Introduction to the Sexually Transmitted Infection “I Know” Program
The Centers for Disease Control and Prevention (CDC) estimate 20 million new cases annually of sexually transmitted infections, with a prevalence of over 110 million total STI’s among men and women in the United States (1). Chlamydia and Gonorrhea, caused by the bacterium Chlamydia trachomatis and Neisseria gonorrhoeae, are two of the most widespread and frequently reported sexually transmitted infections, yet are completely curable by oral antibiotics (1, 2). The majority of women are often asymptomatic, propagating the potential for spread of infection, which without treatment can lead to pelvic inflammatory disease, ectopic pregnancy, infertility and in rare cases endocarditis and death (2).
Sexually transmitted infections (STIs) have been strongly associated with age, race, ethnicity, and poverty (1—3). Young people, ages 15—24, account for 50% of all new STI’s and young Latin American and African American women have the highest reported rates of infection. Los Angeles County, with an estimated population of 10 million, has the highest number of Chlamydia cases (43, 806 cases in 2009) and third highest number of Gonorrhea cases (8, 482 cases in 2009) in the United States (2, 4). In 2008, a reported 29,463 new cases of Chlamydia and 3,626 Gonorrhea cases in L.A. County were in Latin American and African American women younger than 25 year of age (5).
In response to the high incidence of Chlamydia and Gonorrhea infections in Los Angeles County, the Los Angeles County Sexually Transmitted Disease Program (LACSTD) implemented a STI home testing program in 2009 targeting Latin American and African American women aged 12—25 years of age (2, 4). The “Don’t Think Know” campaign, also known as “I Know” or “Yo sé”, features young Latin American and African American women who “know” their status and “know” they can fight Chlamydia and Gonorrhea infection by getting themselves tested (5). The “I Know” home testing program enables women to order a free home testing kit online. The home testing kit is shipped to their home in discreet packaging with materials available in English or Spanish, and women are given a choice of how to access results: e-mail, text message, or not to be notified (2). The public health campaign utilizes advertisements in newspapers, buses, billboards and youth-focused marketing like graffiti murals, sidewalk chalk art, drink coasters, stickers in nightclubs and gyms (6). The program’s first year, June 2009—June 2010, tested only 2,659 clients (5% of the new cases) and more than half of the clients were from the targeted population (2).
The “I Know” home testing program has a high potential for success; however, the current program uses the Health Belief Model, which is an individual level model that does not incorporate environmental or social factors associated with health behavior. The current “I Know” campaign inadequately addresses Framing theory and does not address Social Learning Theory, self-efficacy, or Optimistic Bias. A campaign focused on addressing social and behavioral theories and cognitive biases including Social Learning Theory, Framing Theory, Advertising Theory, and Optimistic Bias will be more effective in reaching young adult, minority women and decreasing STI morbidity in Los Angeles County.
Critique 1: Weak Supporting Frames in Campaign Advertisements
The “I Know” campaign has a weak-supporting frame identified by the core position of “Get tested” (5). A frame is a social construction of an issue that communicates a specific message to the observer and is composed of five key elements including a core position, metaphors, catch phrases, symbols and images, and a core value (7). A strong frame is important because it has the power to influence both public opinion of an issue and individual behavior. The “I Know” campaign’s core position revolves around “getting young adults tested for STIs so they can know their status”. The core value of this frame is knowledge and key catch phrases include “Get tested! It’s the only way to know” and “I know. Getting some can mean getting something else”. The “I Know” campaign’s website attempts to appeal to their target population by depicting individual women of minority groups being confident that they know their STI status and telling their “girlfriends” to get tested also. However, the images do not convey an emotional response nor do they appeal to young minorities’ desire for independence, happiness, and excitement. The overall frame of the campaign is unsuccessful because it lacks effective metaphors, does not elicit strong symbols or images and has a weak core value of knowledge (5). The core value of knowledge is weak because it does not appeal to the powerful core principles in American consciousness, notably freedom, individual rights, economic opportunity, family, fairness, or equality (7).
The “I Know” campaign’s website and video-advertisements also do not align with Advertising Theory. The campaign’s advertisements do not successfully influence individual behavior because the message delivered, ie, “knowledge”, is not a strong or desired promise in the target population and the manner in which the message is delivered is not convincing. The only promise to the individual is they will gain knowledge by getting tested and there is no support for the benefits of getting tested. The campaign attempts to increase persuasion of STI testing in young minority women by using them in their campaign; however the women depicted are unrealistic and do not evoke deep emotions that will convince a viewer to take action. The women in the advertisements are supposed to be confident; however their message comes off as arrogant and annoying which makes the characters less likable and less similar to the targeted population. In order for the “I Know” campaign to be more successful the campaign must be re-framed and delivered with messengers that are more likable to the target population.
