Challenging Dogma - Spring 2008

...Using social sciences to improve the practice of public health

Monday, April 21, 2008

“Get Tested” Campaigns Should Get Lost: Many Ads Encouraging HIV/STD Testing in Young Adults Fail to Make the Grade – Monica Morrison

It is estimated that for every four teens that have become sexually active, at least one of them will contract a sexually transmitted disease (STD) every year, amounting to roughly four million cases annually. In fact, people under age 25.4 account for approximately half of all new HIV infections in the United States (1). Public health professionals have begun targeting this group with interventions promoting abstinence, safe-sex practices, and encouraging HIV/STD screening. The public health community has been especially successful in getting the issue onto the national agenda and gaining attention from the media. Such efforts help to raise public awareness around this issue.

Recently, encouraging HIV/STD testing has become a cornerstone of many interventions trying to stop the spread of these diseases. Campaigns created by several public health organizations across the country prompting young people to “Get Tested” can be found in magazines, on the television, on the radio, and in other forms at increasing rates. It has been a great initiative, seeing as many people who transmit HIV or other STDs to their partners do so unknowingly. According to a report given at the National HIV Prevention Conference in 2005, it was estimated that 25% of those infected with HIV are unaware of it (2). However, the ways in which these campaigns aim to encourage testing are, for the most part, based on ineffective models of behavior, and they do not consider all of the factors affecting whether or not a person will choose to be tested. Also, many of these campaigns bombard the audience with facts and statistics to get their attention and to demonstrate why testing is so important. However, by only playing to their targets’ intellect, they fail to generate an emotional response to the subject. These ads may not affect young people as strongly as other campaigns that are not based on the typical health behavior models and help to evoke an emotional connection to the issue.

Right Idea, Wrong Approach
Many ineffective campaigns attempting to encourage young people to be tested for STDs and HIV are based on traditional behavior models, particularly the Health Belief Model. According to the Health Belief Model, behavior is determined by an individual’s weighing of the benefits of doing a behavior, which are influenced by the perceived susceptibility and perceived severity, and the costs of doing a behavior. Consideration of the benefits versus the costs leads to their intentions regarding the behavior, which then directly determines whether or not they will do the behavior (3). This model predicts behavior at the level of the individual and relies on a rational thinking process.

The “Don’t Think. Know.” Campaign developed by the Los Angeles County Department of Public Health is a great example of an ad based on the Health Belief Model. The ads feature a young woman standing confidently by the phrase “I know.” Other phrases surround her including “that hooking up can have a downside,” “that over 35,000 women in the LA County get chlamydia and gonorrhea every year,” and “that it’s important to get tested for chlamydia and gonorrhea.” The ads also urge the audience to “KNOW the facts,” “KNOW about testing” and “KNOW what you can do” (4).

The “Get Real. Get Tested.” Campaign implemented by the North Carolina Department of Health and Human Services is another example. The statewide campaign is designed to educate people about HIV and AIDS and to encourage screening. A press release announcing its implementation explains that “the TV spots give people fast facts about HIV/AIDS and getting tested” (5).

These campaigns, based on the Health Belief Model, count on rational decision making by their audience to influence testing behavior. They rely on the fact that once their targets “know” all about STDs and testing, they will intend to get tested. And as the Health Belief Model states, intention to do a behavior leads directly to doing the behavior. However, this is not always the case because many other factors contribute to this decision (6). A person’s attitudes, beliefs, and emotions about the behavior, their up-bringing, their environment, and social norms are just a few influential factors that are not accounted for by the Health Belief Model and are not considered in these campaigns. Ads such as these are doomed to fail because they use only facts and figures to encourage young people to get tested.

Other Factors to Consider

These campaigns fail to recognize and, therefore, to address other aspects of an individual’s decision-making process such as social and emotional factors. Based on the Health Belief Model, many campaigns, like the previous examples, assume that the costs and benefits are the only factors upon which individuals base their decisions of whether or not to get tested for HIV and STDs (7).

