional increase in rate was most prominent among younger people (13), an indication that the problem has expanded to society at large and individuals across all age groups have been increasingly feeling the burden to take their life as an escape from environmental pressures.

Ultimately, neither the Werther effect nor Social Cognitive Theory can fully explain the depth of this prevalent suicide phenomenon in South Korea nor provide an adequate solution out. What is necessary is a return to unity and a collective effort to raise the morale of everyone from peasants to millionaires, and to instill hope that alternative methods of dealing with life’s uncertainties and anxieties are better options than ending one’s life.

SOLUTIONS IN RESPONSE

MAKING THE MOST OF CELEBRITY INFLUENCE

While the consequence brought on by a celebrity death can be categorized under “unintended media effects ” that stem from Social Cognitive Theory (14), South Korea can take advantage of the massive popularity of celebrities and the uniquely intimate dynamic between public figures and the public to launch an anti-suicide television show or education series. The underlying assumption of Social Cognitive Theory is that individuals mimic behavior they see in others. As a result, mere 30 second advertisements or empty, cheery words may have little effect. However, should well-loved and respected public figures partake in a documentary or television show that brings together the reality of individual struggles and shows how these individuals deal with them or help others address them, this may substantially provide examples of solutions or encouragement that viewers are not alone in their problems and as a result, restore a sense of unity and promotes greater openness in confrontation and discussion of such problems.

Another way of bringing about positive and “intended media effects” is to take advantage of social media outlets and make a push for positive blogs and anti-suicide pieces. Studies have shown that a reliable preliminary indicator for suicide attempt is the posting of some “final words” on the individual’s blog or homepage. In a country like South Korea where such a large proportion of the population have ready access to the internet, online communication has over the years come to replace in-person interaction, especially among many of the younger generation. The internet provides an anonymous, removed setting on which one has the freedom to express anything on their mind – and many times have served as breeding ground for malicious remarks and bullying. Many times, celebrity’s personal pages are the most consistently followed. If there can be a campaign launched where celebrities agree to post encouraging messages or sharing of their struggles onto these sites, these entries can serve as a platform for greater dialogue among individuals young and old who read them.

INTERVENE EARLY AND APPROPRIATELY

As discussed earlier, one of the shortcomings of attempting to set-up subway screens and pesticide purchase monitoring is that the financial resource could instead be used for more early intervention that more directly target the root of suicide attempts. Instead of money spent that poses as physical barriers to a behavior, money should instead be allocated for the creation of a community in which individuals can mutually entrust and encourage, as supported by the Social Support Theory (14). The Theory posits how networking and interacting help individuals cope with stressful events.

Erecting screen doors on subways and denying individuals of poison will only more glaringly put them face to face with their suicide ideation and negatively represent government’s role in addressing the problem. Instead, if support groups can be created, either through local religious groups or grassroot groups that will take individuals from their isolation and plug them into a community that builds long-term relationships and support, this will minimize feelings of alienation and other ideations that pushes one to take extreme measures. It also provides a system of accountability and mutual monitoring for warning signs of potential harmful behavior.

GETTING TO THE ROOT OF THE PROBLEM

Finally, no single campaign with slogans or visuals can provide a long-term solution, because it doesn’t address the root cause of why individuals undergo depression and eventually spiral into suicide ideation instead of recovering from their condition. The first step to bringing suicide rates down is to truly understand what factors are involved that has made them rise. The societal stresses placed on men differ from that on women, and the anxieties that plague the youth lies in great contrast to those that demoralize the old. Only when these factors are identified and explored can they then be addressed with hope of being resolved.

For youths in South Korea today, life can be both suffocating and strenuous. On one hand, there is immense academic and parental pressure to perform in school and to excel, because the reality is there is a limited number of jobs and opportunities domestically. On the other hand, the allure of the glamour and ease that comes from the media’s portrayal of celebrity life draws hundreds of thousands youths each year to try out for talent agencies, each with hopes of being a part of the next international-hit boy band or girl group. For young girls, the issue of self-image is particularly hurtful, as societal pressure dictates very clearly a very narrow standard of beautiful, and a single fold in the eyelid could be the determinant of whether or not you are hired. Growing up in such a stifling and psychologically tumultuous environment, and many times devoid of open dialogue with parents, youths often find they have no true guidance or support. In a study that examined the main risk factors in relation to suicidal ideation among high school girls and boys, it found that for males, all behavioral variables (i.e. smoking, drinking) were predictive of suicidal ideation while for females, sexual orientation and bullying were predictive factors (15). Such results reflect the need for greater parental intervention and school education that covers such heavily stigmatized topics as divorce and sexual health.

The public figures who have died in recent years suffered from depression brought on by a variety of psychological burdens. Former president Roh hung himself following a number of high-profile corruption investigations. Actor Park Yong-ha had a terminally ill father and felt financially burdened despite his many sources of incomes. Singer U;Nee committed suicide reportedly as a result of work pressure and depression over her overly-sexualized public image. Actress Jang ja-yeon left a suicide note listing in detail all the sexual favors and forced services she was forced by her entertainment agency to perform in order to secure roles and advance her career (16). These few individuals’ rationale for taking their own lives highlights a vast array of deeply entrenched problems with Korea’s society as a whole – from corruption to sexual assault, work pressure to financial paranoia.

FINAL THOUGHTS

The suicide epidemic that has overtaken a South Korea that gleams so brightly from the outside illustrates the complexity and challenge of public health intervention. On the surface, the mortality figures may not seem so shocking – a high profile death here and there, with most of the suicides going unreported or publicized. However, a closer look at the few cases that do get more deeply investigated unveils a multitude of societal problems that is undermining the mental health of an entire nation. Difficulties, challenges, environmental pressures will always exist, especially within emerging nations like those of East Asia where old conservatism and new openness have created a life that is at once bustling with life and locomotion but at the same time, eating away at long withstanding lifestyles grounded in peace and simplicity. While people are sacrificing their time and their health for the pursuit of a larger house, greater purchasing power, and improved social standing, it is twined with irony that in the process of gaining what is disposable, they are disposing of what cannot be regained.

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