Critique 2: Does not Acknowledge Social and Environmental Factors
The “I Know” campaign structures its program around individual behavior, developing advertisements with individuals from the targeted population and focusing on information about risk and severity of Chlamydia and Gonorrhea infection. The program follows the Health Belief Model (HBM), which attempts to explain and predict health behaviors by focusing on the beliefs of individuals (8). The HBM is based on the assumptions that an individual will take a health-related action if that individual has high-perceived susceptibility, high-perceived severity, low perceived barriers, and a cue to action. The “I Know” program follows this model by increasing perceived susceptibility and severity for getting an STI (providing information on disease), as well as providing cues to action (advertisements) and decreasing perceived barriers (free home testing). There are several fundamental flaws associated with the HBM individual-level model including: failure to address social and environmental factors, failure to recognize disparity in knowledge, failure to address self-efficacy, and the assumption that people will act rationally if given disease information (8).
The “I Know” campaign depicts individual women with no reference to social norms or environmental factors. The Health Belief model is flawed in this campaign because sex involves more than one individual and the decision for STI testing is based on social norms and environmental influence. The campaign does not adequately address partners getting tested, men getting tested, groups of people talking about getting tested, or the physical environment of these women (5, 9). In order to be an effective STI public health intervention one must make information about STIs and STI testing available to not only the targeted populations but also their social networks. A descriptive study conducted by Meyer et al. (2011) analyzed current Internet content on STI testing available to adolescents and found that out of 18 websites dedicated to STI information only 22% provided information on male risk factors/testing recommendations and only 28% addressed partner testing (10). STI public health interventions target certain populations but seem to fail at educating family or parents of these populations who have a large impact on their individual behavior.
The “I Know” campaign focuses on individual minority women; however this racial discrimination can enhance the stigma behind STI testing and promote risky sexual behavior. According to Social Learning Theory, knowledge acquisition is a dynamic and ongoing process that includes individual, behavioral and environmental factors (social norms, access in community, and influence of others) that exert influence upon each other (11). An individual’s sexual behavior can be influenced by social norms, observed attitudes towards a behavior (stigma) and environmental factors (racial discrimination). A study conducted by Fortenberry et al. (2002) examined social norms associated with STI testing and showed that STI-related stigma was highly associated with a decreased likelihood of being tested for STIs (Odds ratio for Gonorrhea testing=0.77, Confidence Interval 0.67, 0.97) (12).
Another study, using a prospective cohort, by Roberts et al. (2012) examined the relationship between early racial discrimination and risky sexual behavior in African American families (13). Perceived racial discrimination was high in the children (aged 10—12) of families studied holding socioeconomic status constant. A reported 89% of children experienced “at least one” act of discrimination and 38% experienced acts of discrimination “several times”. Sexual behavior was initially low at 7.3% of children and by the end of the study 85.1% (children now aged 17—19) were sexually active. Of those who were sexually active at the end of the study, 41% reported not consistently using condoms and 64% reported having sex with three or more partners. The study showed that there was a significant effect of early discrimination on risky sexual behavior (p<0.001) and those that perceived more racial discrimination at age 10—11 years of age were more likely to engage in sexual risk taking at 18—19 years of age. The study presents evidence that racial differences in health can be influenced by social and environmental factors and racial discrimination can negatively affect individual behavior. The obvious targeting of African American and Latin American women in the “I Know” campaign is sexual and racial discrimination that can negatively impact the behavior of these populations to get STI-tested.
Critique 3: Does not Account for Self-Efficacy or Cognitive Biases
The “I Know” campaign focuses on knowledge and accessibility of STI-home testing; however, it fails to explain why young minority women take sexual risk in the first place. Alternative models of group-level behavior, specifically cognitive biases, offer potential explanations to understand and predict why these populations of women take sexual risks. Lack of self-efficacy for communicating about STIs can also further explain individual behavior. The “I Know” campaign does not consider self-efficacy or Optimistic Bias, the misperception of individual risk.