In a 2004 study examining the barriers to screening and utilization of other STD services for young adults, several focus group discussions were conducted consisting of individuals from varying ethnic and social backgrounds with ages ranging from 14 to 24. One deterrent from being tested mentioned frequently was “the feeling of shame” associated with visiting a testing center. Many participants were concerned about being seen entering a testing center and/or about the level of confidentiality that was maintained by the clinic (8). Another study identified the stigma attached to HIV/STD testing to be a primary barrier to testing (9).

Emotions such as fear and anxiety are also factors that play a role in making the decision to get tested. If an individual has never been through the screening process before, their fear of the unknown may outweigh their perceived need to be tested. In some cases, prior knowledge of what the tests entail can also scare young people away. In the first study mentioned previously regarding barriers to testing, “almost all male participants expressed a strong aversion to urethral swabs as a specimen collection” method. For many female participants, the expected fear and anxiety concerning the whole process including the test results themselves was also a deterrent. They stated that it was very important for a clinic or testing center to offer “health education and counseling services at the time of screening or testing” (8).

One campaign that successfully addresses these other factors is the “It’s Your (Sex) Life” campaign co-developed by the Kaiser Family Foundation and MTV (10). The success of the campaign can be attributed to incorporating principles of social expectations theory, which basically states that behavior can be influenced by an individual’s perception of social and cultural norms, and because the mass media depicts these norms they can, therefore, influence an individual’s behavior (11). The campaign’s goal is unique in that it aims to encourage HIV/STD testing among young people not by appealing to their intellect and rationality, but by attempting to change the social and cultural norms surrounding testing, making it more socially acceptable. Short segments airing on MTV News depict their peers being tested for HIV and/or other STDs. One segment follows a young couple as they go to be tested for HIV together and another follows a popular MTV News anchor, Gideon Yago, as he is tested for STDs (12,13).

Not only are these segments recognizing the social factors that go into the decision to get tested by attempting to change the norms associated with the behavior, but they are also acknowledging the emotions that may act as deterrents to being tested. By increasing the social acceptability of being tested for HIV/STDs and normalizing the behavior, the feelings of shame that accompany going to a testing clinic can be diminished. In addition, by following their peers through the entire process of being screened for HIV and STDs, from the pre-test consultation, to the test itself, and then to the results and post-test consultation, feelings of fear and anxiety are subdued and the target audience now knows exactly what they can expect when getting tested.

Forming An Emotional Connection
By only connecting with their targets on a facts and statistics basis, most of these campaigns fail to generate an emotional response from the audience to the issue, and as a result, they may not affect young people as strongly. In order for young people to realize the importance of being tested, they have to care about it. They need to feel how this issue affects them on a personal basis. For example, telling them that this particular number of people contracts an STD every year or that the rate of infection is increasing this much every day will not affect them as strongly as finding out that their best friend is HIV positive or that their significant other has an STD. The strength of the influence that a testing campaign has on its audience depends on the way in which the issue is framed. Framing theory explains that the same message can be perceived several different ways when it is presented from different perspectives and/or using varying approaches to the subject. Basically, “it’s not what you say; it’s how you say it” (14). Campaigns trying to frame testing in a way that will evoke an emotional connection from the target audience to the issue will be more successful than those that do not.

The “It’s Your (Sex) Life” campaign mentioned previously is a great example of a campaign that effectively uses framing theory to generate an emotional connection in young people to HIV/STD testing. One segment shows the day-to-day lives of real young people who are HIV-positive, and that these people could be your neighbor, your best friend, your classmate, etc (10). This helps to drive home that anyone can be affected by HIV, whether directly by being infected by the virus or indirectly by just knowing someone who has. The way that testing is framed in these ads makes young people care about it and brings the issue down to a personal level, where facts and figures alone cannot.

Recent research conducted by the Kaiser Family Foundation to determine the effects of the campaign have shown that it has been successful in increasing HIV/STD testing among young people. In a report summarizing this research it was stated that “65% of those ages 16-24 who have seen the ads say that they are much more likely to be tested for HIV and other STDs. [And] 24% of those ages 16-24 who have seen the ads said that they have been tested for HIV or other STDs as a result of the campaign” (1).

In order to be successful in future endeavors attempting to encourage HIV/STD testing behavior in young people, we must move away from using the traditional behavioral models, like the Health Belief Model, and towards using alternative models, such as framing theory and social expectations theory. One main advantage that these models have over the traditional Health Belief Model is that they do not focus on changing behavior at the individual level but rather at the group level. This alone is a major factor in the success of those ads that have been based on the alternative models. Changing the behavior of the group is a much more powerful strategy than targeting only individuals.

Social expectations theory, specifically, should be the foundation of these campaigns. With an issue such as HIV/STD testing, reason and rationality are not the major players in making the decision to be tested. Because there is an undesirable stigma attached to testing and to the people who are seen at testing centers, this behavior is not the social norm yet. This is one of the major barriers for young people to testing. With the use of Social expectations theory, campaigns can help to normalize this practice and make it more socially acceptable. In doing so, it will help to lessen any feelings of shame or embarrassment that testing may produce, thereby eliminating a barrier to testing. In addition, by normalizing testing behavior, feelings of fear and anxiety concerning the test itself will not diminish altogether, but they may be dominated by the perceived need to be tested. For example, women do not necessarily look forward to annual visits to their gynecologist to be screened for cervical cancer, nor do people joyfully anticipate getting vaccinations, but these services, as being considered part of a normal healthcare regimen, are viewed as necessary evils. An individual’s fear and anxiety regarding these prevention procedures do not overshadow their perceived need to be tested and lead them to avoid the situation altogether, as they do in the case of HIV/STD testing.

In Conclusion
Public health professionals can continuously push sobering facts and figures onto young people, but until the social norms surrounding HIV/STD testing are changed, and it can be viewed as part of routine health care, their messages will do little to change testing behavior. In order to create successful and effective campaigns to encourage testing, we have to abandon the typical strategies that have been used thus far. These new campaigns should show young people that their peers are getting tested, they should address emotions that play a role in the decision-making process, and they should engage the audience on an emotional and personal level before thrusting facts and statistics at them.

1. Henry J. Kaiser Family Foundation. Reaching the MTV Generation: Recent Research on the Impact of the Kaiser Family Foundation/MTV Public Education Campaign on Sexual Health. Menlo Park, CA: Henry J. Kaiser Family Foundation, 2003.
2. Glynn MK, Rhodes P. Estimated HIV Prevalence in the United States at the end of 2003. Atlanta, GA: Presentation, National HIV Prevention Conference, 2005.
3. Edberg M. Individual health behavior theories (pp. 35-49). In: Edberg M. Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Sudbury, MA: Jones and Bartlett Publishers, 2007.
4. County of Los Angeles Department of Public Health. Don’t Think. Know. Los Angeles, CA: County of Los Angeles Department of Public Health.
5. North Carolina Department of Health and Human Services. “Get Real. Get Tested.” Campaign Comes to Charlotte Feb. 28. Raleigh, NC: North Carolina Department of Health and Human Services, 2007.
6. Salazar MK. Comparison of four behavioral theories: a literature review. AAOHN Journal 1991; 39:128-135.
7. Choi K, Yep GA, Kumekawa E. HIV prevention among Asian and Pacific Islander American men who have sex with men: a critical review of theoretical models and directions for future research. AIDS Education and Prevention 1998; 10, Supplement A:19-30.
8. Tilson EC, Sanchez V, Ford CL, et al. Barriers to asymptomatic screening and other STD services for adolescents and young adults: focus group discussions. BMC Public Health 2004; 4:21.
9. Fortenberry JD, McFarlane M, Bleakley A, et al. Relationships of stigma and shame to gonorrhea and HIV screening. American Journal of Public Health 2002; 92:378-381.
10. Think MTV. It’s Your (Sex) Life. Viacom International Inc., 2007.
11. DeFleur ML, Ball-Rokeach SJ. Socialization and theories of indirect influence (pp. 203-227). In: DeFleur ML, Ball-Rokeach SJ. Theories of Mass Communication, Fifth Edition. White Plains, NY: Longman Inc., 1989.
12. MTV News. ‘Didn’t Even Feel It’: Getting an HIV Test. Viacom International Inc., 2007.
13. MTV News. Gideon Yago Gets Tested for STDs. Viacom International Inc., 2007.
14. Scheufele DA, Tewksbury D. Framing, agenda setting, and priming: the evolution of three media effects models. Journal of Communication 2007; 57:9-20.

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