The “I Know” campaign is based on the assumption that increased knowledge of STIs will heighten an individual’s perceived susceptibility and perceived severity to affect behavior (STI testing). However, higher levels of knowledge of STIs have not been significantly associated with safer sexual behavior (14). Self-efficacy, the belief in one’s ability to take action, is thought to mediate the connection between intention and behavior (8). Hale et al. (1996) conducted a cross-sectional study to examine the relationship of sexually active college women’s perceived risk, self-efficacy and STI risk prevention behavior (15). Despite a high level of knowledge about STI transmission (mean rate of 87%) there was a lack of reported condom use (78%) in study subjects which shows risky sexual behavior. The perceived risk for STI infection were also low in study subjects with 83% of women reporting their chances of STI infection were somewhat, very unlikely, or not possible. Women were asked questions regarding their self-efficacy including “How sure are you that you could use a condom every time you had sexual intercourse?” Findings showed that only 36.8% of study subjects were certain they could use condoms every time they had intercourse, however only 12.4% reported “usually” or “always” providing condoms during sexual intercourse. The study showed that high self-efficacy was a predictor of lower numbers of sexual partners and more consistent condom use. According to this study self-efficacy is associated with sexual risk behavior and findings suggest that STI testing campaigns should address the development of self-efficacy.
Optimistic bias offers another explanation of why knowledge does not equate to behavior. Optimistic bias occurs when individuals overemphasize the extent of others’ risk and underestimate their own personal risk to health-related hazards. Optimistic bias has been demonstrated in epidemiological studies investigating the risks of Human Immunodeficiency Virus (HIV), pregnancy, cancer, smoking, and general health risks (16). Several current epidemiological studies indicate that teens are very aware of the risks associated with unprotected sex, yet the percentage of sexually active teens has increased over the past few decades with youth 12—25 regarded as the predominately-affected population for STIs. According to Optimistic Bias individuals are fully aware of health risks, but they envision themselves as the exception and less vulnerable than others. Youth especially see themselves as invincible and sincerely believe that “it could never happen to me”. Chapin (2001) conducted a study on minority at-risk youth aged 10—17 to test the degree of optimistic bias in regard to pregnancy. As predicted, urban, minority, at-risk youth exhibited optimistic bias (p<0.001) by perceiving that they were less likely than their peers to become pregnant (16). The study showed that 32% of the sample population reported having protected sex at least once, 27% reported having unprotected sex at least once, and 58% stated the intention of being sexually active in high school, with the mean age of 12 for sexually active youth. Findings suggest that optimistic bias is associated with sexual risk taking in youth, sexual intentions, and attitudes toward sexual activity.
Proposal for Improvement of Current “I Know” Campaign
Youth behavior is rooted in ideas of freedom, truth, and innovation. In order to effectively change youth behavior we must appeal to these core values and enforce the idea that getting tested for STIs promotes freedom in life. The “I Know” campaign does not evoke freedom; a more effective name will be “Sex Out Loud”. Here, I propose the “Sex Out Loud” campaign to promote freedom and independence from preventable STIs (Chlamydia and Gonorrhea). This campaign will effectively use models of social and behavioral theory to increase the rate of STI testing in young adult populations in Los Angeles County.
The campaign will target young adult populations (aged 16—25) in Los Angeles County with concentrated advertisements on beaches (Lifeguard posts, bathrooms, parking lots), in movie theaters (video clip before film, bathrooms), in malls, and online. The core position of the campaign will be “No one can stop sex, but everyone together can stop STIs”. Metaphors can be used to compare STI testing to battling the burden of human diseases and the world coming together to stop disease. The “I Know” campaigns effective catch phrases of “get tested” can still be used along with others that promote speaking freely about sexual behavior. Freedom and independence will be evoked by video and image visualizations of groups of people talking about sex and getting tested together, as well as individuals with their partners and families who support them getting tested.
The campaign’s website and social networking sites (Facebook and Twitter) will be directed at both men and women of mixed ethnicities with stories, blogs, and images of groups of people speaking openly about sex and sexually transmitted diseases. The website will focus on sexual behavior communication, but will also address disease knowledge (disease severity, disease distribution by neighborhood), annual STI testing and Pap smear by physician, availability of clinics by neighborhood (website map), and online ordering of the home test kit (based on current “I Know” campaign). Advertisements for events and home testing will also be put into La Opinión and the Los Angeles Times. Invitations to events will be distributed by student volunteers in at-risk neighborhoods. The campaign will still be funded by Los Angeles County Department of Public Health, however I propose that undergraduate student interns and public health students run the online websites and participate in community special-events. The unique perspective of young adults on these websites will make stories more realistic and increase individual risk perception in the target population.
The “Speak Out Loud” campaign will utilize social events to stimulate a long-lasting movement. Specialized weekend events such as “Sex Out Loud” Volleyball, “Sexo en Voz Alta” Soccer, and “Think Sex” Parties at colleges (partially funded by college) and public beaches. Events will utilize volunteer music groups and celebrity spokespersons to advertise the idea that “Sex Shouldn’t Be Silenced” and everyone is capable of openly speaking about sex and sexual health. Both real life and celebrity messengers will be between 18—25 and will not lecture about “getting tested”, but insetad tell their story (positive or negative) about how they got tested for STIs and how they were treated successfully. Promotional items will include “Sex Out Loud” wristbands, buttons, and T-shirts. In order to effectively address distinct minority populations, specifically those working with children, advertising campaigns can be held in public parks, target parking lots, or malls.
Re-Framing the Intervention
The re-framing of STI testing as freedom and independence to speak freely about sex will create a stronger impact on the young adult population and will potentiate the message to get tested for STIs. Sexual freedom and independence are strong motivators for young adult populations and will effectively address the lack of STI testing in target populations. The “Truth” campaign, a national youth-focused anti-tobacco education campaign, showed that by re-framing the tobacco companies’ freedom and truth frames they could decrease smoking among 12—17 year olds (17). The campaigns core position highlights the deceptive tobacco industry’s marketing advertisements and deadly health effects of cigarette smoking. Strong supportive images of youth piling body bags outside the door of major tobacco companies illustrate the daily deaths from tobacco use. This campaign showed that effective advertisements with core values pertaining to youth can decrease the risk of smoking initiation (relative risk=0.80, p=0.001). “Sex Out Loud” would have a more positive connotation versus the “Truth” campaign; however it will be the same concept of shifting the frame from health and knowledge to freedom, truth and independence.
The “Sex Out Loud” campaign’s use of real people and celebrities can be very effective in increasing risk perception. By choosing spokespersons that are similar and familiar to young adults of the target population there can be effective long-term messages that advocate STI testing. The likability of the real people and celebrities will be assessed among the target population to increase the emotional response to advertisements. The messengers will tell true stories that elicit the idea “I’m like you, it can happen to you because it happened to me”.
Incorporating Social and Environmental Factors
The proposed campaign will follow the Social Learning Theory Model by addressing the dynamic relationship between the individual, behavior, and the environment. Young adult populations as a whole will be targeted to eliminate the impact of racial discrimination on the campaign’s effectiveness. The “Sex Out Loud” campaign will encourage and support the mixing of races, social classes, and families in order to effectively decrease the negative social norms and stigma associated with sex and STI testing. The main goal of the “Sex Out Loud” campaign will be to change the way people perceive STIs and attempt to decrease risk perception through open discussion with the target population, social groups, and families. The change in social norms will increase the rate of STI testing among at-risk populations and decrease the overall prevalence of Chlamydia and Gonorrhea in Los Angeles County.
California has the second lowest prevalence of adult smoking and lowest per capita cigarette-use in the U.S. (18). This low prevalence can be associated with the 1989 implementation of a social norm change paradigm model by the California Tobacco Control Program (CTCP). The CTCP concentrated on opposing pro-tobacco influences, reducing secondhand smoke and reducing tobacco availability. Ultimately, this social norm model affected behavior change at the individual level and lead to decreased prevalence of smoking. The “Sex Out Loud” campaign will take a similar approach, however instead of restricting availability we will promote the ease and accessibility of STI testing to targeted populations through free home kits, promotion of STI clinics, annual physician visits, and advertisements for sexual behavior communication. With increased success of STI testing we could also advocate a policy that requires an annual pap smear with Chlamydia and Gonorrhea test for sexually active adults aged 18—25.
Addressing Self-Efficacy and Optimistic Bias
The campaign will address self-efficacy and optimistic bias towards STI testing by allowing individuals to actively communicate about sexual preventative behaviors with their peers. Individuals can also build self-efficacy by viewing video scenarios of STI testing or getting tested regularly if sexually active. Optimistic bias will be reduced through identification with spokesmen and emphasis on personal risk. Interactive maps will show the prevalence of STIs in their neighborhoods to increased perceived risk. A study by Chen et al. (2011) demonstrated the positive correlation associated with introducing STI preventative behavior (condom-use) at earlier ages and increased self-efficacy for that behavior over time (19). The “Sex Out Loud” campaign will constantly illustrate young adults that are capable of speaking about sex, STIs and STI testing and will provide opportunities for increased self-efficacy and decreased optimistic bias.
In summary, the proposed intervention will focus on increasing sexual behavior communication to effectively increase STI testing among young adults and ultimately decrease incidence of STI infection in Los Angeles County.
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